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One specialized treatment for borderline personality disorder (BPD) is Schema Therapy (ST), a relatively new treatment (Young et al., 2003). Based on the findings from meta-analyses, ST has been found effective (Cristea et al., 2017; Oud et al., 2018; Rameckers et al., 2021; Storebø et al., 2020). However, more knowledge about factors related to ST treatment success is useful to improve its effectiveness and could also benefit personal treatment selection. The most important and central concept in ST are schemas, which are knowledge representations that consist of memories, cognitions, emotions, and body sensations which in turn influence our behaviour. These central schemas develop in response to adverse childhood experiences when important childhood needs (e.g., connectedness, worthiness) are not met. If such rigid, early schemas become dysfunctional later in life, they are referred to as early maladaptive schemas (EMSs). There are different ways people can cope with the activation of EMSs. A cluster of several active schemas and coping modes is also called a schema mode. BPD patients often experience sudden changes in schema modes. Therefore, the goal of ST is to change the EMSs and schema modes (Nysæter & Nordahl, 2008; Sempértegui et al., 2013; Young et al., 2003). As EMSs develop when basic childhood needs are not met, there might be a strong etiological link with childhood trauma (CT). In addition, CT is also an important etiological factor for BPD. Therefore, CT might be an important factor related to treatment outcomes. In general, we can divide CT into five types: physical, sexual and emotional abuse, and physical and emotional neglect. Early research mainly focussed on sexual and physical abuse, and both experiences are prevalent amongst BPD patients (Herman et al., 1989; Zanarini et al., 2006) compared to non-clinical controls (Lobbestael et al., 2005). It has also been shown that children who were abused and neglected had a higher chance of developing BPD as adults (Widom et al., 2009). While most studies support the relationship between CT and BPD, this is not found in all studies (Stepp et al., 2016). However, a recent meta-analysis suggested that patients with BPD are 13 times more likely to experience CT compared to non-clinical controls, due to a higher prevalence of mainly emotional abuse and neglect (Porter et al., 2020). Exposure to childhood adversities is also related to a higher severity of BPD complaints. For example, when the three types of childhood abuse (i.e., physical, emotional, sexual) were examined, it was found that only emotional abuse was related to a higher BPD severity (Bornavalova et al., 2006). In two studies where all five types of CT were examined, sexual and emotional abuse, and emotional neglect positively predicted BPD severity (Kuo et al., 2015; Lobbestael et al., 2010). Moreover, an examination of all five CT types indicated that emotional abuse and neglect were associated with more emotion regulation difficulties in BPD patients (Carvalho Fernando et al., 2014). These findings suggest that CT is related to BPD severity and there are indications that especially emotional abuse and neglect and sexual abuse play an important role. However, many studies fail to include or test the five childhood trauma types. This can bias the results as the presence of other CT types is not controlled for. In addition to CT, another factor of interest in relationship with BPD outcomes is dissociation. Dissociation is thought to be strongly related to psychological trauma (Vermetten & Spiegel, 2014) and BPD. For example, emotional abuse and neglect, and physical neglect were found to be positively related to dissociation in BPD (Watson et al., 2006), although not all studies have supported the relationship between CT and dissociation (Johnston et al., 2009). Dissociation also has a strong link with BPD (Scalabrini et al., 2017a) and a meta-analysis concluded that levels of dissociation in BPD patients are similar to those in patients with PTSD (Scalabrini et al., 2017b). While it is unclear if dissociation is a direct consequence of CT, it is likely related to CT. In addition, dissociation might have a negative influence on treatment effectiveness as it has a negative effect on the processing of information during treatment (Arntz et al., 2015). Therefore, dissociation might be an interesting additional construct related to treatment outcomes. One previous study has examined CT and dissociation as predictors of treatment outcomes of Transference-Focused-Psychotherapy (TFP) compared to individual ST (Arntz et al., 2015). The authors showed that physical abuse predicted a higher chance of treatment discontinuation and dissociation predicted worse treatment outcomes. Interestingly, when patients had high levels of dissociation, ST was more effective compared to TFP. Moreover, the dropout and recovery were better in ST compared to TFP. An explanation for this finding might be the stronger focus on trauma processing during individual ST, which is a unique feature (Arntz & van Genderen, 2020), and the ability of therapists to deal with dissociation during sessions. However, ST is now often offered in group formats with no or limited additional individual sessions. This is more efficient, but it does not leave much room for individual trauma processing and perhaps effectively dealing with dissociation. In a recent trial, combined individual and group ST (IGST; fifty-fifty proportion of individual vs group), predominantly group ST (PGST; group-ST with a very limited number of individual ST), and optimal treatment as usual (TAU) were compared. The focus of individual ST on trauma processing was an important argument to add individual sessions to the group treatment format (Wetzelaer et al, 2014; Arntz et al, 2022). The findings showed that both ST variants combined were superior to TAU in decreasing general BPD severity. In addition, the combined ST format was more effective compared to PGST and TAU, whereas PGST did not differ from TAU (Arntz et al., 2022). This raises the question if exposure to CT and dissociation differentially influence the effectiveness of different ST formats (combined/individual formats vs. group). Therefore, the aim of the present study is to examine whether CT and dissociation moderate the effectiveness (as defined by improvements in BPD severity and dropout) of different treatment formats (combined individual formats vs. group). We will also exploratively examine the same research question for each of the separate CT types (i.e., physical, emotional and sexual abuse, physical and emotional neglect).

Posttraumatic Stress Disorder (PTSD) has traditionally been associated with fear. The primary focus on fear is also reflected by the origins of the disorder. PTSD first came to light in soldiers who experienced a range of stress and fear symptoms in response to the horrific experiences they were exposed to in war. This often-misunderstood condition, which can be seen as an important predecessor of PTSD, was referred to as shell shock (Shively & Perl, 2012). It was not until the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) that the term PTSD was officially introduced as a psychiatric classification (American Psychiatric Association (APA), 1980). However, since its introduction in the DSM-III, many changes and adjustments have been made. For example, in contrast to earlier versions, the current DSM-5 criteria no longer state that patients have to experience a specific (often fearful) emotion in direct response to a traumatic experience. In addition, a new criterium (i.e., D4) was added. This criterium, which belongs to the D category in which alterations in cognitions and mood are described, states that: “patients experience negative emotions, such as anger, guilt or shame” (APA, 2013). Together, these changes illustrate a possible shift from a primary emphasis on fear to the acceptance of the role of other emotions. The idea that other emotions than fear might also play a role in PTSD is supported by the literature. For example, patients often experience a wide range of emotions in response to trauma, such as sadness and anger (Grey & Holmes, 2008). Both these emotions have also been associated with the severity of PTSD complaints (Lancaster, Melka & Rodriguez, 2011; Orth & Wieland, 2006). In addition, disgust has also been related to PTSD (Engelhard, Olatunji & de Jong, 2011). Two important emotions in particular which have been studied extensively in relation to PTSD are shame and guilt. Both shame and guilt have been found to predict the severity of PTSD symptoms (Beck et al, 2011; Robinaugh & McNally, 2010; Saraiya & Lopez-Castro, 2016). While these studies suggest that shame and guilt play an equally important role, other studies suggest a greater importance of shame compared to guilt (Leskela, Dieperink & Thuras, 2002). Based on these studies, we can conclude that the literature supports the idea that PTSD patients not only experience fear, but many other emotions as well. A group of PTSD patients for whom other emotions than fear might be especially relevant are patients with Childhood-related PTSD (Ch-PTSD). This so-called subtype refers to PTSD that develops in response to childhood experiences. Although the nature of these childhood experiences varies, they are often interpersonal, and they are thought to trigger a complex combination of emotions and symptoms (e.g., Briere, Kaltman & Green, 2008). Indeed, interpersonal trauma has been strongly connected to the experience of the newly added D4 criterion (Badour, Resnick & Kilpatrick, 2017). So, if these emotions are related to the severity of PTSD, they possibly also play an important role in its development. Interestingly, two studies showed that changes in PTSD related cognitions (e.g., self-blame) predicted reductions in PTSD symptoms in prolonged exposure therapy and not the other way around (Cooper, Zoellner, Roy-Byrne, Mavissakalian & Feeny, 2017; Zalta et al., 2014). In another study that investigated the predictive value of shame and guilt, two treatments were combined: Imagery Rescripting (ImRs) and Imaginal exposure (Øktedalen, Hoffart & Langkaas, 2015).The results showed that shame and guilt were predictive of the change in PTSD symptoms at each subsequent treatment session, whereas the reverse was not found. To our knowledge, no other comparable studies focusing on other emotions (e.g., anger and disgust) have been conducted. These findings indeed suggest that emotions other than fear might serve as central change processes during treatment and that specifically targeting these emotions in treatment might thus help improve treatment effectiveness. Therefore, the aim of the present study will be to examine the relationships between specific emotions (i.e., shame, guilt, anger and disgust) and PTSD symptom severity in time during the treatment of Ch-PTSD with EMDR or ImRs. Our research question will be tested based on two different sets of time comparisons. We will test the time varying relationships between these emotions and PTSD symptoms on a session-by-session and assessment-by-assessment basis. We will use data from the IREM study (Boterhoven de Haan et al., 2017), a recently completed Randomized Controlled Trial (RCT) in which two treatments for Ch-PTSD are compared: EMDR and ImRs.

Posttraumatic Stress Disorder (PTSD) that develops after traumatic events in childhood is also referred to as Childhood-related PTSD (Ch-PTSD). Ch-PTSD is related to a high symptom severity and complexity (Agorastos et al., 2014; Briere et al., 2008), but there are effective treatment options available. These treatments can be categorized into trauma-focused treatment (TFT) and non-TFT. Compared to non-TFT, TFT has been found to be more effective (Ehring et al., 2014). Two promising TFTs for the treatment of (Ch-)PTSD are Eye Movement Desensitization and Reprocessing (EMDR) and the relatively new Imagery Rescripting (ImRs). The present study will focus on studying the underlying working mechanisms of these two treatments. During EMDR, the therapist conducts bilateral stimulation, often by making rapid horizontal finger movements that patients have to follow with their eyes. At the same time, patients keep a traumatic memory in mind. As both tasks are performed simultaneously and are taxing for the working memory (WM), the negative valence and vividness of the traumatic memory are thought to decrease (Van den Hout & Engelhard, 2012). This has been supported by research conducted in non-clinical settings (Leer et al., 2014; van den Hout et al., 2013). In contrast, during ImRs, traumatic memories are rescripted by imagining a different and positive outcome that meets the needs of the patient. This process is thought to facilitate change in schemas and core cognitions, which in turn leads to a decrease in PTSD symptoms (Arntz & Weertman, 1999; Arntz, 2012; Arntz, Tiesema & Kindt, 2007). Studies have indeed shown that after one ImRs session, the strength of core beliefs, but also the negative valence of traumatic memories, decreased (Çili et al., 2017; Lee & Kwon, 2013). Interestingly, not all studies support the idea that changes in the vividness (or negative valence) are unique to EMDR. While in two studies the vividness of the memory did not change (Çili et al., 2017; Lee & Kwon, 2013), other studies found that the vividness and negative valence of traumatic memories also decreased after one ImRs session (Nilsson et al., 2012, 2019; Wild et al., 2007). Similarly, EMDR might also influence the strength of encapsulated beliefs, as during EMDR, negative cognitions are also identified, and the strength of positive cognitions is increased. It would not be plausible to expect that both mechanisms, changes in vividness and encapsulated belief strength, are unique to both treatments. Both treatments will influence changes in the negative valence and vividness of traumatic memories and the strength of the encapsulated beliefs. This is also supported by findings from the literature. However, based on the theories underlying both treatments, it is more likely that EMDR has primarily a positive effect on PTSD symptoms via changes in the vividness of traumatic memories, while ImRs is thought to primarily change encapsulated beliefs. In addition, as both treatments have a positive effect on PTSD symptoms, both treatments will likely not differ in their positive influence on the negative valence of traumatic memories. To our knowledge, a direct comparison of the change mechanisms of EMDR and ImRs has not yet been conducted. For this reason, the aim of the present study is to examine the underlying change mechanisms of EMDR and ImRs in patients with Ch-PTSD. This will be the first study to focus on this patient population who receive 12 sessions EMDR or ImRs. Many studies described above focusing on EMDR and ImRs were laboratory studies. However, it is important to also study the effects of a complete treatment according to the full protocol, which are not always fully used in experimental studies. First, we will test if the mean change in the vividness, negative valence and encapsulated belief strength between the treatment outcome assessments differs between EMDR and ImRs (see hypothesis section below). Second, we will study if the strength of the relationship between changes in the vividness, negative valence and encapsulated belief strength and PTSD symptoms differs between the two treatments. Third, an additional aim of the present study will be to study if changes in these mediators predict changes in PTSD symptoms at the next assessment (and vice versa). This will allow us to gain insight into the change patterns over time between these mediators and PTSD symptoms during trauma-focused treatment (i.e., is there a reciprocal relationship or do changes in one (e.g., vividness) precede the other).

Post-Traumatic Stress Disorder (PTSD) develops in response to traumatic experiences, such as sexual or physical abuse. Diagnosis is based on the A-criterion, which states that “The person was exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence” (American Psychiatric Association, 2013). However, findings from several studies suggest that some types of experiences that do not satisfy the A-criterion are also related to PTSD. Patients with PTSD, especially childhood-related PTSD, have often experienced a wide range of negative childhood experiences. Cumulative traumas are related to a more severe presentation of PTSD and increased symptom complexity ((Briere, Agee & Dietrich, 2016; Briere, Kaltman & Green, 2008). Many studies examined the relationship between trauma frequency and PTSD severity for trauma types that satisfy the A criterion. For example, childhood sexual abuse and physical abuse are related to anxiety disorders and PTSD (Briere, Kaltman & Green, 2008; Cougle, Timpano, Sachs-Ericsson, Keough & Riccardi, 2010). However, these effects are also found for other trauma types. For example, Pederson, and Wilson (2009) found that severe emotional neglect in childhood was related to a higher PTSD severity compared to low emotional neglect. Emotional maltreatment has also been found to be related to trauma symptoms (English, Thompson, White & Wilson, 2015). Lastly, Sullivan, Fehon, Andres‐Hyman, Lipschitz, and Grilo, (2006) found that emotional and sexual abuse were predictive of PTSD symptom clusters and overall PTSD among hospitalised adolescents. Thus, there appear to be several types of negative childhood experiences that might play a role in PTSD. The aim of the present study is to examine the unique relationship between five different early trauma types (i.e., sexual abuse, physical abuse, emotional abuse, physical neglect and emotional neglect) and the severity of PTSD complaints in a sample of adult patients with childhood-related PTSD – thus in patients who experienced trauma in the DSM-5 definition. We might also explore these relationship for the separate PTSD clusters. We will test all these predictors simultaneously, but we are mostly interested in which trauma types remain after a model selection procedure. This study is important to replicate earlier studies and to explore the differential impact of negative childhood experiences on PTSD even further.

This project contains the data that we used in our meta-analysis on the effectiveness of treatments for Borderline Personality Disorder (BPD). The attached excel file contains an overview of the included studies, outcomes, domains and effect sizes (and related statistics).

Background: Academic research on deception detection has largely focused on the detection of past events. For many applied purposes, however, the detection of false reports about someone's intention merits attention. Based on the verbal deception detection paradigm, we explored whether true statements on intentions were more detailed and more specific than false statements on intentions, particularly when instructed to be as specific as possible.Method: Participants (n = 222) lied or told the truth about their upcoming travel plans either providing 'as much information as possible’ (standard instructions) or being 'as specific as possible’ (i.e., mentioning times, locations, places; specific instructions), resulting in four conditions (truthful vs. deceptive intention by standard instructions vs. specific instructions). We collected data via a custom-made web app and performed automated verbal content analysis of participants’ written answers.Findings: We did not find a significant difference in participants’ statements specificity. The instruction to be as specific as possible promoted more specific information but did not help to discern honest from deceptive flying intentions. Conclusion: The experiment reported here attempted to demonstrate automated detection of verbal deception of intentions. The difficulty in capturing genuine, intentions, and the non-intrusive, non-interactive questioning approach might explain the null findings and raise questions for further research towards large-scale applicability. We conclude with suggestions for a novel framework on semi-interactive information elicitation.

Additional file 1.

Additional file 2.Interview therapists..

Additional file 3. Overview of syndrome disorders assessed with the SCID-5-S.

"A proportion of those with eating disorders have also experienced traumatic events and ongoing symptoms of PTSD such as re-experiencing of the trauma and nightmares. We implemented an innovative trauma intervention called Imagery Rescripting (ImRs) to explore whether for those undergoing inpatient treatment for an eating disorder (in an underweight phase), it would be possible to treat the various trauma-related symptoms as well as the eating problems. Since this has not been investigated before, we asked the participants in this study to recount their experiences. Twelve participants who were underweight, reported a past history of trauma and were in an inpatient eating disordertreatment program participated in ImRs therapy intervention. One of these participant did not engage in the ImRs therapy because she discontinued the inpatient ED treatment. Analysis of interviews with these participants found that -although they were reluctant before the start of the treatment- the ImRs treatment during their inpatient admission had given them hope again. They added that it was important to have support from group members, sociotherapists and therapists. They shared a number of ways that the ImRs treatment could be adapted to people with eating disorders. Their experiences indicated that given these factors it was possible to treat PTSD during an underweight phase. This is important: until now, treatment for eating disorders has not specifically been trauma-focused and these tips have scope to improve the ImRs intervention and eating disorder treatment more broadly in the future."

Additional file 4. Candidate predictors based on clinicians��� appraisals (Table 1) and candidate predictors based on the literature and suggestions of a patient representative of the Borderline Foundation of the Netherlands (Table 2).

Additional file 1: Sample size calculation for multicentre RCT on GST for BPD. (PDF 152 KB)

Additional file 1.Interview patients.

Additional file 2. Informed consent form (Appendix A) and additional informed consent form videoconferencing (Appendix B).

Background: Guilt and shame regulate basic human processes such as social cognition and relations. Both emotions are also involved in the aetiology and maintenance of trauma-related mental disorders such as posttraumatic stress disorder (PTSD). However, a concise scale that adequately captures these constructs is currently lacking, impeding research efforts to understand them more thoroughly. Objective: To this end, we developed the eight-item Guilt and Shame Questionnaire (GSQ-8) in English, German, and Dutch. Method: We examined the reliability and validity of the GSQ-8 in a clinical sample of adults seeking treatment for childhood-trauma-related posttraumatic stress disorder (n = 209), a sample of adults who had suffered at least one traumatic life event reporting different levels of PTSD symptoms (n = 556), and a non-clinical sample of adults (n = 156). Results: Theory-driven confirmatory factor analyses confirmed two correlated latent factors guilt and shame with four items for each factor. Across all samples, two-factor models yielded better model fit than one-factor solutions. Measurement invariance across the three samples, gender, and Dutch and German language was mostly established. Guilt and shame composite scores were associated with PTSD symptoms, depressive symptoms, life satisfaction, mental health-related quality of life, and self-blame, thus supporting scale validity. Importantly, both subscales predicted PTSD symptoms, depression, life satisfaction, and mental health-related quality of life over and above cognitions of self-blame. Conclusions: The GSQ-8 is a parsimonious, reliable, and valid tool to assess guilt and shame in clinical, sub-clinical, and non-clinical populations, allowing applications across a broad range of research questions. We present the 8-item Guilt and Shame Questionnaire (GSQ-8), a parsimonious tool to assess guilt and shame.We found strong psychometric properties of the GSQ-8 across three samples and different languages.The GSQ-8 can be reliably used to assess shame and guilt in clinical and non-clinical work. We present the 8-item Guilt and Shame Questionnaire (GSQ-8), a parsimonious tool to assess guilt and shame. We found strong psychometric properties of the GSQ-8 across three samples and different languages. The GSQ-8 can be reliably used to assess shame and guilt in clinical and non-clinical work.

Additional file 1.

Borderline personality disorder (BPD) has a core embodied in affective and behavioral dysregulations, impulsivity, and relational disturbance. Clinical presentation might be heterogeneous due to a combination of different symptoms listed in the DSM-5. Clinical diagnosis and assessment of the severity of manifestations might be improved through the administration of structured interviews such as the Borderline Personality Disorder Severity Index, 4th edition (BPDSI-IV). The psychometric properties of the Italian version of the BPDSI-IV were examined for the first time in 248 patients affected by BPD and 113 patients affected by bipolar disorder, proving to be a valid and accurate instrument with good internal consistency and high accuracy. The Italian version also demonstrates significant validity in the discrimination between these clinical groups (p < 5001).

Supplemental Material, SupplementaryMaterial_Kunze2019_JEP for Investigating the effects of imagery rescripting on emotional memory: A series of analogue studies by Anna E. Kunze, Arnoud Arntz and Merel Kindt in Journal of Experimental Psychopathology

Supplemental material, Supplementary_Material for Specialized psychotherapies for adults with borderline personality disorder: A systematic review and meta-analysis by Matthijs Oud, Arnoud Arntz, Marleen LM Hermens, Rogier Verhoef and Tim Kendall in Australian & New Zealand Journal of Psychiatry

There is an increasing demand for automated verbal deception detection systems. We propose named entity recognition (NER; i.e., the automatic identification and extraction of information from text) based on three established theoretical principles: (i) truth-tellers provide accounts that are richer in detail, (ii) contain more contextual references (specific persons, locations, and times), and (iii) liars tend to withhold potentially checkable information. We test whether NER captures these theoretical concepts and can automatically identify truthful vs. deceptive hotel reviews. We extracted the proportion of unique named entities and compared its discriminative ability to a lexicon word count approach (LIWC) and a competing measure of sentence specificity (speciteller). Named entities discriminated truthful from deceptive hotel reviews and outperformed the lexicon approach by LIWC and sentence specificity by speciteller in diagnostic efficiency. This investigation suggests that named entities may be a useful addition to existing automated verbal deception detection approaches.

Mutual Agreement IREM Study. The mutual agreement endorsed by each of the participating sites outlining the roles and responsibilities of each university representative and site coordinator. The mutual agreement also includes the study timeline and planned publications. Appendix 2. World Health Organization Trial Registration Data Set. WHO Trial Registration Data Set completed to support SPIRIT Guidelines Checklist. Appendix 3. Consent form example. An example of the consent form that will be given to participants to read and sign to ensure informed consent. Appendix 4. Additional items added to the Impact of Events Scale Revised (IES-R). Four items that were added to the IES-R to assess trauma-related guilt, anger, disgust, and shame. Appendix 5. Additional items added to the Life Events Checklist (LEC-5). Additional items have been added to the LEC-5 to assess emotional abuse/neglect and physical neglect. (DOCX 136Â kb)

Treatment rationale of imaginal exposure (IE) and imagery rescripting (IR) for nightmares. (PDF 67 kb)

SPIRIT flow diagram. (PDF 143 kb)

SPIRIT 2013 checklist. (PDF 121 kb)

SPIRIT checklist. (PDF 160 kb)

Children and adolescents with Autism Spectrum Disorder (ASD) show difficulties in social interaction and communication. This thesis explored the desire for social interaction in youth with ASD. The results were mixed. A potential explanation for these mixed results is that the desire for social interaction in ASD might be context-related. Additionally, other variables like social skills and social anxiety might play a role. The desire for social interaction in children and adolescents with ASD deserves more attention at a scientific level, but also on the individual level. In clinical practise social skills training is often applied for children with ASD. This thesis investigated the effectiveness of this kind of intervention for children with ASD. The results showed that participation in group social skills training improved the social skills and this generalized to the home and school setting.

Behavioral activation is a relatively new psychological treatment that could be a viable alternative and effective treatment for people with major depressive disorder. The findings of this thesis show that those participants who preferred psychological treatment for treatment of depression, might be benefitting more from behavioral activation than antidepressant medication. The drop out of the treatment was higher for the group that preferred psychological treatment, but at the same time received antidepressant medication. To implement behavioral activation in clinical settings is easier than cognitive behavioral therapy. It can be disseminated by mental health professionals with short-term training. Behavioral activation treatment might be a very cost-effective intervention for depression.

In forensic psychiatry, it is important to carefully assess the recidivism risk of patients going on leave or being released. This is complicated work, because the wrong assessment can have serious consequences for society. In this research we looked for cognitive predictors of aggressive behaviour that could be assessed in a reliable way using computer tasks. We found that measuring cognitive processes (e.g. attention, emotion recognition, interpretation) helps predict aggressive behaviour. In the future these cognitive tasks can possibly be used to support current risk assessment in forensic psychiatry.