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Background: Childhood maltreatment (CM) is a risk factor for developing and maintaining depression. It is unclear whether CM influences the effect of treatments for depression. This study examined CM's predictor and moderator effect in Behavioral Activation (BA) and Metacognitive Therapy (MCT)., Method: CM was analyzed in a trial comparing a six months treatment program of either BA or MCT for 122 outpatients with major depressive disorder (MDD). Depression was assessed by the Hamilton Rating Scale for Depression (HRSD-24). CM was assessed using the Childhood Trauma Questionnaire (CTQ)., Results: Linear mixed models showed no predictor or moderator effects for the CTQ total score (all p > .58) but revealed a moderator effect for 'sexual abuse' on the reduction of depressive symptoms (β = 10.98, SE = 4.48, p = .015) indicating that patients with experiences of childhood sexual abuse benefited more from BA. There also was a predictor effect for 'physical neglect' (β = -3.35, SE = 1.70, p = .049): patients without the experience of physical neglect benefited more from treatment regardless of condition. Exploratory analyses indicated no predictor or moderator effects for the onset or persistence of depression, comorbid anxiety disorders or Cluster-C PDs (all p > .28)., Limitations: Limitations include small sample sizes for some of the subsamples., Conclusion: Childhood sexual abuse seems to moderate treatment effectiveness in a sample of severely affected outpatients with MDD treated with MCT or BA. If confirmed in further trials, a history of sexual abuse might guide the choice between MCT and BA., Trial Registration: German Clinical Trials Register DRKS-ID: DRKS00011536 (retrospectively registered on February 13, 2017, without changes to the study protocol)., Competing Interests: Declaration of competing interest EF and JPK have provided training or published books on Depression, MCT, or BA. The remaining authors declare that the research was conducted without commercial or financial relationships construed as a potential conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

We studied the mechanisms of eye movement desensitization and reprocessing (EMDR) and imagery rescripting (ImRs). We hypothesized that EMDR works via changes in memory vividness, that ImRs works via changes in encapsulated beliefs (EB), and that both treatments work via changes in memory distress. Patients (N = 155) with childhood-related posttraumatic stress disorder (Ch-PTSD) received 12 sessions of EMDR or ImRs. The vividness, distress, and EB related to the index trauma were measured with the Imagery Interview. PTSD severity was assessed with the Impact of Events Scale-Revised and the Clinician-Administered PTSD Scale for DSM-5. We conducted mixed regressions and Granger causality analyses. EMDR led to initially stronger changes in all predictors, but only for distress this was retained until the last assessment. No evidence for vividness as a predictive variable was found. However, changes in distress and EB predicted changes in PTSD severity during ImRs. These findings partially support the hypothesized mechanisms of ImRs, while no support was found for the hypothesized mechanisms of EMDR. Differences in the timing of addressing the index trauma during treatment and the timing of assessments could have influenced the findings. This study provides insight into the relative effectiveness and working mechanisms of these treatments., Competing Interests: Declaration of competing interest A. Arntz publishes scientific articles and book chapters about ImRs, and occasionally gives workshops. The financial remuneration received go to the university to support research. C. W. Lee reports grants and receives personal fees from Psychology Training. E. Fassbinder gives workshops and lectures on ImRs and PTSD treatment and received personal fees and grants. There are no other conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The relationship between trauma-related negative cognitions and post-traumatic stress disorder (PTSD) symptoms has been studied frequently. Several studies found a mediating effect of trauma-related negative cognitions on symptom reduction in studies on different psychotherapeutic treatments, however, this relationship has never been studied in imagery rescripting (ImRs) or eye movement desensitization and reprocessing (EMDR). Objective: To analyse the role of trauma-related negative cognitions in the treatment of PTSD due to childhood trauma with EMDR and ImRs. Method: N  = 155 patients with PTSD due to childhood trauma aged between 18 and 65 ( M  = 38.54) participated in a randomized clinical trial and were treated with either EMDR or ImRs in Australia, Germany, and the Netherlands between October 2014 and June 2019. We analysed the relationship between PTSD symptoms (Clinician-administered PTSD Scale for DSM-5, CAPS-5 and Impact of Event Scale revised; IES-R, completed twice for index trauma and for all other traumas) and trauma-related negative cognitions (Post-Traumatic Cognitions Inventory, PTCI) using Granger Causality analyses with linear mixed models on person-centered variables. Assessments were conducted pre-treatment, post-treatment (12 sessions in 6 weeks), eight weeks post-treatment, and one year after the pre-treatment assessment. Results: Changes in negative cognitions (PTCI) preceded changes in PTSD symptoms (unidirectional) as measured by the CAPS and the IES-R for index trauma. For the IES-R related to all other traumas, a unidirectional relationship was found in which changes in PTSD symptoms preceded changes in negative cognitions. No moderating effect of treatment was found. On the level of PTCI subscales only changes in cognitions about oneself preceeded changes in PTSD symptoms. Conclusions: The results support the idea of a general role of trauma-related negative cognitions in the treatment of PTSD. The analyses should be replicated with a higher frequency of assessments.

Introduction: In the treatment of borderline personality disorder (BPD), there is empirical support for both dialectical behavior therapy (DBT) and schema therapy (ST); these treatments have never been compared directly. This study examines whether either of them is more effective than the other in treating patients with BPD., Methods: In this randomized, parallel-group, rater-blind clinical trial, outpatients aged between 18 and 65 years with a primary diagnosis of BPD were recruited in a tertiary outpatient treatment center (Lübeck, Germany). Participants were randomized to DBT or ST with one individual and one group session per week over 1.5 years. The primary outcome was the BPD symptom severity assessed with the mean score of the Borderline Personality Disorder Severity Index at 1-year naturalistic follow-up., Results: Between November 26, 2014, and December 14, 2018, we enrolled 164 patients (mean age = 33.7 [SD = 10.61] years). Of these, 81 (49.4%) were treated with ST and 83 (50.6%) with DBT, overall, 130 (79.3%) were female. Intention-to-treat analysis with generalized linear mixed models did not show a significant difference at 1-year naturalistic follow-up between DBT and ST for the BPDSI total score (mean difference 3.32 [95% CI: -0.58-7.22], p = 0.094, d = -24 [-0.69; 0.20]) with lower scores for DBT. Pre-to-follow-up effect sizes were large in both groups (DBT: d = 2.45 [1.88-3.02], ST: d = 1.78 [1.26-2.29])., Conclusion: Patients in both treatment groups showed substantial improvements indicating that even severely affected patients with BPD and various comorbid disorders can be treated successfully with DBT and ST. An additional non-inferiority trial is needed to show if both treatments are equally effective. The trial was retrospectively registered on the German Clinical Trials Register, DRKS00011534 without protocol changes., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Sudden gains, defined as large and stable improvements in symptom severity during psychological treatment, have consistently been found to be associated with better outcomes across treatments and diagnoses. Yet, insights on coherent predictors of sudden gains and on emotional changes around sudden gains in post-traumatic stress disorder (PTSD) are lacking. We aimed at replicating a measure of intraindividual variability as a predictor for sudden gains and testing its independence from change during treatment. Furthermore, we expected changes in emotions of guilt, shame and disgust prior to sudden gains to predict sudden gains. Data from a pre-registered randomized controlled trial (RCT) of eye-movement desensitization and reprocessing (emdr) and Imagery Rescripting (ImRs) for PTSD in 155 adult survivors of childhood abuse were used. Intraindividual variability of PTSD symptoms in both treatments did not predict sudden gains status and was not independent of change during treatment. In the EMDR condition, levels of shame during treatment predicted sudden gains and shame decreased shortly before a sudden gain in both treatments. Reductions in all emotions during sudden gains were significantly higher for participants with sudden gains than for comparable intervals in non-sudden gainers. Our findings do not support the predictive validity of intraindividual variability for sudden gains. The decrease of guilt, shame and disgust during sudden gains warrants further research on their role as a mechanism of treatment change for PTSD., (© 2023 The Authors. Clinical Psychology & Psychotherapy published by John Wiley & Sons Ltd.)

Objective: Chairwork is one of the core experiential techniques of Schema Therapy (ST) which is used in the treatment of patients with borderline personality disorder (BPD). However, little is known about how people with BPD experience chairwork. The aim of this study was to explore the experiences of patients with BPD with chairwork in ST., Method: Qualitative data were collected through semi-structured interviews with 29 participants with a primary diagnosis of BPD who experienced chairwork as part of their ST treatment. The interview data were analyzed using qualitative content analysis., Findings: Many participants reported initial skepticism, and difficulties with engaging in chairwork. Specific therapist behaviors as well as some external (e.g., restricted facilities, noise) and internal factors (especially feeling ashamed or ridiculous) were named as hindering factors. Participants described several therapist behaviors facilitating chairwork such as providing safety, clear guidance through the process as well as flexible application of the technique according to their needs, and sufficient time for debriefing. Participants experienced emotional pain and exhaustion as short-term effects of the technique. All participants reported positive long-term effects including an improved understanding of their mode model as well as positive mode changes (e.g., less Punitive Parent and more Healthy Adult Mode), greater self-acceptance, improvements in coping with emotions and needs as well as improvements in interpersonal relationships., Conclusions: Chairwork is experienced as an emotionally demanding but valuable technique. Based on the participants' statements, the delivery of chairwork can be optimized which can help to improve treatment outcome., Competing Interests: AA reported receiving grants from the Netherlands Organization for Health Research and Development and Netherlands Foundation for Mental Health, and receiving other grants outside the submitted work from Netherlands' Organization for Scientific Research (NWO), Netherlands Organization for Health Research and Development (ZONMW), Stichting Achmea Gezondheidszorg, CZ Fonds, Stichting Volksbond Rotterdam, and Stichting tot Steun VCVGZ; receiving royalties (paid to the university) from Academic Press, American Psychological Association Press, Beltz, Bohn Stafleu van Loghum, Boom Uitgevers, Cambridge University Press, Context Press, Guilford, De Tijdstroom, Oxford University Press, SAGE Publications, Uitgeverij Nieuwezijds, Wiley; providing workshops and lectures on cognitive behavioral therapy (CBT), imagery rescripting, personality disorders, schema therapy, and small-scale research in clinical practice (remuneration to the university) for the BABCP, Bulgarian Association for CBT, Clinical Academic Group for Psychotherapy Denmark, Danish Competence Center for Psychotherapy, EABCT, ECNP, ESSPD, Estonian CBT Association, German Psychosomatic Congress, GGZ InGeest, Greek CBT Association, ICCP, Institut für Schematherapie Frankfurt, ISC International, ISSPD, ISST, Jellinek, Kenniscentrum Persoonlijkheidsstoornissen, Leiden University Medical Center, Lemion, Moroccan Association of CBT, Norwegian Psychological Association, Parnassia/PsyQ, Polish Association for Cognitive and Behavioral Therapies, Portuguese Association of Behavior Therapy, Psyflix, SCEM, Scuole APC-SPC-SICC-IGB-AIPC, Tunisian Association of CBT, Turkish Association for Cognitive & Behavioral Psychotherapies, Ukraine Association for CBT, Ukraine Institute for CBT, University of Bordeaux, VGCT, VST, WCBCT; supervising research at the mental health institute PsyQ (remuneration to the University of Amsterdam); and being chair of the board of the PDO foundation, North Holland postgraduate training institute (unpaid). NA provided workshops on schema therapy (Institut für Schematherapie Hamburg). EF reported receiving grants for the PROBPD study from the Else Kröner-Fresenius-Stiftung and the University of Lübeck, and grants outside the submitted work from Addisca GmbH; receiving royalties from Beltz Verlag and Elsevier Books; receiving personal fees from supervision in schema therapy and group schema therapy and from workshops and presentations on CBT, imagery re-scripting, personality disorders, schema therapy, and behavioral activation for Ausbildungsinstitut für Verhaltenstherapie und Verhaltensmedizin Hannover, Arbeitsgemeinschaft Wissenschaftliche Psychotherapie Berlin, the DGPPN, IPAM Marburg, IFT-Nord Institut für Therapie- und Gesundheitsforschung gemeinnützige GmbH Kiel, IPP Halle, Institut für Schematherapie Hamburg, Institut für Schematherapie Köln, Institut für Schematherapie Berlin, Oberberg Kliniken, and the WCBCT; and being co-chair of the Deutscher Fachverband für Verhaltenstherapie eV (unpaid) and member of the board of the Gesellschaft zur Erforschung und Therapie von Persönlichkeitsstörungen (GePs) e.V. US received royalty fees from Beltz, Herder, Hogrefe, Kohlhammer, and Springer; fees for workshops for Institutes associated with the Deutsche Fachverband für Verhaltenstherapie on psychotherapy topics; and was Vice President of the Deutsche Fachverband für Verhaltenstherapie (no honorarium). AS reported receiving a grant from the University of Lübeck and receiving royalties for published articles or chapters on schema therapy and imagery rescripting as well as receiving personal fees from supervision and workshops (Institut für Schematherapie Hamburg) for schema therapy and imagery re-scripting. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Josek, Schaich, Braakmann, Assmann, Jauch-Chara, Arntz, Schweiger and Fassbinder.)

Introduction: Major depressive disorder (MDD) is a highly prevalent and disabling disorder. This study examines two psychotherapy methods for MDD, behavioral activation (BA), and metacognitive therapy (MCT), when applied as outpatient treatments to severely affected patients., Methods: The study was conducted in a tertiary outpatient treatment center. Patients with a primary diagnosis of MDD (N = 122) were included in the intention-to-treat sample (55.7% female, mean age 41.9 years). Participants received one individual and one group session weekly for 6 months (M). Assessments took place at baseline, pretreatment, mid-treatment (3 M), post-treatment (6 M), and follow-up (12 M). The primary outcome was depressive symptomatology assessed by the Hamilton Rating Scale for Depression at 12 M follow-up. Secondary outcomes included general symptom severity, psychosocial functioning, and quality of life., Results: Linear mixed models indicated a change in depressive symptoms (F(2, 83.495) = 12.253, p < 0.001) but no between-group effect (F(1, 97.352) = 0.183, p = 0.670). Within-group effect sizes were medium for MCT (post-treatment: d = 0.610; follow-up: d = 0.692) and small to medium for BA (post-treatment: d = 0.636, follow-up: d = 0.326). In secondary outcomes, there were improvements (p ≤ 0.040) with medium to large within-group effect sizes (d ≥ 0.501) but no between-group effects (p ≥ 0.304). Response and remission rates did not differ between conditions at follow-up (response MCT: 12.9%, BA: 13.3%, remission MCT: 9.7%, BA: 10.0%). The deterioration rate was lower in MCT than in BA (χ21 = 5.466, p = 0.019, NTT = 7.4)., Discussion: Both MCT and BA showed symptom reductions. Remission and response rates were lower than in previous studies, highlighting the need for further improvements in adapting/implementing treatments for severely affected patients with MDD., (© 2022 S. Karger AG, Basel.)

Borderline personality disorder (BPD) is a severe mental disorder, comprised of heterogeneous psychological and neurobiological pathologies. Here, we propose a predictive processing (PP) account of BPD to integrate these seemingly unrelated pathologies. In particular, we argue that the experience of childhood maltreatment, which is highly prevalent in BPD, leaves a developmental legacy with two facets: first, a coarse-grained, alexithymic model of self and others - leading to a rigidity and inflexibility concerning beliefs about self and others. Second, this developmental legacy leads to a loss of confidence or precision afforded beliefs about the consequences of social behavior. This results in an over reliance on sensory evidence and social feedback, with concomitant lability, impulsivity and hypersensitivity. In terms of PP, people with BPD show a distorted belief updating in response to new information with two opposing manifestations: rapid changes in beliefs and a lack of belief updating despite disconfirmatory evidence. This account of distorted information processing has the potential to explain both the instability (of affect, self-image, and interpersonal relationships) and the rigidity (of beliefs about self and others) which is typical of BPD. At the neurobiological level, we propose that enhanced levels of dopamine are associated with the increased integration of negative social feedback, and we also discuss the hypothesis of an impaired inhibitory control of the prefrontal cortex in the processing of negative social information. Our account may provide a new understanding not only of the clinical aspects of BPD, but also a unifying theory of the corresponding neurobiological pathologies. We conclude by outlining some directions for future research on the behavioral, neurobiological, and computational underpinnings of this model, and point to some clinical implications of it.

According to previous research, borderline personality disorder (BPD) is associated with high cost-of-illness. However, there is still a shortage of cost-of-illness-studies assessing costs from a broad societal perspective, including direct and indirect costs. Further, there are considerable differences in the results among the existing studies. In the present study, 167 German men and women seeking specialized outpatient treatment for BPD were included. We assessed societal cost-of-illness bottom-up through structured face-to-face interviews and encompassed a wide range of cost components. All costs were calculated for the 2015 price level. Cost-of-illness amounted to € 31,130 per patient and year preceding disorder-specific outpatient treatment. € 17,044 (54.8%) were direct costs that were mostly related to hospital treatment. Indirect costs amounted to € 14,086 (45.2%). Within indirect costs, costs related to work disability were the most crucial cost driver. The present study underlines the tremendous economic burden of BPD. According to the present study, both the direct and indirect costs are of significant importance for the societal costs associated with BPD. Besides the need for more disorder-specific treatment facilities for men and women with BPD, we assume that education and employment are topics that should be specifically targeted and individually supported at an early stage of treatment.Trial Registration: German Clinical Trial Registration, DRKS00011534, Date of Registration: 11/01/2017, retrospectively registered., (© 2021. The Author(s).)

Importance: Schema therapy (ST), delivered either in an individual or group format, has been compared with other active treatments for borderline personality disorder (BPD). To our knowledge, the 2 formats have not been compared with treatment as usual (TAU) or with each other. Such comparisons help determine best treatment practices., Objective: To evaluate whether ST is more effectively delivered in a predominantly group or combined individual and group format and whether ST is more effective than optimal TAU for BPD., Design, Setting, and Participants: In this multicenter, 3-arm randomized clinical trial conducted at 15 sites in 5 countries (Australia, Germany, Greece, the Netherlands, and the UK), outpatients aged 18 to 65 years who had BPD were recruited between June 29, 2010, and May 18, 2016, to receive either predominantly group ST (PGST), combined individual and group ST (IGST), or optimal TAU. Data were analyzed from June 4, 2019, to December 29, 2021., Interventions: At each site, cohorts of 16 to 18 participants were randomized 1:1 to PGST vs TAU or IGST vs TAU. Both ST formats were delivered over 2 years, with 2 sessions per week in year 1 and the frequency gradually decreasing during year 2. Assessments were collected by blinded assessors., Main Outcomes and Measures: The primary outcome was the change in BPD severity over time, assessed with the Borderline Personality Disorder Severity Index (BPDSI) total score. Treatment retention was analyzed as a secondary outcome using generalized linear mixed model survival analysis., Results: Of 495 participants (mean [SD] age, 33.6 [9.4] years; 426 [86.2%] female), 246 (49.7%) received TAU, 125 (25.2%) received PGST, and 124 (25.0%) received IGST (1 of whom later withdrew consent). PGST and IGST combined were superior to TAU with regard to reduced BPD severity (Cohen d, 0.73; 95% CI, 0.29-1.18; P < .001). For this outcome, IGST was superior to TAU (Cohen d, 1.14; 95% CI, 0.57-1.71; P < .001) and PGST (Cohen d, 0.84; 95% CI, 0.09-1.59; P = .03), whereas PGST did not differ significantly from TAU (Cohen d, 0.30; 95% CI, -0.29 to 0.89; P = .32). Treatment retention was greater in the IGST arm than in the PGST (1 year: 0.82 vs 0.72; 2 years: 0.74 vs. 0.62) and TAU (1 year: 0.82 vs 0.73; 2 years: 0.74 vs 0.64) arms, and there was no significant difference between the TAU and PGST arms (1 year: 0.73 vs 0.72; 2 years: 0.64 vs 0.62)., Conclusions and Relevance: In this randomized clinical trial, IGST was more effective and had greater treatment retention compared with TAU and PGST. These findings suggest that IGST is the preferred ST format, with high retention and continuation of improvement in BPD severity after the completion of treatment., Trial Registration: trialregister.nl Identifier: NTR2392.

Background Cognitive Behavioral Analysis System of Psychotherapy (CBASP) and Metacognitive Therapy (MCT) are effective for depression. CBASP might offer most benefit in patients reporting childhood emotional abuse (CEA). This needs to be confirmed in real-world settings and in comparisons with depression-specific psychotherapies. This study examines the moderating influence of CEA on the effectiveness of CBASP versus MCT. Methods In this observational study, we recruited patients treated with either CBASP or MCT in an intensive day treatment program for depression. CEA was assessed using the Childhood Trauma Questionnaire (CTQ). Patients reported symptoms weekly using the Quick Inventory of Depressive Symptoms (QIDS-SR). Mixed model analysis was run on the Intention to Treat dataset (ITT) using propensity matching to overcome baseline imbalances. Results A total of 141 patients were included in the analysis (MCT n = 78, CBASP n = 63). CEA moderated the treatment effect (time x CEA x treatment: β = 0.03, SE = 0.01, p = 0.014). Post-hoc analyses revealed that CBASP was more effective than MCT in patients without CEA (time x treatment: β = -0.01, SE = 0.007, p = .045). The difference between CBASP and MCT was not statistically significant for patients with CEA (β = 0.015, SE = 0.008, p = .11). Limitations Because of non-random treatment allocation the differences between CBASP and MCT can be due to unobserved baseline imbalances. Conclusions Our findings suggest that in patients reporting CEA, CBASP might not offer additional benefits above other depression-specific psychotherapies. Public Health Significance Statements This study shows that, on average, individuals with depression benefit equally from CBASP and MCT under the conditions of routine practice. Yet, CBASP was more effective than MCT for those without childhood emotional abuse. If childhood emotional abuse was present, CBASP and MCT were equally effective., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Dialectical behavior therapy (DBT) is currently the most researched therapy method to treat borderline personality disorder (BPD). A major component of DBT is learning and practicing specific skills to regulate emotions. Qualitative studies found that patients perceived DBT skills as helpful in dealing with emotions. However, DBT consists of more than 60 different skills, and earlier qualitative studies had a broad focus. The present study explores patients' experience with a specific skill, opposite action (OA). The skill is one of the major DBT skills assumed to play an important role in symptom improvement. OA means deliberately performing a behavior that is opposite to the emotional urge to act and is intended to weaken the original emotion. Qualitative data from semistructured interviews with 23 patients diagnosed with BPD receiving DBT were analyzed following qualitative content analysis procedures. The participants generally had a good understanding of the skill, although it was often mixed with other skills of DBT. Performing OA was perceived as exhausting. Adverse effects of OA, intense emotions and high distress were reported as barriers to OA use. However, participants named several factors that helped them overcome these barriers, including their thoughts and actions, support from others, and treatment elements. Participants described positive effects of OA such as positive emotional changes and a decrease in problem behavior and more freedom in everyday life. The findings of the study provide valuable information to optimize the delivery of OA and DBT and can help to improve treatment outcome for patients with BPD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background: Trauma-focused treatments for posttraumatic stress disorder (PTSD) are commonly delivered either once or twice a week. Initial evidence suggests that session frequency affects treatment response, but very few trials have investigated the effect of session frequency. The present study's aim is to compare treatment outcomes of twice-weekly versus once-weekly sessions of two treatments for PTSD related to childhood trauma, imagery rescripting (ImRs) and eye movement desensitization and reprocessing (EMDR). We hypothesize that both treatments will be more effective when delivered twice than once a week. How session frequency impacts treatment response, whether treatment type moderates the frequency effect, and which treatment type and frequency works best for whom will also be investigated., Methods: The IREM-Freq trial is an international multicenter randomized clinical trial conducted in mental healthcare centers across Australia, Germany, and the Netherlands. We aim to recruit 220 participants, who will be randomized to one of four conditions: (1) EMDR once a week, (2) EMDR twice a week, (3) ImRs once a week, or (4) ImRs twice a week. Treatment consists of 12 sessions. Data are collected at baseline until one-year follow-up. The primary outcome measure is clinician-rated PTSD symptom severity. Secondary outcome measures include self-reported PTSD symptom severity, complex PTSD symptoms, trauma-related cognitions and emotions, depressive symptoms, dissociation, quality of life, and functioning. Process measures include memory, learning, therapeutic alliance, motivation, reluctance, and avoidance. Additional investigations will focus on predictors of treatment outcome and PTSD severity, change mechanisms of EMDR and ImRs, the role of emotions, cognitions, and memory, the optimization of treatment selection, learned helplessness, perspectives of patients and therapists, the network structure of PTSD symptoms, and sudden treatment gains., Discussion: This study will extend our knowledge on trauma-focused treatments for PTSD related to childhood trauma and, more specifically, the importance of session frequency. More insight into the optimal session frequency could lead to improved treatment outcomes and less dropout, and in turn, to a reduction of healthcare costs. Moreover, the additional investigations will broaden our understanding of how the treatments work and variables that affect treatment outcome., Trial Registration: Netherlands Trial Register NL6965, registered 25/04/2018., (© 2021. The Author(s).)

Background: Perceived social support (PSS) is a crucial factor in physical and mental health. Previous studies found a negative association between childhood maltreatment (CM) and current PSS., Objective: In this paper, we investigate whether psychopathology moderates this association in a sample of patients with Depressive Disorder (DD) and Borderline Personality Disorder (BPD)., Method: Sixty-nine patients with DD and 110 patients with BPD were recruited to inpatient/day clinic treatment programmes for either DD or BPD. All participants completed the Childhood Trauma Questionnaire (CTQ) and the Social Support Questionnaire (F-SozU). Our hypothesis was tested with a moderator analysis in a multiple linear regression model., Results: We found a significant interaction between diagnosis and CM for the CTQ total score and the emotional abuse subscale. Post hoc analyses revealed a significant negative correlation between CM and PSS only for patients suffering from BPD and not for patients with DD., Conclusion: Our results suggest that the negative association between CM and PSS might be more pronounced in certain patient groups, particularly patients with BPD., Competing Interests: JPK received funding for clinical trials (German Federal Ministry of Health, Servier - distributor of the internet intervention ‘Deprexis’), payments for presentations on internet interventions (Servier), payments for workshops and books (Beltz, Elsevier, Hogrefe and Springer) on psychotherapy for chronic depression and on psychiatric emergencies. EF obtained funding for research trials by Else Kröner-Fresenius-Stiftung, Addisca gGmbH and University of Lübeck. Funding bodies played no role in the design of the study, in the collection, analysis and interpretation of data, in the writing of the manuscript and in the decision to submit the manuscript for publication. EF received payments for workshops and DVDs, books (BELTZ) on BPD, depression and psychotherapy., (© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Importance: Borderline personality disorder (BPD) is a severe mental disorder that is often inadequately treated., Objective: To determine if adding a self-management intervention to care as usual (CAU) is effective and safe., Design: Randomised, controlled, rater-blind trial. Duration of treatment and assessments: 12 months., Setting: Secondary care, recruited mainly via the internet., Participants: Patients with BPD and BPD Severity Index (BPDSI) of at least 15., Interventions: CAU by treating psychiatrist and/or psychotherapist alone or adjunctive use of an internet-based self-management intervention that is based on schema therapy (priovi)., Main Outcome Measure: Outcomes were assessed by trained raters. The primary outcome was change in BPDSI. The safety outcome was the number of serious adverse events (SAEs). The primary outcome time point was 12 months after randomisation., Results: Of 383 participants assessed for eligibility, 204 were included (91.7% female, mean age: 32.4 years; 74% were in psychotherapy and 26% were in psychiatric treatment). The slope of BPDSI change did not differ significantly between groups from baseline to 12 months (F 3,248 = 1.857, p=0.14). At 12 months, the within-group effect sizes were d=1.38 (95% CI 1.07 to 1.68) for the intervention group and d=1.02 (95% CI 0.73 to 1.31) for the control group. The between-group effect size was d=0.27 (95% CI 0.00 to 0.55) in the intention-to-treat sample and d=0.39 (95% CI 0.09 to 0.68) for those who used the intervention for at least 3 hours (per-protocol sample). We found no significant differences in SAEs., Conclusions: We have not found a significant effect in favour of the intervention. This might be due to the unexpectedly large effect in the group receiving CAU by a psychiatrist and/or psychotherapist alone., Trial Registration: NCT03418142., Competing Interests: Competing interests: AH-vM, GJ, JM and BW are employees of GAIA AG, Hamburg, Germany, the company that owns and runs the self-management interventions (SMI) tested in this trial. Both EF and GJ have received payments for training and published books/DVDs on schema therapy (ST) and treatment of borderline personality disorder. AH-vM receives payments for an ST card set published by Beltz. JPK received funding for clinical trials (German Federal Ministry of Health, Servier: distributor of the SMI 'Deprexis'), payments for presentations on internet interventions (Servier) and payments for workshops and books (Beltz, Elsevier and Hogrefe) on psychotherapy for chronic depression and on psychiatric emergencies., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Patients with posttraumatic stress disorder (PTSD) frequently have comorbid diagnoses such as major depressive disorder (MDD) and anxiety disorders (AD). Studies into the impact of these comorbidities on the outcome of PTSD treatment have yielded mixed results. The different treatments investigated in these studies might explain the varied outcome. The purpose of this study was to examine the impact of these comorbidities on the outcome of two specific PTSD treatments. MDD and AD were analyzed as predictors and moderators in a trial comparing 12 sessions of either eye movement desensitization and reprocessing (EMDR) or imagery rescripting (IR) in 155 adult patients with PTSD from childhood trauma. The primary outcome was reduction of PTSD symptoms (clinician-administered PTSD Scale for DSM-5, CAPS-5) assessed at eight-week follow-up and a secondary outcome was self-report PTSD symptoms (Impact of Event Scale, IES-R). MDD was not a predictor of treatment outcome but did have a significant moderator effect. Patients with MDD showed a better outcome if they were treated with IR, whereas patients without MDD improved more in the EMDR condition. No impact of AD emerged. It seems essential to consider comorbid MDD when planning PTSD treatment to improve treatment outcomes. More research is needed to replicate our findings and focus on different kinds of PTSD treatments and other comorbidities.

Background: Interpersonal skills deficits and dysfunctional metacognitive beliefs have been implicated in the etiology and maintenance of depression. This study aimed to investigate the association between changes in these skills deficits and change in depressive symptoms over the course of treatment with Cognitive Behavioral Analysis System of Psychotherapy (CBASP) and Metacognitive Therapy (MCT). Methods: In this prospective, parallel group observational study, data was collected at baseline and after 8 weeks of an intensive day clinic psychotherapy program. Based on a shared decision between patients and clinicians, patients received either CBASP or MCT. Ninety patients were included in the analyses (CBASP: age M = 38.7, 40.5% female, MCT: age M = 44.7, 43.3% female). Interpersonal deficits were assessed with the short-form of the Luebeck Questionnaire for Recording Preoperational Thinking (LQPT-SF) and the Impact Message Inventory (IMI-R). Metacognitive beliefs were assessed with the Metacognition Questionnaire-30 (MCQ-30). The Quick Inventory of Depressive Symptomatology (QIDS-SR16) was utilized to assess depressive symptoms. A regression analysis was conducted to assess variables associated with outcome. ANCOVAs were utilized to investigate whether improvement in skills deficits is dependent on type of treatment received. Results: Improvements in preoperational thinking and increases in friendly-dominant behavior were associated with change in depressive symptoms. There was no association between reductions in dysfunctional metacognitive beliefs and a decrease in depressive symptoms. While both treatment groups showed significant improvements in interpersonal and metacognitive skills, there was no significant between-group difference in the change scores for either of these skills. Conclusion: Our findings suggest that changes in interpersonal skills seem to be of particular relevance in the treatment of depression. These results have to be replicated in a randomized-controlled design before firm conclusions can be drawn., Competing Interests: JK received funding for clinical trials (German Federal Ministry of Health, Servier), payments for lectures on Internet interventions (Servier) and payment for workshops and books (Beltz, Elsevier, Hogrefe, Springer) on psychotherapy of chronic depression and psychiatric emergencies. EF received funding for a clinical trial comparing MCT and Behavioral Activation in the treatment of depression (Addisca gemeinnützige GmbH) and for a clinical trial in patients with Borderline Personality Disorder (Else Kröner-Fresenius Stiftung), payments for workshops, presentations and books (Beltz) on psychotherapy for depression and other disorders. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Sürig, Ohm, Grave, Glanert, Herzog, Fassbinder, Borgwardt and Klein.)

Background: Childhood maltreatment and difficulties in emotion regulation are common in patients with Borderline Personality Disorder (BPD) and Depressive Disorders (DD)., Objective: This study examines differences between patients with BPD and patients with DD, regarding childhood maltreatment and difficulties in emotion regulation as well as the mediating effect of different aspects of emotion regulation deficits on the association between childhood maltreatment and BPD-symptoms., Method: A total of 305 participants, 177 with BPD and 128 with DD completed an assessment including the Childhood Trauma Questionnaire (CTQ), the Emotion Regulation Scale (DERS), the Brief Symptom Inventory (BSI), and the Structured Clinical Interview for DSM-IV (SCID). Data was analyzed using multiple analyses of variances and mediation analyses., Results: Patients with BPD reported more childhood maltreatment and more difficulties in emotion regulation than patients with DD. When general symptom severity, age, and gender were included in the analysis as covariates only group differences regarding 'impulse control difficulties' ( F (1,299) = 38.97, p < .001, η p 2 = .115), 'limited access to emotion regulation strategies' ( F (1,299) = 4.66, p = .032, η p 2 = .015), and 'lack of emotional clarity' ( F (1,299) = 9.38, p = .002, η p 2 = .030) remained statistically significant. A mediation analysis, including above-mentioned covariates, indicated an association between emotional abuse and BPD-symptoms, which was mediated by difficulties in emotion regulation (indirect effect B = .012, 95% CI [.001; .031], R 2 = .429). Subscale analyses revealed 'impulse control difficulties' as the aspect of difficulties in emotion regulation that has the greatest impact on this association ( B = .021, 95% CI [.003; .045])., Conclusions: Patients with BPD display more childhood maltreatment and difficulties in emotion regulation than patients with DD. Difficulties in emotion regulation, especially difficulties in impulse control, seem to play an important role in the association between childhood emotional abuse and BPD-symptoms., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Distress Tolerance Skills (DTS) are an important component of Dialectical Behavioral Therapy (DBT), a therapy method frequently used for treating patients with Borderline Personality Disorder (BPD). However, little is known about how DTS-training is experienced by individuals with BPD. The aim of this study was to explore BPD patients' experiences with receiving DTS-training. Qualitative data were collected through semi-structured interviews with 24 individuals (87.5% females) with a primary diagnosis of BPD who received DTS-training in the context of 18 months of DBT treatment. Interview data were analyzed following the procedures of qualitative content analysis. Participants reported various effects of DTS including an immediate reduction of tension. Patients perceived DTS as a tool to cope with difficult interpersonal situations and emergencies and stated that this helped them to feel stable, safe and self-confident. Patients reported difficulties during the initial engagement, the learning process and the application of DTS as well as various facilitating factors. Implications of the findings for further research and for optimizing DTS-training in clinical practice are discussed., Competing Interests: US, EF and DB have provided trainings and presentations on DBT, BPD, dissociation or skills training, US and EF have published books providing information on emotion regulation and distress tolerance skills in other disorders. AS, MR, JA, CM, SB, and NA declare that they have no conflict of interest. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

This study aimed to explore patients' and therapists' experiences with trauma-focused treatments in patients with posttraumatic stress disorder from childhood trauma (Ch-PTSD). Semi-structured interviews were conducted with patients ( n = 44) and therapists ( n = 16) from an international multicentre randomised clinical trial comparing two trauma-focused treatments (IREM), imagery rescripting and eye movement and desensitisation (EMDR). Thematic analysis was used to identify key themes within the data. Patients and therapists commented about the process of therapy. The themes that emerged from these comments included the importance of the patients' willingness to engage and commit to the treatment process; the importance and difficulty of the trauma work, observations of how the trauma focused therapy produced changes in insight, and sense of self and empowerment for the future. In addition, therapists made suggestions for optimising the therapist role in the trauma-focused treatment. This included the importance of having confidence in their own ability, confronting their own and their client's avoidance and the necessity and difficulties of adhering to the treatment protocols. These reported experiences add further support to the idea that trauma-focused treatments, without a stabilisation phase, can be tolerated and deepens our understanding of how to make this palatable for individuals with Ch-PTSD.

Imagery Rescripting (IR) is a therapeutic technique that is used in a wide spectrum of therapeutic methods for various mental disorders. As an important component of Schema Therapy (ST), IR is frequently used in the treatment of patients with borderline personality disorder (BPD). However, little is known about how IR is experienced by individuals with BPD. The aim of this study was to explore BPD patients' experiences with receiving IR. Qualitative data were collected through semi-structured interviews with 21 individuals (86% females) with a primary diagnosis of BPD who received IR within their ST treatment. Interview data were analyzed following the procedures of qualitative content analysis. Participants reported various effects of IR including initial high emotionality and exhaustion. Long-term effects included a better understanding of schemas and an improvement regarding emotion regulation and interpersonal relationships. Participants reported factors hindering the successful implementation of IR, such as external noise, stress, and a fast pace during IR. Facilitating factors included adequate time for debriefing, a transparent structure, and preparation of IR as well as the therapist providing safety. Implications of the findings for optimizing IR in clinical practice are discussed., Competing Interests: EF, AA, and US have provided trainings and/or published books on ST and IR. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2020 Schaich, Braakmann, Richter, Meine, Assmann, Köhne, Arntz, Schweiger and Fassbinder.)

Background: Investigation of treatments that effectively treat adults with post-traumatic stress disorder from childhood experiences (Ch-PTSD) and are well tolerated by patients is needed to improve outcomes for this population., Aims: The purpose of this study was to compare the effectiveness of two trauma-focused treatments, imagery rescripting (ImRs) and eye movement desensitisation and reprocessing (EMDR), for treating Ch-PTSD., Method: We conducted an international, multicentre, randomised clinical trial, recruiting adults with Ch-PTSD from childhood trauma before 16 years of age. Participants were randomised to treatment condition and assessed by blind raters at multiple time points. Participants received up to 12 90-min sessions of either ImRs or EMDR, biweekly., Results: A total of 155 participants were included in the final intent-to-treat analysis. Drop-out rates were low, at 7.7%. A generalised linear mixed model of repeated measures showed that observer-rated post-traumatic stress disorder (PTSD) symptoms significantly decreased for both ImRs (d = 1.72) and EMDR (d = 1.73) at the 8-week post-treatment assessment. Similar results were seen with secondary outcome measures and self-reported PTSD symptoms. There were no significant differences between the two treatments on any standardised measure at post-treatment and follow-up., Conclusions: ImRs and EMDR treatments were found to be effective in treating PTSD symptoms arising from childhood trauma, and in reducing other symptoms such as depression, dissociation and trauma-related cognitions. The low drop-out rates suggest that the treatments were well tolerated by participants. The results from this study provide evidence for the use of trauma-focused treatments for Ch-PTSD.

The existing therapeutic strategies of Tourette syndrome (TS) do not lead to sufficient improvement in a significant number of patients. Recently published studies show that paying attention to tics increases whereas directing attention away decreases tic frequency. The aim of the present case series in three patients with TS was to investigate the effect of attention training technique (ATT) on TS symptoms. ATT is a technique derived from metacognitive therapy that aims on training patients to consciously (re-)focus their attention away from themselves. Friedman's chi-square test indicated a trend regarding the reduction of tic frequency and tic severity and a significant reduction of positive metacognitions from pre-baseline to follow-up. Reliable Change Indices (RCIs) are given for each measure and patient. Given the small number of patients, further studies including randomized controlled trials appear warranted., (Copyright © 2020 Schaich, Brandt, Senft, Schiemenz, Klein, Faßbinder, Münchau and Alvarez-Fischer.)

eHealth programs have been found to be effective in treating many psychological conditions. Regarding Borderline Personality Disorder (BPD), few programs have been tested; nevertheless, results are promising. The therapeutic alliance is an important factor predicting treatment outcome in BPD. However, we do not know yet to what extent BPD patients form a therapeutic alliance with an eHealth tool and how this relationship differs from the relationship with their human therapist. This study aims to address this question using priovi, an interactive schema therapy-based eHealth tool for BPD. Semi-structured interviews were conducted to explore how patients perceived the therapeutic alliance with priovi and its differences compared to the alliance with their human therapist (N = 9). Interview data were analyzed following the procedures of qualitative content analysis. Additionally, the Working Alliance Inventory (WAI-SR) was administered in two versions (regarding the human therapist and priovi, N = 16) every three months during the treatment phase of one year. Results indicate that patients were able to form a good therapeutic relationship with priovi, but it differed from the relationship to their human therapist. Important categories were "priovi is helpful, supportive and always there" and "priovi is less flexible". WAI ratings for the task subscale were high in both relationships but significantly higher in WAI therapist compared to WAI priovi in two measurements (nine-months measurement: t = 2.76, df = 15, p = 0.015; twelve-months measurement: t = 3.44, df = 15, p = 0.004). These results indicate that BPD patients can form a functioning alliance with an eHealth program and that eHealth programs may be especially useful for psychoeducation and cognitive exercises.

Background: Electronic health (eHealth) programs have been found to be effective in treating many psychological conditions. However, regarding borderline personality disorder (BPD), only a few eHealth programs have been tested, involving small interventions based on the dialectical behavior therapy treatment approach. We investigated priovi, a program based on the schema therapy (ST) approach. priovi is considerably more comprehensive than prior programs, offering broad psychoeducation content and many therapeutic exercises., Objective: We tested the acceptability and feasibility of priovi in 14 patients with BPD as an add-on to individual face-to-face ST., Methods: Patients received weekly individual ST and used priovi over a period of 12 months. We assessed BPD symptom severity using self-reported and interview-based measures. Qualitative interviews were conducted with both patients and therapists to assess their experiences with priovi., Results: BPD symptoms improved significantly (Cohen d=1.0). Overall, qualitative data showed that priovi was positively received by both patients and therapists. Some exercises provoked mild anxiety; however, no serious threat to safety was detected., Conclusions: priovi is a potentially helpful and safe tool that could support individual ST. It needs to be further tested in a randomized controlled study., Trial Registration: German Clinical Trials Register DRKS00011538; https://www.drks.de/drks&#95;web/navigate.do? navigationId=trial.HTML&TRIAL&#95;ID=DRKS00011538 (Archived by WebCite at http://www.webcitation.org/74jb0AgV8)., (©Gitta Anne Jacob, Andrea Hauer, Sandra Köhne, Nele Assmann, Anja Schaich, Ulrich Schweiger, Eva Fassbinder. Originally published in JMIR Mental Health (http://mental.jmir.org), 17.12.2018.)

Schema therapy (ST) has been found to be effective in the treatment of borderline personality disorder (BPD). However very little is known about how the therapy is experienced by individuals with BPD including which specific elements of ST are helpful or unhelpful from their perspectives. The aim of this study is to explore BPD patients' experiences of receiving ST, in intensive group or combined group-individual format. Qualitative data were collected through semi-structured interviews with 36 individuals with a primary diagnosis of BPD (78% females) who received ST for at least 12 months. Participants were recruited as part of an international, multicenter randomized controlled trial (RCT). Interview data (11 Australian, 12 Dutch, 13 German) were analyzed following the procedures of qualitative content analysis. Patients' perceptions of the benefits gained in ST included improved self-understanding, and better awareness and management of their own emotional processes. While some aspects of ST, such as experiential techniques were perceived as emotionally confronting, patient narratives informed that this was necessary. Some recommendations for improved implementation of ST include the necessary adjunct of individual sessions to group ST and early discussion of therapy termination. Implications of the findings are also discussed, in particular the avenues for assessing the suitability of patients for group ST; management of group conflict and the optimal format for delivering treatment in the intensive group versus combined group-individual formats., Competing Interests: The authors have declared that no competing interests exist.

Background: Borderline Personality Disorder (BPD) is a severe mental illness that is associated with low quality of life, low psychosocial functioning, and high societal costs. Treatments for BPD have improved in the last decades. Dialectical behavior therapy (DBT) and Schema therapy (ST) have demonstrated efficacy in reducing BPD symptoms and costs. However, research has not compared these two treatment approaches. In addition, there is a lack of 'real world studies' that replicate positive findings in regular mental healthcare settings. Thus, the PROgrams for Borderline Personality Disorder (PRO*BPD) study will compare the (cost-) effectiveness of DBT and ST in structured outpatient treatment programs in the routine clinical setting of an outpatient clinic., Methods/design: We aim to recruit 160 BPD patients, who will be randomly assigned to either DBT or ST. In both conditions, patients receive one group therapy and one individual therapy session/week for a maximum of 18 months. Both treatment programs have similar frameworks, which guarantee clinical equipoise. The primary outcome is a reduction of BPD-symptoms. Also, the costs related to BPD are assessed and an economic evaluation is performed from a societal perspective. Secondary outcomes examine other measures of BPD-typical and general psychopathology, comorbidity, quality of life, psychosocial functioning and participation. Data are collected prior to the beginning therapy and every six months until the end of therapy, as well as at six months, one year and two years of follow-up after the end of therapy. Finally, we conduct a qualitative study to understand patients' experiences with the two methods., Discussion: The PRO*BPD study is the first randomized trial to compare the (cost-) effectiveness of DBT and ST. By examining the clinical effectiveness of a broad spectrum of outcome parameters, conducting an economic evaluation and assessing patients' experiences, this study will significantly advance our knowledge on psychotherapy for BPD and will provide insight into the treatment approaches that should be offered to different BPD patients from clinical, economic and stakeholder's perspectives., Trial Registration: German Clinical Trial Register, DRKS00011534 , Date of registration: 11/01/2017, retrospectively registered.