The Alternative Model of Personality Disorders suggests that borderline personality disorder (BPD) is characterized by disturbed personality functioning (self- and other), along with elevated levels of negative affectivity, antagonism, and disinhibition. This study explored the extent to which BPD Compass, a cognitive-behavioral intervention targeting maladaptive personality variants most associated with BPD, addresses the components of Alternative Model of Personality Disorders-defined BPD. In addition, we explored whether improvements in personality functioning were associated with improvements in BPD symptoms. Our intent-to-treat sample included 100 adults (N = 93 who started treatment and had data available for analyses) who met criteria for BPD and were, on average, 28.13 (SD = 8.80) years old, White (n = 88; 88.9%), identified as female (n = 73; 73.7%), and identified as sexual minorities (n = 64; 64.6%). We employed a series of hierarchical linear models to evaluate changes across personality domains and facets during 18 sessions of BPD Compass delivered via telehealth. We also tested whether changes in personality functioning were associated with changes in BPD symptoms using multilevel structural equation modeling. Results suggest significant improvements in negative affectivity, antagonism, disinhibition, and personality functioning during treatment, with medium-to-large effect sizes observed for multiple facets. BPD Compass also was associated with significant improvements in BPD symptoms, and changes in symptoms were significantly correlated with changes in each higher order personality trait. This pattern of results provides support for the feasibility of targeting dimensional traits and indicates that targeting higher order personality traits may streamline care and improve outcomes for BPD patients. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

Borderline personality disorder (BPD) is defined by the presence of at least five of nine symptoms in Section II of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. In the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, Section III Alternative Model of Personality Disorders (AMPD), BPD is defined by deficits in self and/or interpersonal functioning (Criterion A), elevated negative affectivity, and elevated antagonism and/or disinhibition (Criterion B). However, it is unclear if these definitions describe the same people and if the AMPD criteria explain unique variability in treatment outcomes in this population. In a treatment-seeking sample of adult participants diagnosed with BPD according to Section II criteria (n = 65, Mage = 27.60, 70.8% female, 76.9% White), we found a majority (66.2%) would have also received the diagnosis based on AMPD criteria. Those meeting AMPD criteria reported more severe Section II BPD symptoms than those who did not, ps < .02, ds > 0.60, and the presence or severity of Section II fears of abandonment and inappropriate anger uniquely predicted AMPD BPD diagnoses, ps < .03, ORs ≥ 2.31. Changes in AMPD dimensions explained 34% of the variability in change in work/social adjustment (p = .13) and quality of life (p = .22), respectively, over and above changes in Section II symptoms during a novel cognitive-behavioral treatment for BPD. These results suggest that AMPD criteria capture a more severe subset of BPD than Section II criteria and may be important predictors of treatment outcomes. We discuss the potential trade-offs of this shift in diagnosis. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Researchers have shown neuroticism decreases with treatment (Roberts et al., 2017), although it is unclear if this reflects fleeting state-level changes (state-artifact position) or trait-level change (cause-correction hypothesis). These theories further propose that changes in neuroticism predict symptom change (cause-correction hypothesis) or are predicted by symptom change (state-artifact position). We compared these theories in a clinical trial of the Unified Protocol (UP). Participants (N = 38; Mage = 34.55, 71.1% female, 78.9% Caucasian) meeting DSM-5 criteria for a primary emotional disorder completed up to 12 weekly sessions of the UP. Neuroticism exhibited state-level changes by Session 6 but trait-level changes by Session 12. Within-person reductions in neuroticism exhibited bidirectional relations with anxiety symptom change but predicted unidirectional session-to-session reductions in depression. These findings provide relatively more nuanced support for the cause-correction hypothesis that the UP leads to trait changes in neuroticism that tend to precede symptom change.

Objective:Both the therapeutic alliance and the specific skills taught in treatment are thought to contribute to change in cognitive-behavior therapy (CBT), but it is unclear if or how these processes influence each other and outcomes in treatment. We tested the hypothesis that the degree to which patients used CBT skills would mediate the relation between the alliance and session-to-session changes in anxiety and depression. Method:Adult participants (N = 70; Mage = 33.74, 67% female, 70% White) with emotional disorders were randomized to receive 6 or 12 sessions of the Unified Protocol. Before each session, participants reported anxiety and depression severity and past-week skillfulness. After each session, participants rated the strength of the alliance. We tested whether greater within-person skillfulness mediated the relation between within-person alliance strength and session-to-session changes in anxiety and depression. Results:Skillfulness significantly mediated the effect of the alliance on session-to-session changes in anxiety, ab = -.02, p = .04, and depression, ab = -.02, p = .02, such that a stronger alliance predicted greater next-session skillfulness, which predicted session-to-session decreases in anxiety and depression. When alliance subscales were examined separately, the strongest effect was observed for agreement on therapy tasks. Conclusions:Improvements in the alliance may facilitate skill use and indirectly predict reductions in anxiety and depression through skill use in CBT. We encourage research on how to enhance both the alliance and skillfulness in CBT.

Borderline personality disorder (BPD) is a heterogeneous condition that is particularly associated with three broad personality dimensions: neuroticism (i.e., high negative affectivity), agreeableness (i.e., low antagonism), and conscientiousness (i.e., low disinhibition). The purpose of the present study was to explore whether treatment with BPD Compass, a novel personality-based intervention for BPD, results in greater reductions in BPD symptoms, neuroticism, agreeableness, and conscientiousness compared to a waitlist control (WLC) condition. We also aimed to characterize within-treatment effects for participants assigned to the BPD Compass condition and evaluate patients' satisfaction with treatment. Participants (N = 51; Mage = 28.38; 83.3% female; 93.8% White; 54.2% sexual minority) meeting DSM-5 criteria for BPD were enrolled in a randomized controlled trial to evaluate the efficacy of BPD Compass. Patients were randomly assigned to receive 18 sessions of BPD Compass or complete an 18-week waiting period. BPD Compass led to larger reductions in BPD symptoms (assessor-rated [β = -0.47] and self-reported [β = -0.62]) and neuroticism (β = -0.37), but not agreeableness (β = 0.08) or conscientiousness (β = 0.10), compared to the WLC condition. Within the BPD Compass condition, pre- to posttreatment improvements in BPD symptoms, neuroticism, and conscientiousness were significant and large in magnitude (Hedges' gs: -1.38 to -1.08). Patients were highly satisfied with BPD Compass and generally perceived it to be an appropriate length. Thus, BPD Compass may be an accessible and useful complement to more specialty or intensive treatments for BPD. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Unified Protocol (UP) theoretically leads to reductions in emotional disorder symptoms by reducing aversive reactions to emotions. However, aversive reactions can take many forms (e.g., non-acceptance, behavioral avoidance). We examined if (1) multiple aspects of aversive reactivity predicted session-to-session changes in anxiety and depression in the UP, (2) these aspects reflected a single latent construct, and (3) changes in this latent construct predicted changes in anxiety and depression. Participants (N = 70, Mage = 33.74, 67.1% female, 74.3% white) completed six sessions of UP modules and measures of aversive reactivity, anxiety, and depression before each session. We used hierarchical linear modeling and random-intercept cross-lagged panel models to test aspects of aversive reactivity and a latent factor of aversive reactivity, respectively, as predictors of session-to-session changes in anxiety and depression. Within-person improvements in four of five aspects of aversive reactivity predicted decreases in anxiety, and improvements in two aspects predicted decreases in depression. However, within-person improvements in latent aversive reactivity predicted decreases in anxiety at five sessions and in depression across all sessions. These results add to the growing literature highlighting the role of aversive reactivity as a potential transdiagnostic process involved in improvements in emotional disorder symptoms during treatment.

Borderline personality disorder (BPD) is characterized by maladaptive levels of neuroticism, agreeableness, and conscientiousness. The Unified Protocol (UP), a treatment for neuroticism, has previously demonstrated promising effects when applied to BPD; however, not all individuals with BPD respond, suggesting the UP may be incomplete for some BPD presentations. This secondary analysis explored the extent to which adapted versions of UP represent an efficacious treatment approach for BPD symptoms. Data from a subset of twelve participants with clinically-significant BPD features were included. We explored within-group changes in BPD symptoms and differences in within-person changes in BPD scores based on patients’ personality profiles. The UP resulted in improvements in BPD symptoms that were moderate in magnitude, Hedges’s g = 0.48, 95% CI [0.35, 0.62]. Individuals with personality profiles characterized by high neuroticism and low conscientiousness exhibited early gains in the UP but did not sustain them, whereas those with at least moderate levels of conscientiousness generally continued to improve across 12 weeks. Possible explanations and limitations were discussed.

Researchers use ecological momentary assessment (EMA) to study a range of behaviors related to psychopathology. However, it is unclear whether brief measures of coping behaviors accurately capture the intended responses. In this secondary analysis of a single-case experimental design, eight individuals with borderline personality disorder ( Mage = 21.57, 63% female, 63% Asian American) completed daily diary entries for 12 weeks, along with hourly EMA entries on 2 days. Participants provided qualitative descriptions of their behaviors and classified them into one of five functional categories. Independent researchers also classified each qualitative description into the same categories. Overall, agreement between participants and researchers was low, Krippendorff’s α = .47, 95% confidence interval [0.43, 0.52]. The type of emotion experienced, researcher confidence, and word count of responses affected agreement. Generating items that capture the breadth of possible behaviors, are brief enough for frequent administration, and are consistently understood by participants is an important continued challenge in EMA research.

Objective:This study explores whether early change on a putative mechanism maintaining symptoms can serve as a proximal indicator of response to prompt discontinuation.Method:Patients (N = 70; M-age = 33.74, 67% female, 74% white) with heterogeneous anxiety and depressive disorders completed a sequential multiple assignment randomized trial (SMART). Patients received 6 sessions of skill modules from the Unified Protocol and then underwent a second-stage randomization to either receive the remaining 6 sessions (Full duration) or discontinue treatment (Brief duration). All participants completed weekly self-report measures of anxiety and depressive symptoms and distress aversion for the full 12-week treatment window. We used structural equation modeling to test (1) if distress aversion demonstrated significant variability during the first-stage randomization and (2) if distress aversion during the first-stage randomization predicted second-stage changes in anxiety and depression.Results:Participants demonstrated significant variability in first-stage distress aversion. Latent distress aversion slopes significantly predicted latent second-stage anxiety slopes, whereas latent distress aversion intercepts significantly predicted latent second-stage depression slopes.Conclusions:These results suggest that early mechanism engagement may have potential as a trigger to prompt personalized termination. Shorter courses of care may reduce patient costs and increase the mental health service system's capacity.

Aversive reactivity to negative affect has been described as a transdiagnostic mechanism that links distal temperamental vulnerabilities to clinically relevant behaviors. However, the abundance of constructs reflecting aversive reactivity has resulted in a proliferation of models that may ultimately be redundant. We performed a circumscribed review of studies measuring associations between six constructs – anxiety sensitivity, experiential avoidance, distress intolerance, intolerance of uncertainty, thought-action fusion, and negative urgency – and ten relevant coping behaviors. Results suggested that most constructs were measured in relation to a limited number of coping behaviors. Additionally, constructs were most often measured in isolation, rather than with similar constructs. Implications and suggestions for future research and treatment are discussed.

Borderline personality disorder (BPD) is a heterogenous condition, and variations in its presentation may be accounted for by individual differences in personality dimensions. Extant treatments for BPD are long term and intensive; it is possible that prioritizing the personality-based difficulties that underlie an individual's symptoms may improve the efficiency of care. This article describes the conceptual background for the development of a novel, personality-based intervention for BPD (BPD Compass), which was informed by recent research on personality mechanisms maintainin this condition, and was designed to address gaps left by existing treatments and to be maximally efficient and disseminable. BPD Compass is a comprehensive, short-term package with a fully modular design that allows for personalization (e.g., all skills can be presented in isolation or in any order based on pretreatment assessment). We discuss the theoretical background for its development, an overview of the skills included in the treatment, as well as preliminary efficacy data. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Given that over 20 million adults each year do not receive care for their mental health difficulties, it is imperative to improve system-level capacity issues by increasing treatment efficiency. The present study aimed to collect feasibility/acceptability data on two strategies for increasing the efficiency of cognitive behavioral therapy: (1) personalized skill sequences and (2) personalized skill selections. Participants (N = 70) with anxiety and depressive disorders were enrolled in a pilot sequential multiple assignment randomized trial (SMART). Patients were randomly assigned to receive skill modules from the Unified Protocol in one of three sequencing conditions: standard, sequences that prioritized patients’ relative strengths, and sequences that prioritized relative deficits. Participants also underwent a second-stage randomization to either receive 6 sessions or 12 sessions of treatment. Participants were generally satisfied with the treatment they received, though significant differences favored the Capitalization and Full duration conditions. There were no differences in trajectories of improvement as a function of sequencing condition. There were also no differences in end-of-study outcomes between brief personalized treatment and full standard treatment. Thus, it may be feasible to deliver CBT for personalized durations, though this may not substantially impact trajectories of change in anxiety or depressive symptoms.

Clinicians in practice routinely make decisions that, in effect, tailor the care they provide to each individual patient. For example, clinicians must decide which treatment package to administer, or what specific skills to introduce. Providers also determine when to change approaches, the frequency of sessions, and when to terminate treatment. In this review, we describe the empirical literature for personalizing the delivery of psychological care that corresponds to the inflection points in treatment that clinicians face. In addition, we provide data-based recommendations to clinicians for personalizing patient care at each of these decision points and suggest areas for future study.

In Linehan's (1993) biosocial theory, borderline personality disorder (BPD) results in part from frequent, intense, negative emotions and maladaptive behavioral responses to those emotions. We conducted a secondary data analysis of an intensive single-case experimental design to explore hourly relations among behavioral responses and emotions in BPD. Eight participants with BPD (Mage = 21.57, 63% female; 63% Asian) reported their emotions and behaviors hourly on two days. Participants reported a neutral-to-negative average emotional state with substantial variability each day. This emotional state was characterized most frequently by anxiety and joy. Participants tended to "dig into", or savor, experiences of joy, but problem-solve around, push away, or accept anxiety. Acceptance predicted hour-by-hour increases in negative emotion intensity, and pushing emotions away predicted hour-by-hour increases in positive emotion intensity. These results suggest that anxiety dominates the emotional experiences of people with BPD and co-occurs with a variety of emotion regulation strategies, while joy co-occurs with strategies designed to prolong emotional experiences. Despite its general adaptiveness, acceptance may be less effective, and pushing emotions away may be more effective, than other emotion regulation strategies at improving momentary negative emotions for those with BPD. We discuss the preliminary nature of these findings and encourage future researchers to build on them in larger samples with more severe presentations of BPD.