Antisocial behavior reduces the association between subdimensions of ADHD symptoms and alcohol use in a large population‐based sample of adolescents

The aim of this study was to investigate possible effects of antisocial behavior on reducing the association between subdimensions of ADHD symptoms (inattention, hyperactivity and impulsivity) and alcohol use. Boys and girls were analyzed separately using a population‐based Swedish adolescent sample. A randomly selected cross‐sectional survey was performed in secondary and upper secondary schools in Västmanland County during 2010. Participants were a population of 2,439 15–16 year‐olds and 1,425 17–18 year‐olds (1,947 girls and 1,917 boys). Psychosocial adversity, antisocial behaviors, symptoms of ADHD and alcohol use were assessed by questionnaires. Except for girls' inattention, subdimensions of ADHD symptoms were not associated with alcohol use when variance due to antisocial behavior was accounted for. Among boys, instead of an indirect effect of antisocial behavior on the association between impulsivity and alcohol use, a moderating effect was found. Among girls, the inattention component of ADHD was independently associated with alcohol use even when adjusted for antisocial behavior. The reduced associations between symptoms of hyperactivity, impulsivity, and alcohol use for boys and girls after adjusting for antisocial behavior suggest a considerable overlap between hyperactivity, impulsivity, and antisocial behavior. The direct pathway between inattention and alcohol use among girls suggests that girls with inattention symptoms are at risk of alcohol use regardless of antisocial behavior. Special attention should be given to these girls. Accounting for antisocial behavior reduced the relation between subdimensions of ADHD symptoms and alcohol use, and antisocial behaviors should therefore be screened for when symptoms of ADHD are present.     

Friendship Intimacy Exchange Buffers the Relation between ADHD Symptoms and Later Social Problems among Children Attending an After-School Care Program

The friendships of children displaying symptoms of attention-deficit/hyperactivity disorder (ADHD) have been understudied, particularly in comparison to the domain of peer rejection. This study tested whether friendship intimacy exchange buffers the prospective relation between ADHD symptoms and social problems 1 year later in a sample of children attending a community-based after-school program. Children (N?=?131; 53 % boys; 66 % African American) ranging from 5 to 13 years of age participated in this study. At baseline, children reported on friendship intimacy exchange with their identified best friend, and program staff rated children on ADHD symptoms and social problems. Staff ratings of children’s social problems were collected again 1 year later. Multiple regression analyses indicated that, after controlling for demographic variables and baseline social problems, friendship intimacy exchange significantly moderated the association between ADHD symptoms and social problems at the one-year follow-up. Specifically, the relation between ADHD and social problems was no longer significant for children reporting high levels of friendship intimacy exchange. This moderation was not further qualified by either child age or sex, although boys were more likely than girls to report low rates of friendship intimacy exchange. These findings indicate the importance of friendship intimacy for children displaying ADHD symptoms, who often experience significant peer problems. Friendship quality may be a promising target for prevention and intervention efforts in mitigating some of the long-term social problems associated with ADHD symptomatology, and future research is needed to extend these findings to other domains of friendship quality and clinical samples of children with ADHD.     

Trajectories of Attention Deficit Hyperactivity Disorder and Oppositional Defiant Disorder Symptoms as Precursors of Borderline Personality Disorder Symptoms in Adolescent Girls

Little empirical evidence exists regarding the developmental links between childhood psychopathology and borderline personality disorder (BPD) in adolescence. The current study addresses this gap by examining symptoms of attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) as potential precursors. ADHD and BPD share clinical features of impulsivity, poor self-regulation, and executive dysfunction, while ODD and BPD share features of anger and interpersonal turmoil. The study is based on annual, longitudinal data from the two oldest cohorts in the Pittsburgh Girls Study (N = 1,233). We used piecewise latent growth curve models of ADHD and ODD scores from age 8 to 10 and 10 to 13 years to examine the prospective associations between dual trajectories of ADHD and ODD symptom severity and later BPD symptoms at age 14 in girls. To examine the specificity of these associations, we also included conduct disorder and depression symptom severity at age 14 as additional outcomes. We found that higher levels of ADHD and ODD scores at age 8 uniquely predicted BPD symptoms at age 14. Additionally, the rate of growth in ADHD scores from age 10 to 13 and the rate of growth in ODD scores from 8 to 10 uniquely predicted higher BPD symptoms at age 14. This study adds to the literature on the early development of BPD by providing the first longitudinal study to examine ADHD and ODD symptom trajectories as specific childhood precursors of BPD symptoms in adolescent girls.     

Sleep Problems in Childhood and Borderline Personality Disorder Symptoms in Early Adolescence

Sleep disorders, such as insomnia and nightmares, are commonly associated with Borderline Personality Disorder (BPD) in adulthood. Whether nightmares and sleep-onset and maintenance problems predate BPD symptoms earlier in development is unknown. We addressed this gap in the literature using data from the Avon Longitudinal Study of Parents and Children (ALSPAC). Participants included 6050 adolescents (51.4 % female) who completed the UK Childhood Interview for DSM-IV BPD at 11 to 12 years of age. Nightmares and sleep onset and maintenance problems were prospectively assessed via mother report when children were 2.5, 3.5, 4.8 and 6.8 years of age. Psychopathological (i.e., emotional temperament; psychiatric diagnoses; and emotional and behavioural problems) and psychosocial (i.e., abuse, maladaptive parenting, and family adversity) confounders were assessed via mother report. In logistic regressions, persistent nightmares (i.e., regular nightmares at 3 or more time-points) were significantly associated with BPD symptoms following adjustment for sleep onset and maintenance problems and all confounders (Adjusted Odds Ratio = 1.62; 95 % Confidence Interval = 1.12 to 2.32). Persistent sleep onset and maintenance problems were not significantly associated with BPD symptoms. In path analysis controlling for all associations between confounders, persistent nightmares independently predicted BPD symptoms (Probit co-efficient [β] = 0.08, p = 0.013). Emotional and behavioural problems significantly mediated the association between nightmares and BPD (β =0.016, p < 0.001), while nightmares significantly mediated associations between emotional temperament (β = 0.001, p = 0.018), abuse (β = 0.015, p = 0.018), maladaptive parenting (β = 0.002, p = 0.021) and subsequent BPD. These findings tentatively support that childhood nightmares may potentially increase the risk of BPD symptoms in early adolescence via a number of aetiological pathways. If replicated, the current findings could have important implications for early intervention, and assist clinicians in the identification of children at risk of developing BPD.     

Autistic traits in mentalization-based treatment for concurrent borderline personality disorder and substance use disorder: Secondary analyses of a randomized controlled feasibility study

Autism is suggested to be a dimensional construct and often represents a comorbid state. However, research on the clinical implications of the presence of autistic traits is scarce. This study aimed to investigate the impact of subclinical autistic traits in mentalization-based treatment (MBT) for concurrent borderline personality disorder (BPD) and substance use disorder (SUD). Based on the data of a randomized controlled feasibility study by Philips, Wennberg, Konradsson, and Franck (2018), secondary analyses were conducted. It was tested, if patients’ (N = 46) levels of autistic traits were associated with treatment outcome measured in the course of and after treatment using interviews and self-report measures. Participants’ autistic traits were not associated with the change in the severity of BPD throughout and at the end of the treatment. However, results showed associations between autistic traits and the change in patients’ consumption of alcohol in the course of MBT. Furthermore, there was an association between autistic traits and the change in mentalizing capacity at the end of MBT, indicating that elevated autistic traits were associated with an improvement in mentalizing capacity. Autistic traits on a subclinical level do not appear to be a complicating factor in MBT for concurrent BPD and SUD. On the contrary, in terms of mentalizing capacity autistic traits might be associated with a larger potential for improvement or facilitate treatment outcome. Further research is needed to explore the role of higher autistic traits in treatment of this special patient group.     

Associations Between Fathers’ and Mothers’ Psychopathology Symptoms,Parental Emotion Socialization,and Preschoolers’ Social-Emotional Development

In this study we tested whether the relation between fathers’ and mothers’ psychopathology symptoms and child social-emotional development was mediated by parents’ use of emotion talk about negative emotions in a sample of 241 two-parent families. Parents’ internalizing and externalizing problems were measured with the Adult Self Report and parental emotion talk was observed while they discussed a picture book with their children (child age: 3 years). Children’s parent-reported internalizing and externalizing problems and observed prosocial behaviors were assessed at the age of 3 years and again 12 months later. We found that mothers’ use of emotion talk partially mediated the positive association between fathers’ internalizing problems and child internalizing problems. Fathers’ internalizing problems predicted more elaborative mother–child discussions about negative emotions, which in turn predicted more internalizing problems in children a year later. Mothers’ externalizing problems directly predicted more internalizing and externalizing problems in children. These findings emphasize the importance of examining the consequences of parental psychological difficulties for child development from a family-wide perspective.     

The Intergenerational Association Between Parents’ Problem Gambling and Impulsivity-Hyperactivity/Inattention Behaviors in Children

Despite the well-established association between problem gambling and ADHD core categories of impulsivity-hyperactivity and inattention, the link between parents’ problem gambling and impulsivity-hyperactivity/inattention (IH/I) behaviors in children has not been investigated. This study investigated the association between parents’ problem gambling and children’s IH/I behaviors while controlling for potential confounding variables. A population-based prospective cohort followed-up from kindergarten to age 30, the Quebec Longitudinal Study of Kindergarten Children (QLSKC), provided data over three generations. Among 1358 participants at age 30, parents with a child aged 1 year or older (N = 468; Mean age = 4.65 years; SD = 2.70) were selected. Generalized Linear Models included measures of grandparents’ and parents’ problem gambling, parents’ IH/I behaviors in childhood, and a host of risk factors and comorbidities to predict IH/I in children. Intergenerational bivariate associations were observed between grandparents’ problem gambling, parents’ IH/I in childhood and problem gambling at age 30, and between parents’ IH/I, problem gambling, and children’s IH/I behaviors. Parents’ problem gambling predicted children’s IH/I behaviors above and beyond the effects of covariates such as family and socioeconomic characteristics, alcohol and drug use, depression symptoms and parents’ gambling involvement. Parents’ IH/I behaviors in childhood also predicted children’s IH/I and had a moderating, enhancing effect on parents’ problem gambling association with their offspring’s IH/I behaviors. Problem gambling is a characteristic of parents’ mental health that is distinctively associated with children’s IH/I behaviors, above and beyond parents’ own history of IH/I and of typically related addictive, psychopathological or socioeconomic risk factors and comorbidities.     

Internalizing and Externalizing Problem Behavior: a Test of a Latent Variable Interaction Predicting a Two-Part Growth Model of Adolescent Substance Use

Externalizing symptoms robustly predict adolescent substance use (SU); however, findings regarding internalizing symptoms have been mixed, suggesting that there may be important moderators of the relationship between internalizing problems and SU. The present study used a longitudinal community sample (N?=?387, 55% female, 83% White) to test whether externalizing symptoms moderated the relationship between internalizing symptoms and trajectories of alcohol and marijuana use from early (age 11–12 years old) to late (age 18–19 years old) adolescence. Two-part latent growth models were used to distinguish trajectories of probability of use from trajectories of amount of use among users. Results suggested that externalizing symptoms moderated the association between internalizing symptoms and probability of alcohol, but not marijuana use. The highest probability of alcohol use was observed at high levels of externalizing symptoms and low levels of internalizing symptoms. A negative protective effect of internalizing symptoms on probability of alcohol use was strongest in early adolescence for youth high on externalizing symptoms. Although moderation was not supported for amount of use among users, both domains of symptomology were associated with amount of alcohol and marijuana use as first-order effects. High levels of externalizing symptoms and low levels of internalizing symptoms were associated with high levels of amount of use among users. These findings suggest that developmental models of substance use that incorporate internalizing symptomology should consider the context of externalizing problems and distinguish probability and amount of use.     

The Cross-Temporal Associations between Rumination Subtypes and Substance Use in Adolescence: Exploring the Moderating Role of Gender

Several studies have linked rumination to substance use. However, only one study thus far has focused on the differential associations between the subtypes of rumination (brooding and reflection) and substance use. This previous study was cross-sectional in nature, so less is known about how these variables are related across time. To address this issue, the present three-wave longitudinal study investigated the cross-temporal associations between subtypes of rumination, alcohol consumption, drug consumption and substance use problems, using cross-lagged path analyses. In addition, the study investigated whether the cross-lagged paths of interest were moderated by gender. The sample consisted of 309 adolescents (62.1 % boys) between the ages of 13 to 20 years old (M _age at T1?=?16.82 years, SD?=?1.32). Results indicated that substance use problems predicted increases in levels of brooding and reflection over time. These effects were moderated by gender so that substance use problems only predicted increases in levels of brooding and reflection in girls. In contrast to our expectations, higher levels of brooding predicted a decrease in alcohol consumption over time, and this effect was not moderated by gender. Cross-lagged analyses also showed that alcohol consumption predicted an increase in substance use problems. All results emerged independently of depressive symptoms. The findings of the present study add to the growing body of literature on the associations between rumination subtypes and substance use in adolescence, and highlight the importance of using longitudinal designs to address the issue of directionality.     

The Effects of Family Type, Family Relationships and Parental Role Models on Delinquency and Alcohol Use Among Flemish Adolescents

This study focused on the effects of family type, family relationships and socialization on alcohol consumption and delinquent behaviour among Flemish adolescents. Data came from the second round of the Leuven Adolescents and Families Study and were collected in 2010 by paper-and-pencil questionnaires in 10 different secondary schools (N = 1,688). The results show that children living in non-intact families are more likely to be delinquent and to drink alcohol at an age it is not legally allowed (below 16 years old). High delinquent behaviour is found among boys in single parent families and among girls in stepfamilies. For alcohol use the reverse is true. A good relationship with the same-sex parent is negatively associated with delinquency. High interparental conflict increases delinquency for boys and alcohol use for girls. Parental role models are highly important, since drinking behaviour of parents, and especially the same-sex parent, are positively associated with externalising problems of children.     

Anxiety and Depression Symptoms in Children with Asperger Syndrome Compared with Attention-Deficit/Hyperactivity Disorder and Depressive Disorder

The objective of this study was to examine (a) anxiety and depression symptoms in children with Asperger syndrome (AS) compared to children with attention-deficit/hyperactivity disorder (ADHD) and children with depressive disorder; (b) parental anxiety and depressive symptoms in the three groups; and (c) the association between the anxiety and depression symptoms of children and their parents. The emotional and behavioral problems of 56 children with AS (48 boys, 8 girls, mean age, 9.39 ± 2.01 years) were compared with 56 ADHD children and 56 depressive disorder children, matched for age and sex. Their parents’ anxiety and depression symptoms were also compared. Trait-anxiety and internalizing problems in AS children were higher than those in ADHD children and as high as those in depressive disorder children (F = 8.83, p < 0.001 and F = 8.21, p < 0.001). Parents’ anxiety and depression symptoms did not differ among the three groups, but correlations between maternal anxiety and depression and children’s emotional and behavioral problems were most prominent in the AS group. We suggest that the assessment and treatment of children with AS should involve detailed assessment, possible concomitant treatment for comorbid anxiety and depression, and parental education about the effect of parental emotional states on children.     

Behavioral Couples Treatment for Substance Use Disorder: Secondary Effects on the Reduction of Youth Internalizing Symptoms

This study examined the secondary effects of Behavioral Couples Treatment (BCT) for parents with substance use disorder on youth reports of internalizing symptoms (i.e., depressive and anxiety symptoms). Participants were 59 triads (father, mothers, and youth; 32 girls, 27 boys) in which one or both parents met criteria for drug or alcohol use disorder (or both). Mothers, fathers, and youth completed pretreatment, post-intervention, and 6-month post-intervention follow-up assessments. Two piecewise latent growth models examined whether number of sessions attended was associated with parents’ relationship satisfaction or its growth over time, and in turn if parents’ relationship satisfaction was uniquely associated with youth depressive/anxiety symptoms or their growth over time. A significant indirect effect at post-intervention revealed the number of sessions attended contributed to decreases in youth depressive symptoms via increases in mothers’ and fathers’ relationship satisfaction. Mothers’ relationship satisfaction uniquely mediated the relationship between number of sessions attended and youth depressive symptoms at post-intervention. With regards to fathers, there was a non-significant trend such that increases in sessions attended was associated with decreases in youth depressive symptoms post- intervention via increasing relationship satisfaction among fathers. Findings suggest that BCT may have protective secondary effects in reducing youth reports of depressive symptoms among couples in which one or both parents have substance use disorder.     

Secular Trends in Depressive Symptoms Among Norwegian Adolescents from 1992 to 2010

Several survey studies among adolescents have shown increasing rates of depressive symptoms over the last two to three decades. We know however little about mechanisms that might explain this increase. The present study uses data from three nationwide representative surveys of 16–17 year-old Norwegian adolescents that were conducted according to identical procedures in 1992, 2002, and 2010 (response rates 97.0, 91.0, 84.3 %, respectively). At each time point, approximately 3,000 adolescents participated (48.8 % girls and 51.2 % boys). Questionnaire data on depressive symptoms and a variety of potential risk and protective factors that might explain time trends in such symptoms were assessed at all time points. The results showed that the prevalence of high scores on depressive symptoms increased significantly between 1992 and 2002 among both boys and girls. No significant changes were observed between 2002 and 2010. The increase from 1992 to 2002 among girls and boys could be partially attributed to increases in eating problems and cannabis use, while reduced satisfaction with own appearance among girls contributed as well. Although the study does not provide information about the causal direction between putative risk factors and depressive symptoms, the results provide some indication that eating problems, cannabis use, and appearance related factors may contribute in explaining secular trends in depressive symptoms.     

Experiential avoidance in adolescents with borderline personality disorder: comparison with a non-BPD psychiatric group and healthy controls

ABSTRACT

Previous research has identified experiential avoidance (EA) as related to a host of adolescent internalizing and externalizing problems, as well as borderline personality disorder, suggesting that it is a crosscutting factor for adolescent psychopathology. It remains unclear whether EA differs among adolescents with BPD compared to adolescents with other psychiatric disorders and healthy adolescents. The aims of this study were to 1) examine EA in adolescents with BPD compared to non-BPD inpatient adolescents and healthy adolescents, and 2) to evaluate whether EA has a unique relationship to borderline pathology over and above internalizing and externalizing. Self-report measures of BPD features, EA, and psychopathology were completed by 692 adolescents (64.5% female, M_age= 15.20). This sample included a group of psychiatric inpatient youth (n = 197 BPD; n = 403 non-BPD) and a group of healthy adolescents (n = 92). Results revealed that EA differed significantly across all three groups, with the highest level of EA evidenced in adolescents who had BPD. Furthermore, there was a significant, unique association between BPD symptoms and EA over afnd above internalizing and externalizing pathology. These findings pinpoint EA as an important risk marker and possible target of prevention or intervention for adolescent BPD.     

Perceived Breast Development and Adolescent Girls’ Psychological Well-Being

This study, based on U.S. nationally-representative data from the National Longitudinal Study of Adolescent Health (8,593 13–18?year old girls), explored how perceived breast development was related to psychological well-being among adolescent girls including variations by age and race-ethnicity. It was hypothesized that greater breast development would detrimentally influence adolescent girls’ psychological well-being, although these associations were expected to be stronger for younger adolescent girls and for Whites. Results using multivariate regression analyses with robust standard errors showed that greater perceived breast development was associated with lower self-esteem and higher depressive symptoms for 13–15?year old White, African American (for self-esteem only), and Hispanic (for depressive symptoms only) girls. Although perceived breast development was not associated with 16–18?year old girls’ self-esteem, supplemental analyses found that 16–18?year old Asian American and White girls with considerable or little breast development had more depressive symptoms than those with some breast development. Menarche at a younger age, overweight BMI, perceptions of being overweight, and efforts to lose weight explained a substantial portion of these associations. This study shows that greater perceived breast development, particularly if it occurs at a younger age, is a risk factor for poorer psychological well-being among adolescent girls including racial-ethnic minorities.     

L’impact du burnout scolaire sur les comportements d’alcoolisation des adolescents

Objective

The aim of this study was to explore the impact of school-related burnout symptoms. on alcohol consumption habits among adolescents. Alcohol consumption is rather common among adolescents. Indeed, recent French research (Spilka et al., 2015) has shown that in a sample of 17-year-old adolescents up to 89.3% declared at least one alcohol consumption experience over lifetime, 58.9% experienced drunkenness over the last year, and 48.8% declared binge drinking experiences over last month. In the meantime, high-school students are exposed to a high level of school-related stress, which could lead to school-related burnout (Salmela-Aro et al., 2009). Previous studies have shown that school-related burnout is associated with several addictive behaviors, such as tobacco use (Moncla, Walburg, Milhaes, 2014) cannabis consumption (Walburg, Moncla, Milhaes, 2015) or problematic Facebook use (Walburg, Milhaes, Moncla, 2016). Therefore, the aim of the present study was to explore weather school-related burnout could influence alcohol use behaviors among high-school students.

Work Stressors,Depressive Symptoms,and Hazardous Drinking Among Navy Members Across Deployment

Few studies have attempted to examine how changes in work stressors from predeployment to postdeployment and reintegration may be associated with changes in mental health symptoms and hazardous drinking. The present study examined associations between work stressors, depressive symptoms, and hazardous drinking, and whether depressive symptoms mediated the association between work stressors and hazardous alcohol use or vice versa across deployment (predeployment, postdeployment, and 6-month reintegration). Participants were 101 U.S. Navy members (72 men; mean age = 28.34 years; SD = 5.99 years) assigned to an Arleigh Burke-class destroyer that experienced an 8-month deployment after recent wars in the Middle East. They completed measures that assessed work stressors, depressive symptoms, and alcohol use at each time point (i.e., predeployment, postdeployment, and 6-month reintegration). Using a parallel process latent growth modeling approach, we found a significant indirect effect at postdeployment such that an increase in work stressors contributed to increases in hazardous drinking via increases in depressive symptoms. Specifically, increases in work stressors significantly predicted increases in depressive symptoms, which in turn significantly predicted increases in hazardous drinking from pre- to postdeployment. Our findings garner support for affect regulation models and indicate that work stressors and changes in work stressors and depressive symptoms may be key to hazardous alcohol use among U.S. Navy members experiencing high pace of deployment. Taken together, our results help identify targets for alcohol prevention efforts among current military members.     

Developmental Trajectories of Chinese Children’s Relational and Physical Aggression: Associations with Social-Psychological Adjustment Problems

The purpose of this short-term longitudinal study was to examine Chinese children's trajectories of physical and relational aggression and their association with social-psychological adjustment problems (i.e., depressive symptoms and delinquency) and gender. Fourth and fifth grade children in Taiwan (n?=?739, age 9-11) were followed across 1?year. Results of Linear Mixed Models demonstrated that, on average, relational aggression increased in a linear fashion for fifth grade children and girls and physical aggression remained stable for boys and increased linearly for fifth grade girls. Further, increases in relational aggression were associated with time-dependent increases in depressive symptoms, and the effect size of this association seemed to be stronger than that of physical aggression. Findings are discussed in the context of Chinese culture.     

Longitudinal Relations Between Parent–Child Conflict and Children’s Adjustment: The Role of Children’s Sleep

Sleep was examined as a process variable in relations between verbal and physical parent–child conflict and change in children’s internalizing and externalizing symptoms over time. Participants were 282 children at T1 (M age?=?9.44 years; 48 % girls), 280 children at T2 (M age?=?10.41 years), and 275 children at T3 (M age?=?11.35 years). Children reported on parent–child conflict, sleep was assessed with actigraphy, and parents reported on children’s internalizing and externalizing symptoms. Autoregressive effects for sleep and internalizing and externalizing symptoms were controlled to examine change over time. Supportive of intervening processes, physical parent–child conflict at T1 and increased change in internalizing and externalizing symptoms at T3 were indirectly related through their shared association with reduced sleep continuity (efficiency, long wake episodes) at T2. Findings build on a small but growing literature and highlight the importance of considering the role of sleep in relations between family conflict and child development.     

Impulsivity mediates the association between borderline personality pathology and body mass index

Borderline personality disorder (BPD) is associated with obesity, a major risk factor for a number of chronic illnesses (e.g., cardiovascular disease). We examined whether impulsivity and affective instability mediate the association between BPD pathology and body mass index (BMI). Participants were a community sample of adults ages 55–64 and their informants. The Structured Interview for DSM-IV Personality measured BPD symptoms and the Revised NEO Personality Inventory measured self- and informant-report impulsivity and affective instability. Mediation analyses demonstrated that only higher self-report impulsivity significantly mediated the association between greater BPD pathology and higher BMI. A subsequent model revealed that higher scores on the impulsiveness (lack of inhibitory control) and deliberation (planning) facets of impulsivity mediated the BPD–BMI association, with impulsiveness exerting a stronger mediation effect than deliberation. Obesity interventions that improve inhibitory control may be most effective for individuals with BPD pathology.