The aim of the study was to investigate the phenomenological differences between intrusive memories and rumination in PTSD. The study population consisted of 31 patients with PTSD referred for cognitive behavioural therapy to specialist services. A semi-structured interview was used to examine the characteristics of the most prominent intrusive memory and rumination. Intrusive memories were predominantly sensory experiences of short duration, whereas rumination was predominantly a thought process of longer duration. Shame was associated more with rumination than with intrusive memories. Anxiety, helplessness, numbness, and threat were greater at the time of the trauma than when experiencing the intrusive memory. In contrast, feelings like anger and sadness were greater when experiencing intrusive memories than at the time of the event. The distinction between intrusive memories and rumination is of clinical importance as intrusive memories usually decrease with imaginal reliving of the trauma, whereas rumination may require different therapeutic strategies, such as rumination-focused or mindfulness-based cognitive therapy.

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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 PARTICIPANTSIn 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 MEASURESThe 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. RESULTSOf 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 RELEVANCEIn 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.

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This study confirms the need for improved documentation of DSH and its coding; this needs to be reviewed at local and national level. The vast majority of older people who attempt suicide do have subsequent contact with psychiatric services. There is a strong likelihood of repeat DSH and a higher risk of death by natural causes, emphasising the need to conceptualise DSH as a risk factor relevant to all medical specialities.