How does mindfulness skills training works on emotion dysregulation in borderline personality disorder?

How does mindfulness skills training works on emotion dysregulation in borderline personality disorder? | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article How does mindfulness skills training works on emotion dysregulation in borderline personality disorder? Carlos Schmidt, Joaquim Soler, Daniel Vega, Stella Nicolaou, Laia Arias, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3976899/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Sep, 2024 Read the published version in Borderline Personality Disorder and Emotion Dysregulation → Version 1 posted 9 You are reading this latest preprint version Abstract Background Mindfulness skills training is a core component of Dialectical Behavior Therapy and aims to improve emotion dysregulation (ED) in people with Borderline Personality Disorder (BPD). However, the underlying mechanisms of change are not fully understood. Methods A total of 75 BPD outpatients participated in a 10-week mindfulness skills training. Decentering, nonjudgment, body awareness and attention awareness was proposed as putative mechanisms. Multilevel models with a time-lagged approach were conducted to examine the temporal dynamics between these mechanisms and ED. Results Greater nonjudgment and body awareness showed within-person effects; participants who reported higher nonjudgement of inner experience and body awareness than their own personal average at a given week showed improvement in ED at the following week. Notably, decentering moderated these associations, such that increased nonjudgment and body awareness predicted improvements in ED more strongly in those participants with high decentering ability. Lastly, a bidirectional relationship between the mechanisms and ED was found; when participants were more emotionally dysregulated than their usual state, they showed less gain in the mechanisms at the following week. Conclusions Knowing how mindfulness training works is relevant to optimize treatments. Clinicians may use strategies to increase these mechanisms when the goal is to improve emotion regulation difficulties in BPD. Mindfulness training mechanisms moderators Emotion regulation Borderline personality disorders Dialectical behavior therapy Figures Figure 1 Figure 2 INTRODUCTION Borderline personality disorder (BPD) is a severe mental illness with an estimated community prevalence of 2.7%. It is characterized by affective dysregulation, unstable identity and interpersonal relationships, and serious behaviors such as non-suicidal self-injury [ 1 , 2 ]. The complexity and severity of BPD is characterized by high comorbidity with other psychiatric disorders, drug and/or alcohol abuse, and a high risk of suicide, which lead to an extensive use of healthcare resources, high costs of treatment, polymedication, as well as impaired psychosocial and occupational functioning [ 3 – 6 ]. One of the main features underlying cognitive, affective, and behavioral instability in BPD is a pervasive pattern of emotion dysregulation (ED) [ 7 , 8 ]. ED involves the inability to regulate or change an emotional response or expression in a desired manner and involves a lack of (or maladaptive use of) emotion regulation strategies [ 9 ], which in turn facilitates the emergence of impulsive and risky behaviors (e.g., self-harm, substance use). These risk behaviors can be understood as a consequence of emotion regulation difficulties or as a strategy to regulate a distressing emotional state [ 10 ]. Therefore, prevention and treatment efforts are focused on addressing ED as a means of reducing distress, suffering, psychosocial impairment, and potentially life-threatening risk behaviors in individuals with a diagnosis of BPD [ 11 ]. Psychotherapy is the main recommended treatment for BPD [ 10 , 12 ]. One of the empirically based therapies for the treatment of BPD is dialectical behavior therapy (DBT) [ 13 ]. DBT is a multifaceted intervention involving individual and group therapy. The group therapy addresses the skills training and comprises four different modules: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. Mindfulness is one of the main components of DBT, and mindfulness training are the first skills taught to support the other DBT skills [ 14 , 15 ]. Interestingly, mindfulness skills training as a stand-alone intervention improves ED in BPD [ 16 , 17 ], but the underlying mechanisms of change are not yet fully understood. An understanding of the mechanisms (i.e., mediators) through which psychological interventions produce changes in desired outcomes (understanding how and why it works) is essential to optimize treatments [ 18 ]. In addition, identifying moderators (i.e., the effects on direction or magnitude of the relation between the intervention and outcome) may guide therapeutic strategies that effectively impact the mechanisms or processes of an intervention in order to obtain therapeutic improvements [ 19 ]. Thus, clinical research based on mechanisms of change (and moderators) may inform which processes (e.g., cognitive, behavioral) of an intervention contribute to the expected outcomes and in what ways. One way to study the mechanisms is to demonstrate that changes in the putative mechanism are related to changes in the expected outcome through a temporal precedence with repeated session-by-session measures [ 18 , 20 ] and also disaggregating within- and between-person effects of the mechanisms [ 21 ]. This method allows for a more precise examination of the process of change within an individual. Research has focused on uncovering the mechanisms of change by which DBT skills training improves ED in BPD [ 22 ]. Studies suggest that a greater use of behavioral skills (learned during DBT skills training) mediates changes in emotion dysregulation [ 9 , 23 ]. More specifically, studies exploring the within-person effects found that greater skills use predicted improvements in ED [ 24 , 25 ] and fewer risk behaviors associated with high ED [ 26 ] after undergoing DBT skills training. However, there is a scarcity of studies focused on studying the mechanisms of change of mindfulness skills training as a stand-alone intervention. For example, a recent study reported that the amount of mindfulness practice at a given week (a required dose of at least 3 days and 30 minutes) predicted improvements in ED at the following week in BPD outpatients [ 27 ]. As noted, previous findings suggest that the use of DBT skills (e.g., mindfulness) improves ED in people with BPD. Although prior theoretical and empirical accounts have proposed decentering (i.e., change in perspective on the self), emotion regulation (i.e., process emotional reactions with non-judgmental stance), body awareness and attention awareness as possible mechanisms or processes by which mindfulness practice may works [ 28 , 29 ], the underlying mechanisms of change remains unclear. Decentering consists of adopting a change in perspective of one's own experience through the disidentification of the mental contents that are usually experienced as defining the self [ 30 , 31 ]. This metacognitive capacity involves a process of meta-awareness by observing thoughts and emotions in a non-attached manner, which results in a reduced reactivity to thought content [ 32 ]. Interestingly, decentering has been proposed as a mediating mechanism both in mindfulness DBT skills training [ 17 ] and in emotion regulation interventions [ 33 ]. The emotion regulation process related to a nonjudgmental stance towards internal experience (i.e., when individuals stop criticizing themselves) is associated with a lower level of psychopathology [ 34 ]. However, individuals with BPD are characterized by a high tendency to judge their internal experience [ 14 , 35 ]. Therefore, strategies that help increase the capacity for nonjudgment are particularly relevant to foster emotional acceptance in BPD [ 15 ]. Interestingly, this capacity (i.e., nonjudgment) is an active component of mindfulness DBT skills training. However, it has been shown to act as a mediating mechanism between DBT skills training and clinical outcomes in BPD [ 36 , 37 ]. For instance, increased levels of nonjudgment over time predict fewer borderline symptoms in women with BPD features [ 38 ]. Body awareness involves paying attention to body information by identifying internal body sensations (e.g., tension) and the associated emotional state (feeling relaxed or stressed) as opposed to avoiding the bodily experience [ 39 ]. Bodily sensations are a common object of attention during mindfulness meditations [ 40 ] and would be cultivated through the ability to observe the inner experience [ 41 ]. Body awareness levels are significantly decreased in individuals with BPD compared to healthy controls, and this deficit is associated with ED [ 42 ]. Therefore, increasing body awareness is a relevant aspect in the treatment of psychological disorders, including BPD [ 15 , 28 ]. Attention awareness is another putative mechanism underlying mindfulness practice and involves cultivating a present-moment awareness. For instance, mindfulness meditation involves focusing attention on an object (e.g., breathing), noticing distraction, and returning to the object of attention [ 43 ]. Promoting attention regulation in individuals with BPD is relevant to ameliorate ED and impulse control by teaching participants to observe what they are experiencing in the present moment, without attachment or avoidance of the content of the experience [ 15 ]. To our knowledge, no study has evaluated these proposed mechanisms at the same time in a mindfulness training for individuals with BPD. Knowing these specific mechanisms of change may be useful for clinicians to understand how mindfulness training works. In summary, the main question guiding this study is how participants with BPD improve their level of ED through a mindfulness skills training. Therefore, this study explored the potential mechanisms of change within mindfulness training, focusing on decentering, nonjudgment, body awareness and attention awareness. Firstly, we evaluated whether these mechanisms and ED showed improvement over the course of mindfulness skills training. Secondly, we explored the temporal dynamics between mechanisms and ED throughout mindfulness skills training. Thirdly, based on previous findings [ 44 ], we explored decentering as a metacognitive ability that could moderate (i.e., increase the strength) the relationship between the other proposed mechanisms and ED. In summary, our hypotheses were: (1) Decentering, nonjudgment, body awareness and attention awareness would increase and ED would decrease during mindfulness skills training; (2) greater within- and between-person effects of mechanisms would predict improvements in ED in the following week; and this relationship would be bidirectional; and (3) the association between nonjudgment, body awareness, and attention awareness with ED would be greater among participants with higher decentering capacity. METHOD Participants Participants were recruited from the Department of Psychiatry Unit of the Hospital de la Santa Creu i Sant Pau (Barcelona, Spain). This outpatient program is part of the Public National Mental Health Service of Spain and provides specialized care for people with BPD diagnosis. A total of 95 BPD outpatients were enrolled in a DBT skill training. Of these, 75 participants were included in the present study (13 discontinued treatment before starting the first session; 7 had very low attendance and completed less than 3 weekly assessments). All participants were evaluated by a psychiatrist and a clinical psychologist from the psychiatry unit, both with a doctoral degree and experience in the treatment of people with BPD. The clinical diagnosis was based on two semi-structured interviews: Structured Clinical Interview for DSM IV axis II Disorders (SCID II) [ 45 ]and the Revised Diagnostic Interview for Borderlines (DIB-R) [ 46 ]. The inclusion criteria were: (i) diagnostic confirmation of BPD; (ii) age between 18–55 years; (iii) absence of any of the following comorbid conditions: schizophrenia, drug-induced psychosis, organic brain syndrome, substance dependence, bipolar disorder, intellectual disability; (iv) not receiving any other type of psychotherapy at the time of study enrollment. Patients were allowed to continue with the drug regimen followed prior to study enrollment. However, they were not allowed to change the type or dose of drugs during the study period. Participants had not previously participated in DBT skills training. Procedure Participants were enrolled in a 10-week DBT mindfulness skills training. In total, 7 groups were conducted between February 2020 and October 2023 (12–15 participants/group). Each intervention group followed the same structure and weekly sessions were 2.5 hours in length. All groups were led by the same team (2 clinical psychologists with training and experience in DBT, and expertise in mindfulness meditation). For each participant, written informed consent was obtained prior to inclusion in the study. The study was approved by the Clinical Research Ethics Committee of the Hospital de la Santa Creu i Sant Pau and was conducted in accordance with the criteria of the Declaration of Helsinki. The intervention was based on the DBT skills training protocol [ 15 ]. The 10-week mindfulness training program consisted of 1 week of orientation and goals, 6 weeks of mindfulness skills, and 3 weeks of acceptance skills (taken from the distress tolerance module). This mindfulness training for BPD is proposed by Linehan as an alternative to standard DBT skills training [ 15 ] and its efficacy has been shown in previous clinical trials [ 16 , 47 ]. The mindfulness and acceptance skills taught were (i) Wise Mind; (ii) "What" Skills (i.e., observing, describing, participating); (iii) "How" Skills (i.e., nonjudgmentally, one-mindfully, and effectively); (iv) Radical Acceptance; (v) Mind Turning and Willingness; (vi) Half-smile and willing hands; and (vii) Mindfulness of current thoughts. Formal and informal mindfulness practice were taught during the sessions. In each session, a new skill was introduced and practiced through role-playing and discussion. Participants were then given meditation audios and worksheets related to the skills and instructed to practice at home. In the next session, the homework was reviewed and each participant commented on his or her experience with the practice, as well as any difficulties encountered. The therapist then reinforced the participants' progress and suggested effective ways to improve skill practice. The meditation audios were recorded by the lead therapist and lasted 10 minutes. Measures Several repeat measures were collected on a weekly basis during the mindfulness training. Only the first introduction/orientation session was not assessed because it did not include mindfulness skills practice. In order to assess the participants’ level of ED and specific mechanism of change, they were asked to complete the following scales before starting a new session (i.e., session 2 onwards). Emotion Dysregulation . The Brief Version of the Difficulties in Emotion Regulation Scale was used to capture how participants managed their weekly difficult emotional experiences (DERS-18) [ 48 ]. The 18-items Spanish translation of this self-report scale was administered and the total score was used in the analyses as an overall measure of emotion dysregulation. Items were rated on a scale from 1 (almost never) to 5 (almost always). This scale has high internal reliability (Cronbach's α = .91). In the current study, this scale obtained a good internal reliability at session 1 (Cronbach's α = .87). For each mechanism of change proposed, the 3 most representative items of each original scale were used based on the highest factor loadings, with the aim of facilitating the weekly assessment of the participants. The same Likert scale was used for all items, from 1 (almost never) to 5 (almost always). Decentering . It was assessed with the Experiencing Questionnaire (EQ) [ 31 ]. The EQ is a 20-item self-report scale that assesses decentering and rumination. Decentering is the ability to observe thoughts and feelings in a detached manner [ 31 ]. In the present study, items from the Spanish validation EQ-Decentering was used [ 49 ]. These items were: (i) “ I can separate myself from my thoughts and feelings ” (factor loading: .74); (ii) “ I can observe unpleasant feelings without being drawn into them ” (factor loading: .72); (iii) “ I view things from a wider perspective ” (factor loading: .77). The Spanish EQ version has good internal reliability (Cronbach’s α = .89) [ 49 ] and in the present study the 3-items scale had an acceptable internal reliability at session 1 (Cronbach’s α = .73). Nonjudgment . It was assessed with the Nonjudging of Inner Experience sub-scale of Five Facets Mindfulness Questionnaire (NJ-FFMQ) [ 41 ]. NJ-FFMQ refers to taking a non-evaluative stance toward thoughts and feelings and is closely associated with acceptance, a central component of mindfulness [ 41 , 50 ]. In the present study, items of the Spanish validation of NJ-FFMQ subscale was used [ 50 ]. These items were: (i) “ I make judgments about whether my thoughts are good or bad ” (factor loading: .69); (ii) “ I tell myself I shouldn’t be thinking the way I’m thinking ” (factor loading: .67); (iii) “ I think some of my emotions are bad or inappropriate and I shouldn’t feel them ” (factor loading: .73). The Spanish NJ-FFMQ version has an excellent internal reliability (Cronbach's α = .91) [ 50 ] and the internal reliability of the 3-items in the current study at session 1 was good (Cronbach's α = .81). Body awareness . It was assessed with the Body Awareness of Scale Body Connection (BA-SBC), which measures the conscious attention to sensory signals of the state of the body, such as the sensation of tension or relaxation [ 39 ]. Items of the Spanish BA-SBC version was used in the current study [ 51 ]. These items were: (i) “ I take my body's signals to understand how I feel ” (factor loading: .83); (ii) “ I listen to my body's information about my emotional state ” (factor loading: .85); (iii) “ When I am tense, I pay attention to where the tension is concentrated in my body ” (factor loading: .72). The Spanish BA-SBS has a good internal reliability (Cronbach's α = .86) [ 51 ]. The 3-items scale used in the current study also showed good internal reliability at session 1 (Cronbach's α = .84). Attention awareness : It was assessed with the Mindfulness Attention Awareness Scale (MAAS) [ 52 ]. It is a 15-item self-reported questionnaire, which measures an individual’s awareness of their experience in the present moment, in contrast to having automated behaviors. Items of the Spanish MAAS version were used in the current study [ 53 ]. These items were: (i) " I drive places on ‘automatic pilot’ and then wonder why I went there " (factor loading: .77); (ii) " I find myself doing things without paying attention " (factor loading: .71); (iii) " I snack without being aware that I’m eating " (factor loading: .69). Both the original version [ 52 ] and the Spanish version [ 53 ] present high internal reliability (Cronbach’s α = 0.82 and 0.89, respectively). In the present study, the 3-items scale showed an acceptable internal reliability at session 1 (Cronbach's α = .71). Data analysis First, descriptive analyses of the participants were conducted. Second, pre- and post-intervention correlations were calculated to determine baseline and post-treatment relationships between mechanism of change and ED. Third, multilevel modeling (MLM) analyses with a restricted maximum likelihood (REML) estimation method and with a time-lagged approach were conducted to examine the temporal dynamics over time between the proposed mechanism of change (i.e., mediators) and ED. MLM allows modeling changes in the measures of interest over time and time-lagged predictions allows exploring the association of a previous time point measure (i.e., time x) with a later time point measure (i.e., time x + 1). For these analyses, the between- and within-person variability was disaggregated, that is recommended for multilevel models with repeated measures data [ 21 ]. To calculate the within-person effects (i.e., level 1), the person-mean-centered was calculated by subtracting the participant-level mean across observations from each participant's score at each time point. Thus, scores at each time point become a deviation score, representing the person's deviation from her own average at that time point. To obtain the between-person effects (i.e., level 2), the grand-mean-centered was calculated by subtracting each participant's mean from the sample average of all participants’ means. Thus, the participant-level mean represents the person's deviation from the total sample average [ 54 ]. This approach is recommended to interpret the parameters in MLM [ 55 ]. Then, it was tested whether between- and within-person changes in decentering, nonjudgment, body awareness and attention awareness at session x predicted changes in ED at session x + 1, over mindfulness skills training. The reverse direction was also explored to assess the bidirectional relationship. That is, whether between- and within-person changes in ED level at session x predicted changes in the proposed mechanisms of change at session x + 1. Fourth, cross-level interactions were conducted to assess the moderating role of decentering between the association of the other mechanisms and ED. A cross-level interaction occurs when a level 2 variable (i.e., between-person) moderates the magnitude of a level 1 association (i.e., within-person) [ 55 ]. Separate MLM analyses were performed to explore whether the between-person effect of decentering (level 2) moderates the within-person effects of nonjudgment, body awareness and attention awareness (level 1) on the prediction of ED. Significant interactions were probed by testing the simple slopes of each mechanism (e.g., nonjudgment) on ED at high and low levels of decentering capacity (i.e., ± 1 SD) [ 56 ]. In all MLM analyses the participants' intercept was defined as random effects. The partR 2 package was used [ 57 ] to estimate the marginal and conditional R 2 [ 58 ]. The coefficient of determination R 2 was used to interpret the effect size of the models, which were classified as weak (.02-.13), medium (.13-.26) and large (> .26) [ 59 ]. All models were tested with the lme4 package [ 60 ] in RStudio and IBM SPSS statistics (version 24) was used for descriptive analyses. RESULTS Characteristics of the sample A total of 75 outpatients with a diagnosis of BPD attended a mindfulness skills training (M age = 27.15 [range 18–53], 93.3% female). A total of 499 observations were obtained (Mean = 4.95, SD = 2.60). Most participants were working (33%) or studying (32%) at the time of the evaluation (see Table 1 ). Table 1 Sociodemographic characteristics of total sample Total sample (N = 75) Age , mean (SD) 27.15 (8.62) Sex , female, n (%) 70 (93.3) Educational level , n (%) Middle school High school 33 (44) 23 (30.7) University degree 19 (25.3) Employment Status , n (%) Unemployed 17 (22.7) Employed 25 (33.3) Student 24 (32) Sick leave 4 (5.3) Disability pension 5 (6.7) Clinical characteristics , mean ( SD) DIB-R total score 7 (1.05) Previous self-injury behavior , n (%) Past suicide acts 32 (42.6) Past non-suicide self-injury 53 (70.6) Pharmacological treatment , n (%) Antidepressant 56 (74.6) Benzodiazepines 27 (36) Antipsychotics 17 (22.6) Mood stabilizers 15 (20) Notes. SD = standard deviation. DIB-R = Revised Diagnostic Interview for Borderlines. [Insert Table 1 here] Regarding the weekly practice of the tasks assigned during training, the participants practiced mindfulness skills for a median of 3 days (M = 2.80, SD = 1.97, range = 0–7) and a mean of 27.90 minutes per week (SD = 27.81, range = 0-180). In addition, practice time increased over the course of the training, both in days (b = .16, SE = .02, p < .001) and minutes (b = 1.27, SE = .38, p < .01). Table 2 shows the correlations between ED (DERS-18) and the mechanisms of change proposed in sessions 1 and 9 of the mindfulness training. Correlations were significant both at baseline ( r range from − .306 to − .487) and at the end of the training ( r range from − .573 to − .642). However, more robust correlations were observed in session 9 (moderate to high). Table 2 Correlations between Skills and Emotion Dysregulation DERS Decentering Nonjudgment Body awareness Attention awareness DERS - − .558** − .642** − .593** − .573** Decentering − .487*** - .290* .569** .439** Nonjudgment − .416** .369** - .434** .235 Body awareness − .480** .533** .241 - .443** Attention awareness − .306* − .089 .240 .101 - Notes. Correlations below the diagonal correspond to session 1 scores. Correlations above the diagonal correspond to session 9 scores. DERS = Difficulties in Emotion Regulation Scale; Decentering = Experience Questionnaire - Decentering items [EQ]; Nonjudgment = Five facet Mindfulness Questionnaire – Nonjudge sub-scale items [FFMQ-NJ]; Body Awareness = Scale Body Connection – Body-Awareness sub-scale items [SBC-BA]; Attention Awareness = Mindful Attention Awareness Scale items [MAAS]. *p < .05, ⁎⁎p < .01, ***p < .001 [Insert Table 3 here] Table 3 Time-lagged analysis of changes in mechanisms and improvement in emotion dysregulation DERS Predicted by time-lagged Decentering Decentering Predicted by time-lagged DERS Predictor (session x-1) B SE t p-value B SE t p-value Intercept 2.73 1.42 1.92 .05 − .29 .29 -1.01 .31 Time (sessions) − .58 .17 -3.36 < .001 .08 .03 2.13 < .05 Between-person -3.71 .52 -7.02 < .001 − .12 .01 -7.09 < .001 Within-person − .23 .23 − .98 .32 − .02 .01 -2.17 < .05 R 2 marginal = .31 [95% CI: .19-.41]; R 2 conditional = .69 [95% CI: .66-.74] R 2 marginal = .27 [95% CI: .20-.33]; R 2 conditional = .56 [95% CI: .46-.64] DERS Predicted by time-lagged Nonjudgment Nonjudgment Predicted by time-lagged DERS Predictor (session x-1) B SE t p-value B SE t p-value Intercept 1.78 1.44 1.22 .22 − .88 .32 -2.71 < .01 Time (sessions) − .51 .17 -2.95 < .01 .17 .03 4.42 < .001 Between-person -3.05 .45 -6.74 < .001 − .14 .02 -6.76 < .001 Within-person − .43 .20 -2.10 <. 05 − .02 .01 -2.24 < .05 R 2 marginal = .29 [95% CI: .21-.45]; R 2 conditional = .68 [95% CI: .63-.75] R 2 marginal = .30 [95% CI: .23-.39]; R 2 conditional = .67 [95% CI: .57-.76] DERS Predicted by time-lagged Body Awareness Body Awareness Predicted by time-lagged DERS Predictor (session x-1) B SE t p-value B SE t p-value Intercept 2.35 1.51 1.55 .12 − .52 .35 -1.46 .14 Time (sessions) − .54 .17 -3.19 < .01 .11 .04 2.75 < .01 Between-person -2.29 .47 -4.89 < .001 − .12 .02 -5.13 < .001 Within-person − .59 .20 -2.83 < .01 − .01 .01 -1.00 .31 R 2 marginal = .20 [95% CI: .15-.33]; R 2 conditional = .69 [95% CI: .57-.74] R 2 marginal = .19 [95% CI: .07-.25]; R 2 conditional = .63 [95% CI: .56-.73] DERS Predicted by time-lagged Attention Awareness Attention Awareness Predicted by time-lagged DERS Predictor (session x-1) B SE t p-value B SE t p-value Intercept 2.24 1.48 1.50 .13 − .86 .35 -2.43 < .05 Time (sessions) − .57 .17 -3.36 < .001 .16 .03 4.15 < .001 Between-person -2.28 .40 -5.59 < .001 − .14 .02 -5.80 < .001 Within-person − .35 .22 -1.58 .11 − .03 .01 -2.69 < .01 R 2 marginal = .24 [95% CI: .21-.36]; R 2 conditional = .69 [95% CI: .66-.77] R 2 marginal = .26 [95% CI: .14-.33]; R 2 conditional = .73 [95% CI: .69-.77] Notes. DERS = Difficulties in Emotion Regulation Scale; Decentering = Experience Questionnaire - Decentering items [EQ]; Nonjudgment = Five facet Mindfulness Questionnaire – Nonjudge sub-scale items [FFMQ-NJ]; Body Awareness = Scale Body Connection – Body-Awareness sub-scale items [SBC-BA]; Attention-Awareness = Mindful Attention Awareness Scale items [MAAS]; R 2 marginal = the variance explained by fixed effect predictors relative to the total variance in the response; R 2 conditional = the variance explained by fixed effects plus random effects relative to the total variance in the response. Changes in emotion dysregulation and mechanisms of change during mindfulness training The effects of mindfulness training on ED levels and mechanisms of change was assessed. The mindfulness training (sessions from 1 to 9) prompted improvements in participants' ED over time (b = − .82, p < .001) as well as an increase in each of the mechanisms assessed (decentering: b = .13, p < .001; nonjudgment: b = .20, p < .001; body awareness: b = .12, p < .01; attention awareness: b = .14, p < .01). Subsequently, it was explored whether improvements in ED and gains in mechanisms of change over mindfulness training were moderated by sociodemographic variables (e.g., age, sex) or baseline clinical variables (i.e., score in diagnostic interview for Borderlines [DIB-R], past suicide acts, past non-suicidal self-injury). Improvements in ED and gains in mechanisms were not moderated by sociodemographic variables (all p-values > .11) or by any of the baseline clinical measures (all p-values > .18). Effects of mechanisms of change on emotion dysregulation over time The time-lagged effects of decentering, nonjudgment, body awareness and attention awareness on ED was explored. In these analyses, the effect of both between and within person mechanisms on ED was tested (see Table 3 ). Consistent with our hypothesis, greater both within- and between-person effect of nonjudgment and body awareness at session x predicted improvements in ED at session x + 1. This means that when participants reported higher capacity of nonjudgment and body awareness than their personal average (i.e., higher-than-usual), and more than the total sample average, they also showed an improvement/reduction in their ED level at the following week. Similarly, greater between-person (but not within-person) effects of decentering and attention awareness at session x also predicted improvements in ED at session x + 1. Therefore, when participants reported higher capacity of decentering and attention awareness than the total sample average, they showed improvements in their ED in the following week (see also Table 3 ). Medium-to-large effects size were obtained in all models (R 2 : .20-.31). Subsequently, both the between- and within-person effect was assessed of all mechanisms on ED in the same model (see Table 4 ). Greater between-person effects of decentering, nonjudgment, and attention awareness, as well as greater within-person effects of body awareness in session x predicted improvements in ED at the following week (i.e., session x + 1). The variance of the time lagged fixed effects (i.e., the four mechanisms at session x) explained 52% of the total variance of DERS in the following week, yielding a large effect size. Table 4 Full model time-lagged analysis of mechanisms and improvement in emotion dysregulation DERS Predicted by time-lagged Skills Predictor (session x-1) B SE t p-value Intercept 1.62 1.25 1.30 .19 Time (sessions) − .44 .17 -2.51 < .05 Decentering Between−person -1.73 .52 -3.29 < .01 Decentering Within−person − .006 .24 − .02 .97 Nonjudgment Between−person -2.00 .36 -5.52 < .001 Nonjudgment Within−person − .31 .21 -1.50 .13 Body Awareness Between−person − .58 .39 -1.47 .14 Body Awareness Within−person − .52 .22 -2.34 < .05 Attention-Awareness Between−person -1.42 .29 -4.86 < .001 Attention-Awareness Within−person − .19 .22 − .86 .38 R 2 marginal = .52 [95% CI: .44-.60]; R 2 conditional = .69 [95% CI: .65-.74] Notes. DERS = Difficulties in Emotion Regulation Scale; Decentering = Experience Questionnaire - Decentering items [EQ]; Nonjudgment = Five facet Mindfulness Questionnaire – Nonjudge sub-scale items [FFMQ-NJ]; Body Awareness = Scale Body Connection – Body-Awareness sub-scale items [SBC-BA]; Attention Awareness = Mindful Attention Awareness Scale items [MAAS]; R 2 marginal = the variance explained by fixed effect predictors relative to the total variance in the response; R 2 conditional = the variance explained by fixed effects plus random effects relative to the total variance in the response. [Insert Tables 3 and 4 here] Effects of emotion dysregulation on mechanism of change over time We then explored the lagged effects of ED on each mechanism of change to determine the possibility of bidirectionality (see Table 3 ). Higher within- and between-person level of ED at session x predicted decreased capacity of decentering, nonjudgment and attention awareness at session x + 1. However, only higher between-person level of ED at session x predicted decreased body awareness at session x + 1. This means that when participants had a week with more emotion regulation difficulties than their personal average, they were less able to increase decentering, nonjudgment and attention awareness at the following week. In addition, when participants had more ED than the total sample average, they were also less able to increase body awareness in the following week. In all models, medium-to-large effects size were obtained (R 2 : .19-.30). Thus, a bidirectional temporal dynamic between the proposed mechanisms and ED was found. Decentering moderates the association of body awareness, attention awareness, and nonjudgment with emotion dysregulation Subsequently, the moderating role of decentering as a metacognitive process on the association between nonjudgment, body awareness, attention awareness, and ED was assessed. In these analyses, the between-person effects of decentering as moderator, the within-person effects of nonjudgment, body awareness and attention awareness as predictors, and ED as outcome were used [ 55 ]. First, an interaction effect was found between nonjudgment x decentering in predicting ED (b = − .41, SE = .09, p < .001). Simple slope analysis showed that within-person increase in nonjudgment predicted improvements in ED more strongly among participants with high decentering (b = -2.37, SE = .31, p < .001) than among participants with low decentering (B = − .71, SE = .22, p < .01; see Fig. 1 ). Second, an interaction effect was also found between body awareness x decentering in predicting ED (b = − .25, SE = .08, p < .01). Simple slope analysis showed that a within-person increase in body awareness predicted improvements in ED more strongly among participants with high decentering (B = -1.88, SE = .30, p < .001) than among participants with low decentering (B = − .84, SE = .21, p < .001; see Fig. 2 ). There was no significant moderating effect of decentering on the association between attention awareness and ED (b = − .09, SE = .09, p = .31). In addition, there was no evidence that a within-person effect of decentering was moderated by the between-person effects of nonjudgment, body awareness or attention awareness (all p-value > .69). [Insert Figs. 1 and 2 here] DISCUSSION This study aimed to explore how mindfulness DBT skills training improves emotion regulation in people with BPD. A main finding was that participants who at a given week increased their capacity for nonjudgment of inner experience and body awareness more than their own personal average (i.e., within-person effects), and those who increased their capacity for decentering and attention awareness more than the total sample average (i.e., between-person effects), showed improvements in ED at the following week. Moreover, as expected, a bidirectional relationship was found. That is, when participants were more emotionally dysregulated than their own usual state, they showed less gains in decentering, nonjudgment and attention awareness at the following week. Lastly, decentering moderated the relationship between nonjudgment and body awareness with ED, such that increased nonjudgment and body awareness predicted improvements in ED more strongly in those participants with high decentering capacity compared with those participants with low decentering. The present study is an advance in identifying the possible mechanisms of change involved in a mindfulness DBT skills training as a stand-alone intervention to improve ED in BPD outpatients, using ad hoc methodology [ 20 ]. Previous studies reporting the mechanisms of change involved in a DBT skills training agree that greater use of behavioral skills mediates changes in ED [ 9 ]. Specifically, when participants use more DBT skills than their own personal average, their emotion regulation capacity improve [ 24 , 25 ]. A recent study explored this question only in a DBT mindfulness skills training and also found that greater use of behavioral skills (i.e., mindfulness practice) predicted improvements in ED [ 27 ]. Current results extend previous findings and provide further evidence to report specifically what are the mechanisms of change involved in a mindfulness skill training. Specifically, the within-person effects of nonjudgment and body awareness predicted subsequent improvements in ED. Previous empirical studies support these findings, showing that acceptance without judgment mediated changes in psychiatric symptoms and frequency of nonsuicidal self-injury –ED related outcomes– following DBT skills training [ 36 , 37 ]. Similarly, Eisenlohr-Moul et al. [ 38 ] found that fluctuations in nonjudgment of internal experience over time (i.e., at within-person level) predicted lower borderline symptoms in women with BPD features. The tendency to judge internal experience is characteristic in individuals with BPD and contributes to emotional regulation problems [ 35 , 61 ]. Therefore, strategies focused on improving this ability are key in the treatment of BPD [ 14 ]. The role of body awareness as a mechanism of change has been less studied in DBT interventions and the evidence obtained from other mindfulness-based interventions shows significant but small effects [ 62 ]. However, our results support the role of body awareness as a relevant mechanism to foster emotion regulation in BPD. For example, some of the items used to assess body awareness (" I take my body's signals to understand how I feel ") highlight the importance of the body (e.g., attending to bodily sensations) to facilitate awareness of one's emotions and feelings, which is a pre-condition for regulating them [ 28 ]. An additional finding in the current study was that decentering ability modulated the strength of the association between nonjudgment, body awareness, and ED, such that high decentering capacity reinforced the effect of these mechanisms on reducing ED. This result is consistent with previous studies [ 44 ] and highlights the role of decentering as a metacognitive capacity that promotes emotion regulation [ 33 ]. Decentering is described as a metacognitive awareness that helps us disidentify from the contents of our experience so that instead of fusing with them (e.g., " I am not lovable "), we can perceive them as transient mental events (e.g., " I am having a thought of not being lovable ") [ 32 ]. Given that decentering is diminished in individuals with BPD [ 49 ], a goal of mindfulness skills in DBT is to increase meta-awareness of mental contents by enhancing the ability to detach from thoughts and sensations, and decreasing reactivity to mental events [ 15 ]. Furthermore, the findings support that decentering not only allows for greater meta-awareness of mental contents but also of bodily sensations, but not inversely (i.e., moderating role), suggesting that observing judgmental thought patterns and intense bodily sensations (e.g., associated with distress) from a decentered perspective may help reduce emotional reactivity [ 63 ]. As noted, a bidirectional temporal dynamic between the proposed mechanisms and ED was found. Interestingly, previous studies also found a bidirectional relationship between poorer psychosocial functioning and ED [ 54 ], and between mindfulness practice skills and ED [ 27 ] in people with BPD who attended DBT skill training. These antecedents suggest that when participants with BPD had a previous high level of ED, they tended to practice less and, therefore, improved less in the proposed mechanisms. One explanation for this effect is that mindfulness practice is mood-dependent [ 64 ] and therefore practicing skills is more difficult when one is emotionally dysregulated. This leads to a challenge for clinicians when intervening with individuals diagnosed with BPD who usually have pervasive patterns of ED. However, part of the effectiveness of DBT skill training is that participants are taught to express and manage difficult emotional states within a structured group setting in which the therapist models skills and provides positive feedback and reinforcement [ 22 ]. This encourages exposure to difficult experiences rather than avoidance or fusion with them [ 44 ]. In this way, patients undergoing DBT skills training may feel more capable to apply their newly learned skills to the real-world. The results of this study may have some clinical implications and allow for possible causal interpretations of the mechanisms that favor improvements in ED after mindfulness skill training. Only nonjudgment and body awareness increases were related to within-person effects, whereas increases in decentering and attention awareness were only related to between-person effects. Thus, the more attitudinal aspects of mindfulness, such as nonjudgment and body awareness, seem to be more sensitive to within-person variability, whereas the more attentional and metacognitive aspects seem more stable [ 38 ]. Importantly, when all four proposed mechanisms of change were included in the same model, they explained 52% of the variance of changes in ED in the following week. Thus, these mechanisms appear to complement each other and therapists could consider this information to improve the efficacy of BPD-oriented treatments. In addition, decentering capacity acted as a metacognitive process that enhances the effect of the other mechanisms on ED. This also suggests that therapists may use strategies that increase the decentering ability in BPD treatments. The present study has some limitations that should be considered when interpreting the results. First, a single-arm non-randomized trial was implemented, that limits the generalizability of our conclusions. Second, to facilitate the weekly evaluation of the participants, the 3 most representative items of each measure (i.e., mechanisms of change) was used. However, these items may not be fully representative of the overall construct and may therefore increase risk of false negatives (i.e., type II error). Third, a measure of ED was used as the outcome. However, ED can also be considered as a process that contributes to the development or maintenance of psychopathology [ 65 ]. For example, a repeated measure of borderline symptoms would have enriched the results. Fourth, the sample was mostly composed of women. It is desirable that future studies consider more representative samples of men with BPD. Conclusions The present study provides preliminary evidence on the mechanisms of change underlying mindfulness skill training. Therapists could benefit from this information when treating emotion dysregulation in BPD patients by using strategies that promote decentering, nonjudgment and body awareness. Finally, understanding how mindfulness DBT skills training works can help optimize treatment for BPD. Abbreviations BPD Borderline Personality Disorder ED Emotion Dysregulation DBT Dialectical Behavior Therapy SCID II Structured Clinical Interview for DSM IV axis II Disorders DIB R Revised Diagnostic Interview for Borderlines DERS-18 Brief Version of the Difficulties in Emotion Regulation Scale EQ Experiencing Questionnaire NJ-FFMQ Nonjudging of Inner Experience sub-scale of Five Facets Mindfulness Questionnaire BA-SBC Body Awareness of Scale Body Connection MAAS Mindfulness Attention Awareness Scale MLM Multilevel modeling REML Restricted maximum likelihood Declarations Ethics approval and consent to participate The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of Hospital de la Santa Creu i Sant Pau. Informed consent was obtained from all participants. Consent for publication Not applicable. Availability of data and materials Data are available upon reasonable request. Competing interests The authors report no competing interests to declare. Funding This study was supported by the Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and by a grant from Instituto de Salud Carlos III [PI19/00087 and PI21/00505] and co-financed by the European Regional Development Fund (ERDF). CS was supported by the National Agency for Research and Development (ANID) / Scholarship Program / Doctorado Becas Chile [reference number 72190624]. SN was supported by a fellowship from "La Caixa" Foundation [ID 100010434; code: LCF/BQ/DR21/11880013]. Authors' contributions CS, JS, JCP, designed the study. JCP and LA recruited the participants. JS and DV performed the interventions. CS and SN collected and interpreted the data analyses. All authors approved the final version of the manuscript. Acknowledgements This study was supported by Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM). References American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Reviseds [Internet]. Fifth Edition. American Psychiatric Association. ; 2022 [cited 2011 Nov 10]. Available from: https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787 . Trull TJ, Jahng S, Tomko RL, Wood PK, Sher KJ. Revised NESARC personality disorder diagnoses: gender, prevalence, and comorbidity with substance dependence disorders. J Pers Disord. 2010;24(4):412–26. 10.1521/pedi.2010.24.4.412 . McGlashan TH, Grilo CM, Skodol AE, et al. The Collaborative Longitudinal Personality Disorders Study: baseline Axis I/II and II/II diagnostic co-occurrence. Acta Psychiatr Scand. 2000;102(4):256–64. 10.1034/j.1600-0447.2000.102004256.x . Alvarez-Tomás I, Soler J, Bados A, et al. Long-Term Course of Borderline Personality Disorder: A Prospective 10-Year Follow-Up Study. J Pers Disord. 2017;31(5):590–605. 10.1521/pedi_2016_30_269 . Leichsenring F, Fonagy P, Heim N, et al. Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies. World Psychiatry. 2024;23(1):4–25. 10.1002/wps.21156 . Pascual JC, Martín-Blanco A, Soler J. Twenty-Year Trends in the Psychopharmacological Treatment of Outpatients with Borderline Personality Disorder: A Cross-Sectional Naturalistic Study in Spain. CNS Drugs. 2021;35(9):1023–32. 10.1007/s40263-021-00852-7 . Carpenter RW, Trull TJ. Components of emotion dysregulation in borderline personality disorder: a review. Curr Psychiatry Rep. 2013;15(1):335. 10.1007/s11920-012-0335-2 . Glenn CR, Klonsky ED. Emotion dysregulation as a core feature of borderline personality disorder. J Pers Disord. 2009;23(1):20–8. 10.1521/pedi.2009.23.1.20 . Neacsiu AD, Eberle JW, Kramer R, Wiesmann T, Linehan MM. Dialectical behavior therapy skills for transdiagnostic emotion dysregulation: a pilot randomized controlled trial. Behav Res Ther. 2014;59:40–51. 10.1016/j.brat.2014.05.005 . Bohus M, Stoffers-Winterling J, Sharp C, Krause-Utz A, Schmahl C, Lieb K. Borderline personality disorder. Lancet. 2021;398(10310):1528–40. 10.1016/S0140-6736(21)00476-1 . Chapman AL. Borderline personality disorder and emotion dysregulation. Dev Psychopathol. 2019;31(3):1143–56. 10.1017/S0954579419000658 . 2018 surveillance of personality disorders (NICE guidelines CG77 and CG78) . London: National Institute for Health and Care Excellence (NICE); July 19, 2018. Storebø OJ, Stoffers-Winterling JM, Völlm BA, et al. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2020;5(5):CD012955. 10.1002/14651858.CD012955.pub2 . Published 2020 May 4. Linehan MM. Cognitive-behavioral treatment of borderline personality disorder. 558xvii. p. ed. New York, NY, US: Guilford Press; 1993. (Cognitive-behavioral treatment of borderline personality disorder). Linehan MM. Skills training manual for treating borderline personality disorder. New York, NY, US: Guilford Press; 1993. xii, 180 p. (Skills training manual for treating borderline personality disorder). Carmona i Farrés C, Elices M, Soler J, Domínguez-Clavé E, Pomarol-Clotet E, Salvador R, Pascual JC. Effects of mindfulness training on borderline personality disorder: Impulsivity versus emotional dysregulation. Mindfulness. 2019;10(7):1243–54. https://doi.org/10.1007/s12671-018-1071-4 . Schmidt C, Soler J, Carmona I, Farrés C, et al. Mindfulness in Borderline Personality Disorder: Decentering Mediates the Effectiveness. Psicothema. 2021;33(3):407–14. 10.7334/psicothema2020.437 . Kazdin AE. Mediators and mechanisms of change in psychotherapy research. Annu Rev Clin Psychol. 2007;3:1–27. 10.1146/annurev.clinpsy.3.022806.091432 . Kazdin AE. Evidence-based psychotherapies I: Qualifiers and limitations in what we know. South Afr J Psychol. 2014;44(4):381–403. https://doi.org/10.1177/0081246314533750 . Holmes EA, Ghaderi A, Harmer CJ, et al. The Lancet Psychiatry Commission on psychological treatments research in tomorrow's science. Lancet Psychiatry. 2018;5(3):237–86. 10.1016/S2215-0366(17)30513-8 . Wang LP, Maxwell SE. On disaggregating between-person and within-person effects with longitudinal data using multilevel models. Psychol Methods. 2015;20(1):63–83. 10.1037/met0000030 . Chapman AL, Owens L. Mechanisms of change in dialectical behavior therapy. In: Bedics J, editor. The handbook of dialectical behavior therapy: Theory, research, and evaluation. Elsevier Academic; 2020. pp. 51–69. https://doi.org/10.1016/B978-0-12-816384-9.00003-8 . Asarnow JR, Berk MS, Bedics J, et al. Dialectical Behavior Therapy for Suicidal Self-Harming Youth: Emotion Regulation, Mechanisms, and Mediators. J Am Acad Child Adolesc Psychiatry. 2021;60(9):1105–1115e4. 10.1016/j.jaac.2021.01.016 . Southward MW, Howard KP, Cheavens JS. Less is more: Decreasing the frequency of maladaptive coping predicts improvements in DBT more consistently than increasing the frequency of adaptive coping. Behav Res Ther. 2023;163:104288. 10.1016/j.brat.2023.104288 . Wyatt KP, Eberle JW, Ruork AK, Neacsiu AD. Mechanisms of change in treatments for transdiagnostic emotion dysregulation: The roles of skills use, perceived control and mindfulness. Clin Psychol Psychother. 2023;30(6):1380–92. https://doi.org/10.1002/cpp.2879 . Barnicot K, Gonzalez R, McCabe R, Priebe S. Skills use and common treatment processes in dialectical behaviour therapy for borderline personality disorder. J Behav Ther Exp Psychiatry. 2016;52:147–56. 10.1016/j.jbtep.2016.04.006 . Schmidt C, Soler J, Vega D, Pascual JC. Practice Matters: The Role of Mindfulness Skills in Emotion Dysregulation in Borderline Personality Disorder. Manuscript submitted for publication; 2024. Hölzel BK, Lazar SW, Gard T, Schuman-Olivier Z, Vago DR, Ott U. How Does Mindfulness Meditation Work? Proposing Mechanisms of Action From a Conceptual and Neural Perspective. Perspect Psychol Sci. 2011;6(6):537–59. 10.1177/1745691611419671 . Tang YY, Hölzel BK, Posner MI. The neuroscience of mindfulness meditation. Nat Rev Neurosci. 2015;16(4):213–25. 10.1038/nrn3916 . Carmody J, Baer RA, Lykins LB, Olendzki E. An empirical study of the mechanisms of mindfulness in a mindfulness-based stress reduction program. J Clin Psychol. 2009;65(6):613–26. 10.1002/jclp.20579 . Fresco DM, Moore MT, van Dulmen MH, et al. Initial psychometric properties of the experiences questionnaire: validation of a self-report measure of decentering. Behav Ther. 2007;38(3):234–46. 10.1016/j.beth.2006.08.003 . Bernstein A, Hadash Y, Lichtash Y, Tanay G, Shepherd K, Fresco DM. Decentering and Related Constructs: A Critical Review and Metacognitive Processes Model. Perspect Psychol Sci. 2015;10(5):599–617. 10.1177/1745691615594577 . O'Toole MS, Renna ME, Mennin DS, Fresco DM. Changes in Decentering and Reappraisal Temporally Precede Symptom Reduction During Emotion Regulation Therapy for Generalized Anxiety Disorder With and Without Co-Occurring Depression. Behav Ther. 2019;50(6):1042–52. 10.1016/j.beth.2018.12.005 . Carpenter JK, Conroy K, Gomez AF, Curren LC, Hofmann SG. The relationship between trait mindfulness and affective symptoms: A meta-analysis of the Five Facet Mindfulness Questionnaire (FFMQ). Clin Psychol Rev. 2019;74:101785. 10.1016/j.cpr.2019.101785 . Wupperman P, Neumann CS, Whitman JB, Axelrod SR. The role of mindfulness in borderline personality disorder features. J Nerv Ment Dis. 2009;197(10):766–71. 10.1097/NMD.0b013e3181b97343 . Krantz LH, McMain S, Kuo JR. The unique contribution of acceptance without judgment in predicting nonsuicidal self-injury after 20-weeks of dialectical behaviour therapy group skills training. Behav Res Ther. 2018;104:44–50. 10.1016/j.brat.2018.02.006 . Zeifman RJ, Boritz T, Barnhart R, Labrish C, McMain SF. The independent roles of mindfulness and distress tolerance in treatment outcomes in dialectical behavior therapy skills training. Personal Disord. 2020;11(3):181–90. 10.1037/per0000368 . Eisenlohr-Moul T, Peters JR, Chamberlain KD, Rodriguez M. Weekly fluctuations in nonjudging predict borderline personality disorder feature expression in women. J Psychopathol Behav Assess. 2016;38(1):149–57. 10.1007/s10862-015-9505-y . Price CJ, Thompson EA. Measuring dimensions of body connection: body awareness and bodily dissociation. J Altern Complement Med. 2007;13(9):945–53. 10.1089/acm.2007.0537 . Carmody J, Baer RA. Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. J Behav Med. 2008;31(1):23–33. 10.1007/s10865-007-9130-7 . Baer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L. Using self-report assessment methods to explore facets of mindfulness. Assessment. 2006;13(1):27–45. 10.1177/1073191105283504 . Schmitz M, Bertsch K, Löffler A, Steinmann S, Herpertz SC, Bekrater-Bodmann R. Body connection mediates the relationship between traumatic childhood experiences and impaired emotion regulation in borderline personality disorder. Borderline Personal Disord Emot Dysregul . 2021;8(1):17. Published 2021 May 17. 10.1186/s40479-021-00157-7 . Lutz A, Slagter HA, Dunne JD, Davidson RJ. Attention regulation and monitoring in meditation. Trends Cogn Sci. 2008;12(4):163–9. 10.1016/j.tics.2008.01.005 . Wu JL, Hamilton JL, Fresco DM, Alloy LB, Stange JP. Decentering predicts attenuated perseverative thought and internalizing symptoms following stress exposure: A multi-level, multi-wave study. Behav Res Ther. 2022;152:104017. 10.1016/j.brat.2021.104017 . First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS. Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Washington, DC: American Psychiatric Press, Inc; 2007. Barrachina J, Soler J, Campins MJ, et al. Validación de la versión española de la Diagnostic Interview for Bordelines-Revised (DIB-R) [Validation of a Spanish version of the Diagnostic Interview for Bordelines-Revised (DIB-R)]. Actas Esp Psiquiatr. 2004;32(5):293–8. Elices M, Pascual JC, Portella MJ, et al. Impact of mindfulness training on borderline personality disorder: A randomized trial. Mindfulness. 2016;7(3):584–95. https://doi.org/10.1007/s12671-016-0492-1 . Victor SE, Klonsky ED. Validation of a brief version of the Difficulties in Emotion Regulation Scale (DERS-18) in five samples. J Psychopathol Behav Assess. 2016;38(4):582–9. https://doi.org/10.1007/s10862-016-9547-9 . Soler J, Franquesa A, Feliu-Soler A, et al. Assessing decentering: validation, psychometric properties, and clinical usefulness of the Experiences Questionnaire in a Spanish sample. Behav Ther. 2014;45(6):863–71. 10.1016/j.beth.2014.05.004 . Cebolla A, García-Palacios A, Soler J, Guillen V, Baños R, Botella C. Psychometric properties of the Spanish validation of the Five Facets of Mindfulness Questionnaire (FFMQ). Eur J Psychiatry. 2012;26(2):118–26. https://doi.org/10.4321/S0213-61632012000200005 . Quezada-Berumen LC, González-Ramírez MT, Cebolla A, Soler J, Garcia-Campayo J. Body awareness and mindfulness: validation of the Spanish version of the Scale of Body Connection. Actas Esp Psiquiatr. 2014;42(2):57–67. Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Personal Soc Psychol. 2003;84(4):822–48. https://doi.org/10.1037/0022-3514.84.4.822 . Soler J, Tejedor R, Feliu-Soler A, et al. Psychometric proprieties of Spanish version of Mindful Attention Awareness Scale (MAAS). Actas Esp Psiquiatr. 2012;40(1):19–26. Wilks CR, Korslund KE, Harned MS, Linehan MM. Dialectical behavior therapy and domains of functioning over two years. Behav Res Ther. 2016;77:162–9. 10.1016/j.brat.2015.12.013 . Enders CK, Tofighi D. Centering predictor variables in cross-sectional multilevel models: a new look at an old issue. Psychol Methods. 2007;12(2):121–38. https://doi.org/10.1037/1082-989X.12.2.121 . Aiken LS, West SG. Multiple regression: Testing and interpreting interactions. Sage Publications, Inc; 1991. Stoffel MA, Nakagawa S, Schielzeth H, rptR. Repeatability estimation and variance decomposition by generalized linear mixed-effects models. Methods Ecol Evol. 2017;8:1639–44. https://doi.org/10.1111/2041-210X.12797 . Nakagawa S, Schielzeth H. A general and simple method for obtaining R2 from generalized linear mixed-effects models. Methods Ecol Evol. 2013;4(2):133–42. 10.1111/j.2041-210x.2012.00261.x . Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2th ed. Hillsdale, NJ: Lawrence Erlbaum Associates,; 1988. Bates D, Mächler M, Bolker B, Walker S. Fitting Linear Mixed-Effects Models Using lme4. J Stat Softw. 2015;67(1):1–48. https://doi.org/10.18637/jss.v067.i01 . Elices M, Pascual JC, Carmona C et al. Correction to: Exploring the relation between childhood trauma, temperamental traits and mindfulness in borderline personality disorder. BMC Psychiatry . 2018;18(1):284. Published 2018 Sep 4. 10.1186/s12888-018-1834-4 . Treves IN, Tello LY, Davidson RJ, Goldberg SB. The relationship between mindfulness and objective measures of body awareness: A meta-analysis. Sci Rep. 2019;9(1):17386. 10.1038/s41598-019-53978-6 . Published 2019 Nov 22. Carpenter JK, Sanford J, Hofmann SG. The Effect of a Brief Mindfulness Training on Distress Tolerance and Stress Reactivity. Behav Ther. 2019;50(3):630–45. https://doi.org/10.1016/j.beth.2018.10.003 . Elices M, Tejedor R, Pascual JC, Carmona C, Soriano J, Soler J. Acceptance and present-moment awareness in psychiatric disorders: Is mindfulness mood dependent? Psychiatry Res. 2019;273:363–8. 10.1016/j.psychres.2019.01.041 . Aldao A, Nolen-Hoeksema S, Schweizer S. Emotion-regulation strategies across psychopathology: A meta-analytic review. Clin Psychol Rev. 2010;30(2):217–37. 10.1016/j.cpr.2009.11.004 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 Sep, 2024 Read the published version in Borderline Personality Disorder and Emotion Dysregulation → Version 1 posted Editorial decision: Revision requested 16 Apr, 2024 Reviews received at journal 10 Apr, 2024 Reviews received at journal 03 Apr, 2024 Reviewers agreed at journal 21 Mar, 2024 Reviewers agreed at journal 20 Mar, 2024 Reviewers invited by journal 20 Mar, 2024 Editor assigned by journal 28 Feb, 2024 Submission checks completed at journal 28 Feb, 2024 First submitted to journal 21 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3976899","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":275349354,"identity":"a198deb1-3887-42bc-a280-5440b24cd4bd","order_by":0,"name":"Carlos Schmidt","email":"","orcid":"","institution":"Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica- Sant Pau (IIB-SANT PAU)","correspondingAuthor":false,"prefix":"","firstName":"Carlos","middleName":"","lastName":"Schmidt","suffix":""},{"id":275349355,"identity":"aca594c0-ea9f-414d-9871-43ffdb0d6126","order_by":1,"name":"Joaquim Soler","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYBACxgYGxgNAmoefFC0MYC2SQAaYBRXED8AKDQ4Qq4W5//CBAx/33JMxPn/42eOPO+wSG9gPP3+A12Ez0hIOznhWzGN2I83c4OCZ5MQGnjRDvLYwzuAxOMxzIAGohcFM4mAbc2KDBAMBLf1nDA7/AWox7j/+DailHqiF/SN+LQ05BocZgFoMGHJAthwGauEh5DCgX3qAWiRu5JRJnD1z3LiNJ6dwBj4thv2HDz74cSDBnr//+DaJyh3Vsv3sxzd8wKsFxQ2gCGHDpxwE5FGd2YBd1SgYBaNgFIxsAAAZOlKI2ExEUAAAAABJRU5ErkJggg==","orcid":"","institution":"Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica- Sant Pau (IIB-SANT PAU)","correspondingAuthor":true,"prefix":"","firstName":"Joaquim","middleName":"","lastName":"Soler","suffix":""},{"id":275349356,"identity":"51a85e38-74b0-4762-bb92-ec29e108b8b8","order_by":2,"name":"Daniel Vega","email":"","orcid":"","institution":"Hospital Universitari d’Igualada (Consorci Sanitari de l’Anoia)","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Vega","suffix":""},{"id":275349357,"identity":"4137a0c4-25c9-46f0-8931-c6b597a7a090","order_by":3,"name":"Stella Nicolaou","email":"","orcid":"","institution":"Hospital Universitari d’Igualada (Consorci Sanitari de l’Anoia)","correspondingAuthor":false,"prefix":"","firstName":"Stella","middleName":"","lastName":"Nicolaou","suffix":""},{"id":275349358,"identity":"e33dd488-f0fa-43ab-a7df-5ee50ce1b557","order_by":4,"name":"Laia Arias","email":"","orcid":"","institution":"Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica- Sant Pau (IIB-SANT PAU)","correspondingAuthor":false,"prefix":"","firstName":"Laia","middleName":"","lastName":"Arias","suffix":""},{"id":275349359,"identity":"5ffe57bb-d419-4b53-965a-a089db7ed3bf","order_by":5,"name":"Juan C. Pascual","email":"","orcid":"","institution":"Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica- Sant Pau (IIB-SANT PAU)","correspondingAuthor":false,"prefix":"","firstName":"Juan","middleName":"C.","lastName":"Pascual","suffix":""}],"badges":[],"createdAt":"2024-02-21 21:45:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3976899/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3976899/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40479-024-00265-0","type":"published","date":"2024-09-02T16:05:04+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":51970545,"identity":"a06ee9fc-0d30-43c3-bae3-f19c8b8c0d01","added_by":"auto","created_at":"2024-03-04 18:48:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":231982,"visible":true,"origin":"","legend":"\u003cp\u003eDecentering moderating the association between Nonjudgment and emotion dysregulation.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3976899/v1/5a02c1fed816085e0a41fb79.png"},{"id":51972217,"identity":"671fbabf-15e3-4e8a-94bb-d557b7c70431","added_by":"auto","created_at":"2024-03-04 18:56:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":231698,"visible":true,"origin":"","legend":"\u003cp\u003eDecentering moderating the association between Body awareness and emotion dysregulation.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3976899/v1/45e303f9ae309f92a1666add.png"},{"id":64185732,"identity":"08d847a4-64be-4447-abb5-cf5b46b5c792","added_by":"auto","created_at":"2024-09-09 16:21:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1276578,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3976899/v1/4fc054e0-fa64-4481-81bb-730e7d8f5da8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"How does mindfulness skills training works on emotion dysregulation in borderline personality disorder?","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eBorderline personality disorder (BPD) is a severe mental illness with an estimated community prevalence of 2.7%. It is characterized by affective dysregulation, unstable identity and interpersonal relationships, and serious behaviors such as non-suicidal self-injury [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The complexity and severity of BPD is characterized by high comorbidity with other psychiatric disorders, drug and/or alcohol abuse, and a high risk of suicide, which lead to an extensive use of healthcare resources, high costs of treatment, polymedication, as well as impaired psychosocial and occupational functioning [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne of the main features underlying cognitive, affective, and behavioral instability in BPD is a pervasive pattern of emotion dysregulation (ED) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. ED involves the inability to regulate or change an emotional response or expression in a desired manner and involves a lack of (or maladaptive use of) emotion regulation strategies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], which in turn facilitates the emergence of impulsive and risky behaviors (e.g., self-harm, substance use). These risk behaviors can be understood as a consequence of emotion regulation difficulties or as a strategy to regulate a distressing emotional state [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Therefore, prevention and treatment efforts are focused on addressing ED as a means of reducing distress, suffering, psychosocial impairment, and potentially life-threatening risk behaviors in individuals with a diagnosis of BPD [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePsychotherapy is the main recommended treatment for BPD [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. One of the empirically based therapies for the treatment of BPD is dialectical behavior therapy (DBT) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. DBT is a multifaceted intervention involving individual and group therapy. The group therapy addresses the skills training and comprises four different modules: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. Mindfulness is one of the main components of DBT, and mindfulness training are the first skills taught to support the other DBT skills [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Interestingly, mindfulness skills training as a stand-alone intervention improves ED in BPD [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], but the underlying mechanisms of change are not yet fully understood.\u003c/p\u003e \u003cp\u003eAn understanding of the mechanisms (i.e., mediators) through which psychological interventions produce changes in desired outcomes (understanding how and why it works) is essential to optimize treatments [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In addition, identifying moderators (i.e., the effects on direction or magnitude of the relation between the intervention and outcome) may guide therapeutic strategies that effectively impact the mechanisms or processes of an intervention in order to obtain therapeutic improvements [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Thus, clinical research based on mechanisms of change (and moderators) may inform which processes (e.g., cognitive, behavioral) of an intervention contribute to the expected outcomes and in what ways. One way to study the mechanisms is to demonstrate that changes in the putative mechanism are related to changes in the expected outcome through a temporal precedence with repeated session-by-session measures [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and also disaggregating within- and between-person effects of the mechanisms [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This method allows for a more precise examination of the process of change within an individual.\u003c/p\u003e \u003cp\u003eResearch has focused on uncovering the mechanisms of change by which DBT skills training improves ED in BPD [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Studies suggest that a greater use of behavioral skills (learned during DBT skills training) mediates changes in emotion dysregulation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. More specifically, studies exploring the within-person effects found that greater skills use predicted improvements in ED [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and fewer risk behaviors associated with high ED [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] after undergoing DBT skills training. However, there is a scarcity of studies focused on studying the mechanisms of change of mindfulness skills training as a stand-alone intervention. For example, a recent study reported that the amount of mindfulness practice at a given week (a required dose of at least 3 days and 30 minutes) predicted improvements in ED at the following week in BPD outpatients [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs noted, previous findings suggest that the use of DBT skills (e.g., mindfulness) improves ED in people with BPD. Although prior theoretical and empirical accounts have proposed decentering (i.e., change in perspective on the self), emotion regulation (i.e., process emotional reactions with non-judgmental stance), body awareness and attention awareness as possible mechanisms or processes by which mindfulness practice may works [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], the underlying mechanisms of change remains unclear. Decentering consists of adopting a change in perspective of one's own experience through the disidentification of the mental contents that are usually experienced as defining the self [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. This metacognitive capacity involves a process of meta-awareness by observing thoughts and emotions in a non-attached manner, which results in a reduced reactivity to thought content [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Interestingly, decentering has been proposed as a mediating mechanism both in mindfulness DBT skills training [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and in emotion regulation interventions [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe emotion regulation process related to a nonjudgmental stance towards internal experience (i.e., when individuals stop criticizing themselves) is associated with a lower level of psychopathology [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. However, individuals with BPD are characterized by a high tendency to judge their internal experience [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Therefore, strategies that help increase the capacity for nonjudgment are particularly relevant to foster emotional acceptance in BPD [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Interestingly, this capacity (i.e., nonjudgment) is an active component of mindfulness DBT skills training. However, it has been shown to act as a mediating mechanism between DBT skills training and clinical outcomes in BPD [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. For instance, increased levels of nonjudgment over time predict fewer borderline symptoms in women with BPD features [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBody awareness involves paying attention to body information by identifying internal body sensations (e.g., tension) and the associated emotional state (feeling relaxed or stressed) as opposed to avoiding the bodily experience [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Bodily sensations are a common object of attention during mindfulness meditations [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] and would be cultivated through the ability to observe the inner experience [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Body awareness levels are significantly decreased in individuals with BPD compared to healthy controls, and this deficit is associated with ED [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Therefore, increasing body awareness is a relevant aspect in the treatment of psychological disorders, including BPD [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Attention awareness is another putative mechanism underlying mindfulness practice and involves cultivating a present-moment awareness. For instance, mindfulness meditation involves focusing attention on an object (e.g., breathing), noticing distraction, and returning to the object of attention [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Promoting attention regulation in individuals with BPD is relevant to ameliorate ED and impulse control by teaching participants to observe what they are experiencing in the present moment, without attachment or avoidance of the content of the experience [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. To our knowledge, no study has evaluated these proposed mechanisms at the same time in a mindfulness training for individuals with BPD. Knowing these specific mechanisms of change may be useful for clinicians to understand how mindfulness training works.\u003c/p\u003e \u003cp\u003eIn summary, the main question guiding this study is how participants with BPD improve their level of ED through a mindfulness skills training. Therefore, this study explored the potential mechanisms of change within mindfulness training, focusing on decentering, nonjudgment, body awareness and attention awareness. Firstly, we evaluated whether these mechanisms and ED showed improvement over the course of mindfulness skills training. Secondly, we explored the temporal dynamics between mechanisms and ED throughout mindfulness skills training. Thirdly, based on previous findings [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], we explored decentering as a metacognitive ability that could moderate (i.e., increase the strength) the relationship between the other proposed mechanisms and ED. In summary, our hypotheses were: (1) Decentering, nonjudgment, body awareness and attention awareness would increase and ED would decrease during mindfulness skills training; (2) greater within- and between-person effects of mechanisms would predict improvements in ED in the following week; and this relationship would be bidirectional; and (3) the association between nonjudgment, body awareness, and attention awareness with ED would be greater among participants with higher decentering capacity.\u003c/p\u003e"},{"header":"METHOD","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003e Participants were recruited from the Department of Psychiatry Unit of the Hospital de la Santa Creu i Sant Pau (Barcelona, Spain). This outpatient program is part of the Public National Mental Health Service of Spain and provides specialized care for people with BPD diagnosis. A total of 95 BPD outpatients were enrolled in a DBT skill training. Of these, 75 participants were included in the present study (13 discontinued treatment before starting the first session; 7 had very low attendance and completed less than 3 weekly assessments). All participants were evaluated by a psychiatrist and a clinical psychologist from the psychiatry unit, both with a doctoral degree and experience in the treatment of people with BPD. The clinical diagnosis was based on two semi-structured interviews: Structured Clinical Interview for DSM IV axis II Disorders (SCID II) [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]and the Revised Diagnostic Interview for Borderlines (DIB-R) [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. The inclusion criteria were: (i) diagnostic confirmation of BPD; (ii) age between 18\u0026ndash;55 years; (iii) absence of any of the following comorbid conditions: schizophrenia, drug-induced psychosis, organic brain syndrome, substance dependence, bipolar disorder, intellectual disability; (iv) not receiving any other type of psychotherapy at the time of study enrollment. Patients were allowed to continue with the drug regimen followed prior to study enrollment. However, they were not allowed to change the type or dose of drugs during the study period. Participants had not previously participated in DBT skills training.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cp\u003e Participants were enrolled in a 10-week DBT mindfulness skills training. In total, 7 groups were conducted between February 2020 and October 2023 (12\u0026ndash;15 participants/group). Each intervention group followed the same structure and weekly sessions were 2.5 hours in length. All groups were led by the same team (2 clinical psychologists with training and experience in DBT, and expertise in mindfulness meditation). For each participant, written informed consent was obtained prior to inclusion in the study. The study was approved by the Clinical Research Ethics Committee of the Hospital de la Santa Creu i Sant Pau and was conducted in accordance with the criteria of the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003eThe intervention was based on the DBT skills training protocol [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The 10-week mindfulness training program consisted of 1 week of orientation and goals, 6 weeks of mindfulness skills, and 3 weeks of acceptance skills (taken from the distress tolerance module). This mindfulness training for BPD is proposed by Linehan as an alternative to standard DBT skills training [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and its efficacy has been shown in previous clinical trials [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. The mindfulness and acceptance skills taught were (i) Wise Mind; (ii) \"What\" Skills (i.e., observing, describing, participating); (iii) \"How\" Skills (i.e., nonjudgmentally, one-mindfully, and effectively); (iv) Radical Acceptance; (v) Mind Turning and Willingness; (vi) Half-smile and willing hands; and (vii) Mindfulness of current thoughts. Formal and informal mindfulness practice were taught during the sessions. In each session, a new skill was introduced and practiced through role-playing and discussion. Participants were then given meditation audios and worksheets related to the skills and instructed to practice at home. In the next session, the homework was reviewed and each participant commented on his or her experience with the practice, as well as any difficulties encountered. The therapist then reinforced the participants' progress and suggested effective ways to improve skill practice. The meditation audios were recorded by the lead therapist and lasted 10 minutes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cp\u003eSeveral repeat measures were collected on a weekly basis during the mindfulness training. Only the first introduction/orientation session was not assessed because it did not include mindfulness skills practice. In order to assess the participants\u0026rsquo; level of ED and specific mechanism of change, they were asked to complete the following scales before starting a new session (i.e., session 2 onwards).\u003c/p\u003e \u003cp\u003e \u003cem\u003eEmotion Dysregulation\u003c/em\u003e. The Brief Version of the Difficulties in Emotion Regulation Scale was used to capture how participants managed their weekly difficult emotional experiences (DERS-18) [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. The 18-items Spanish translation of this self-report scale was administered and the total score was used in the analyses as an overall measure of emotion dysregulation. Items were rated on a scale from 1 (almost never) to 5 (almost always). This scale has high internal reliability (Cronbach's α\u0026thinsp;=\u0026thinsp;.91). In the current study, this scale obtained a good internal reliability at session 1 (Cronbach's α\u0026thinsp;=\u0026thinsp;.87).\u003c/p\u003e \u003cp\u003eFor each mechanism of change proposed, the 3 most representative items of each original scale were used based on the highest factor loadings, with the aim of facilitating the weekly assessment of the participants. The same Likert scale was used for all items, from 1 (almost never) to 5 (almost always).\u003c/p\u003e \u003cp\u003e \u003cem\u003eDecentering\u003c/em\u003e. It was assessed with the Experiencing Questionnaire (EQ) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The EQ is a 20-item self-report scale that assesses decentering and rumination. Decentering is the ability to observe thoughts and feelings in a detached manner [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In the present study, items from the Spanish validation EQ-Decentering was used [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. These items were: (i) \u0026ldquo;\u003cem\u003eI can separate myself from my thoughts and feelings\u003c/em\u003e\u0026rdquo; (factor loading: .74); (ii) \u0026ldquo;\u003cem\u003eI can observe unpleasant feelings without being drawn into them\u003c/em\u003e\u0026rdquo; (factor loading: .72); (iii) \u0026ldquo;\u003cem\u003eI view things from a wider perspective\u003c/em\u003e\u0026rdquo; (factor loading: .77). The Spanish EQ version has good internal reliability (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.89) [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] and in the present study the 3-items scale had an acceptable internal reliability at session 1 (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.73).\u003c/p\u003e \u003cp\u003e \u003cem\u003eNonjudgment\u003c/em\u003e. It was assessed with the Nonjudging of Inner Experience sub-scale of Five Facets Mindfulness Questionnaire (NJ-FFMQ) [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. NJ-FFMQ refers to taking a non-evaluative stance toward thoughts and feelings and is closely associated with acceptance, a central component of mindfulness [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. In the present study, items of the Spanish validation of NJ-FFMQ subscale was used [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. These items were: (i) \u0026ldquo;\u003cem\u003eI make judgments about whether my thoughts are good or bad\u003c/em\u003e\u0026rdquo; (factor loading: .69); (ii) \u0026ldquo;\u003cem\u003eI tell myself I shouldn\u0026rsquo;t be thinking the way I\u0026rsquo;m thinking\u003c/em\u003e\u0026rdquo; (factor loading: .67); (iii) \u0026ldquo;\u003cem\u003eI think some of my emotions are bad or inappropriate and I shouldn\u0026rsquo;t feel them\u003c/em\u003e\u0026rdquo; (factor loading: .73). The Spanish NJ-FFMQ version has an excellent internal reliability (Cronbach's α\u0026thinsp;=\u0026thinsp;.91) [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] and the internal reliability of the 3-items in the current study at session 1 was good (Cronbach's α\u0026thinsp;=\u0026thinsp;.81).\u003c/p\u003e \u003cp\u003e \u003cem\u003eBody awareness\u003c/em\u003e. It was assessed with the Body Awareness of Scale Body Connection (BA-SBC), which measures the conscious attention to sensory signals of the state of the body, such as the sensation of tension or relaxation [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Items of the Spanish BA-SBC version was used in the current study [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. These items were: (i) \u0026ldquo;\u003cem\u003eI take my body's signals to understand how I feel\u003c/em\u003e\u0026rdquo; (factor loading: .83); (ii) \u0026ldquo;\u003cem\u003eI listen to my body's information about my emotional state\u003c/em\u003e\u0026rdquo; (factor loading: .85); (iii) \u0026ldquo;\u003cem\u003eWhen I am tense, I pay attention to where the tension is concentrated in my body\u003c/em\u003e\u0026rdquo; (factor loading: .72). The Spanish BA-SBS has a good internal reliability (Cronbach's α\u0026thinsp;=\u0026thinsp;.86) [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. The 3-items scale used in the current study also showed good internal reliability at session 1 (Cronbach's α\u0026thinsp;=\u0026thinsp;.84).\u003c/p\u003e \u003cp\u003e \u003cem\u003eAttention awareness\u003c/em\u003e: It was assessed with the Mindfulness Attention Awareness Scale (MAAS) [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. It is a 15-item self-reported questionnaire, which measures an individual\u0026rsquo;s awareness of their experience in the present moment, in contrast to having automated behaviors. Items of the Spanish MAAS version were used in the current study [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. These items were: (i) \"\u003cem\u003eI drive places on \u0026lsquo;automatic pilot\u0026rsquo; and then wonder why I went there\u003c/em\u003e\" (factor loading: .77); (ii) \"\u003cem\u003eI find myself doing things without paying attention\u003c/em\u003e\" (factor loading: .71); (iii) \"\u003cem\u003eI snack without being aware that I\u0026rsquo;m eating\u003c/em\u003e\" (factor loading: .69). Both the original version [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] and the Spanish version [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] present high internal reliability (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.82 and 0.89, respectively). In the present study, the 3-items scale showed an acceptable internal reliability at session 1 (Cronbach's α\u0026thinsp;=\u0026thinsp;.71).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eFirst, descriptive analyses of the participants were conducted. Second, pre- and post-intervention correlations were calculated to determine baseline and post-treatment relationships between mechanism of change and ED. Third, multilevel modeling (MLM) analyses with a restricted maximum likelihood (REML) estimation method and with a time-lagged approach were conducted to examine the temporal dynamics over time between the proposed mechanism of change (i.e., mediators) and ED. MLM allows modeling changes in the measures of interest over time and time-lagged predictions allows exploring the association of a previous time point measure (i.e., time x) with a later time point measure (i.e., time x\u0026thinsp;+\u0026thinsp;1). For these analyses, the between- and within-person variability was disaggregated, that is recommended for multilevel models with repeated measures data [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. To calculate the within-person effects (i.e., level 1), the person-mean-centered was calculated by subtracting the participant-level mean across observations from each participant's score at each time point. Thus, scores at each time point become a deviation score, representing the person's deviation from her own average at that time point. To obtain the between-person effects (i.e., level 2), the grand-mean-centered was calculated by subtracting each participant's mean from the sample average of all participants\u0026rsquo; means. Thus, the participant-level mean represents the person's deviation from the total sample average [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. This approach is recommended to interpret the parameters in MLM [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Then, it was tested whether between- and within-person changes in decentering, nonjudgment, body awareness and attention awareness at session x predicted changes in ED at session x\u0026thinsp;+\u0026thinsp;1, over mindfulness skills training. The reverse direction was also explored to assess the bidirectional relationship. That is, whether between- and within-person changes in ED level at session x predicted changes in the proposed mechanisms of change at session x\u0026thinsp;+\u0026thinsp;1.\u003c/p\u003e \u003cp\u003eFourth, cross-level interactions were conducted to assess the moderating role of decentering between the association of the other mechanisms and ED. A cross-level interaction occurs when a level 2 variable (i.e., between-person) moderates the magnitude of a level 1 association (i.e., within-person) [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Separate MLM analyses were performed to explore whether the between-person effect of decentering (level 2) moderates the within-person effects of nonjudgment, body awareness and attention awareness (level 1) on the prediction of ED. Significant interactions were probed by testing the simple slopes of each mechanism (e.g., nonjudgment) on ED at high and low levels of decentering capacity (i.e., \u0026plusmn;\u0026thinsp;1 SD) [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn all MLM analyses the participants' intercept was defined as random effects. The partR\u003csup\u003e2\u003c/sup\u003e package was used [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] to estimate the marginal and conditional R\u003csup\u003e2\u003c/sup\u003e [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. The coefficient of determination R\u003csup\u003e2\u003c/sup\u003e was used to interpret the effect size of the models, which were classified as weak (.02-.13), medium (.13-.26) and large (\u0026gt;\u0026thinsp;.26) [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. All models were tested with the lme4 package [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e] in RStudio and IBM SPSS statistics (version 24) was used for descriptive analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the sample\u003c/h2\u003e \u003cp\u003eA total of 75 outpatients with a diagnosis of BPD attended a mindfulness skills training (M\u003csub\u003eage\u003c/sub\u003e = 27.15 [range 18\u0026ndash;53], 93.3% female). A total of 499 observations were obtained (Mean\u0026thinsp;=\u0026thinsp;4.95, SD\u0026thinsp;=\u0026thinsp;2.60). Most participants were working (33%) or studying (32%) at the time of the evaluation (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic characteristics of total sample\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal sample (N\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.15 (8.62)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e, female, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (93.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducational level\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle school\u003c/p\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (44)\u003c/p\u003e \u003cp\u003e23 (30.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (25.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment Status\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (22.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSick leave\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (5.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisability pension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical characteristics\u003c/b\u003e, mean \u003cb\u003e(\u003c/b\u003eSD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDIB-R total score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (1.05)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrevious self-injury behavior\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePast suicide acts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (42.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePast non-suicide self-injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (70.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePharmacological treatment\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntidepressant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (74.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenzodiazepines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntipsychotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (22.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMood stabilizers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNotes. SD\u0026thinsp;=\u0026thinsp;standard deviation. DIB-R\u0026thinsp;=\u0026thinsp;Revised Diagnostic Interview for Borderlines.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[Insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/p\u003e \u003cp\u003e Regarding the weekly practice of the tasks assigned during training, the participants practiced mindfulness skills for a median of 3 days (M\u0026thinsp;=\u0026thinsp;2.80, SD\u0026thinsp;=\u0026thinsp;1.97, range\u0026thinsp;=\u0026thinsp;0\u0026ndash;7) and a mean of 27.90 minutes per week (SD\u0026thinsp;=\u0026thinsp;27.81, range\u0026thinsp;=\u0026thinsp;0-180). In addition, practice time increased over the course of the training, both in days (b\u0026thinsp;=\u0026thinsp;.16, SE\u0026thinsp;=\u0026thinsp;.02, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and minutes (b\u0026thinsp;=\u0026thinsp;1.27, SE\u0026thinsp;=\u0026thinsp;.38, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the correlations between ED (DERS-18) and the mechanisms of change proposed in sessions 1 and 9 of the mindfulness training. Correlations were significant both at baseline (\u003cem\u003er\u003c/em\u003e range from \u0026minus;\u0026thinsp;.306 to \u0026minus;\u0026thinsp;.487) and at the end of the training (\u003cem\u003er\u003c/em\u003e range from \u0026minus;\u0026thinsp;.573 to \u0026minus;\u0026thinsp;.642). However, more robust correlations were observed in session 9 (moderate to high).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations between Skills and Emotion Dysregulation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDERS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDecentering\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNonjudgment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBody awareness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAttention awareness\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDERS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.558**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.642**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.593**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.573**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecentering\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.487***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.290*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.569**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.439**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonjudgment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.416**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.369**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.434**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.235\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.480**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.533**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.241\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.443**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttention awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.306*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.089\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eNotes. Correlations below the diagonal correspond to session 1 scores. Correlations above the diagonal correspond to session 9 scores. DERS\u0026thinsp;=\u0026thinsp;Difficulties in Emotion Regulation Scale; Decentering\u0026thinsp;=\u0026thinsp;Experience Questionnaire - Decentering items [EQ]; Nonjudgment\u0026thinsp;=\u0026thinsp;Five facet Mindfulness Questionnaire \u0026ndash; Nonjudge sub-scale items [FFMQ-NJ]; Body Awareness\u0026thinsp;=\u0026thinsp;Scale Body Connection \u0026ndash; Body-Awareness sub-scale items [SBC-BA]; Attention Awareness\u0026thinsp;=\u0026thinsp;Mindful Attention Awareness Scale items [MAAS]. *p\u0026thinsp;\u0026lt;\u0026thinsp;.05, ⁎⁎p\u0026thinsp;\u0026lt;\u0026thinsp;.01, ***p\u0026thinsp;\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[Insert Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e here]\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTime-lagged analysis of changes in mechanisms and improvement in emotion dysregulation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eDERS Predicted by time-lagged Decentering\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003eDecentering Predicted by time-lagged DERS\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003cp\u003e(session x-1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime (sessions)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBetween-person\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-3.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-7.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-7.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithin-person\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-2.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u003csub\u003emarginal\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.31 [95% CI: .19-.41]; R\u003csup\u003e2\u003c/sup\u003e\u003csub\u003econditional\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.69 [95% CI: .66-.74]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u003csub\u003emarginal\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.27 [95% CI: .20-.33]; R\u003csup\u003e2\u003c/sup\u003e\u003csub\u003econditional\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.56 [95% CI: .46-.64]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eDERS Predicted by time-lagged Nonjudgment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003eNonjudgment Predicted by time-lagged DERS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003cp\u003e(session x-1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-2.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime (sessions)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBetween-person\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-3.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-6.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-6.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithin-person\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;. 05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-2.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u003csub\u003emarginal\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.29 [95% CI: .21-.45]; R\u003csup\u003e2\u003c/sup\u003e\u003csub\u003econditional\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.68 [95% CI: .63-.75]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u003csub\u003emarginal\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.30 [95% CI: .23-.39]; R\u003csup\u003e2\u003c/sup\u003e\u003csub\u003econditional\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.67 [95% CI: .57-.76]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eDERS Predicted by time-lagged Body Awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003eBody Awareness Predicted by time-lagged DERS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003cp\u003e(session x-1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime (sessions)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBetween-person\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-2.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-4.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-5.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithin-person\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u003csub\u003emarginal\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.20 [95% CI: .15-.33]; R\u003csup\u003e2\u003c/sup\u003e\u003csub\u003econditional\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.69 [95% CI: .57-.74]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u003csub\u003emarginal\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.19 [95% CI: .07-.25]; R\u003csup\u003e2\u003c/sup\u003e\u003csub\u003econditional\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.63 [95% CI: .56-.73]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eDERS Predicted by time-lagged Attention Awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003eAttention Awareness Predicted by time-lagged DERS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003cp\u003e(session x-1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-2.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime (sessions)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBetween-person\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-2.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-5.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-5.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithin-person\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-2.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u003csub\u003emarginal\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.24 [95% CI: .21-.36]; R\u003csup\u003e2\u003c/sup\u003e\u003csub\u003econditional\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.69 [95% CI: .66-.77]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u003csub\u003emarginal\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.26 [95% CI: .14-.33]; R\u003csup\u003e2\u003c/sup\u003e\u003csub\u003econditional\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.73 [95% CI: .69-.77]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eNotes. DERS\u0026thinsp;=\u0026thinsp;Difficulties in Emotion Regulation Scale; Decentering\u0026thinsp;=\u0026thinsp;Experience Questionnaire - Decentering items [EQ]; Nonjudgment\u0026thinsp;=\u0026thinsp;Five facet Mindfulness Questionnaire \u0026ndash; Nonjudge sub-scale items [FFMQ-NJ]; Body Awareness\u0026thinsp;=\u0026thinsp;Scale Body Connection \u0026ndash; Body-Awareness sub-scale items [SBC-BA]; Attention-Awareness\u0026thinsp;=\u0026thinsp;Mindful Attention Awareness Scale items [MAAS]; R\u003csup\u003e2\u003c/sup\u003e\u003csub\u003emarginal\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;the variance explained by fixed effect predictors relative to the total variance in the response; R\u003csup\u003e2\u003c/sup\u003e\u003csub\u003econditional\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;the variance explained by fixed effects plus random effects relative to the total variance in the response.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eChanges in emotion dysregulation and mechanisms of change during mindfulness training\u003c/h2\u003e \u003cp\u003eThe effects of mindfulness training on ED levels and mechanisms of change was assessed. The mindfulness training (sessions from 1 to 9) prompted improvements in participants' ED over time (b\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.82, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) as well as an increase in each of the mechanisms assessed (decentering: b\u0026thinsp;=\u0026thinsp;.13, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001; nonjudgment: b\u0026thinsp;=\u0026thinsp;.20, \u003cem\u003ep\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001; body awareness: b\u0026thinsp;=\u0026thinsp;.12, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01; attention awareness: b\u0026thinsp;=\u0026thinsp;.14, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01).\u003c/p\u003e \u003cp\u003eSubsequently, it was explored whether improvements in ED and gains in mechanisms of change over mindfulness training were moderated by sociodemographic variables (e.g., age, sex) or baseline clinical variables (i.e., score in diagnostic interview for Borderlines [DIB-R], past suicide acts, past non-suicidal self-injury). Improvements in ED and gains in mechanisms were not moderated by sociodemographic variables (all p-values\u0026thinsp;\u0026gt;\u0026thinsp;.11) or by any of the baseline clinical measures (all p-values\u0026thinsp;\u0026gt;\u0026thinsp;.18).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eEffects of mechanisms of change on emotion dysregulation over time\u003c/h2\u003e \u003cp\u003eThe time-lagged effects of decentering, nonjudgment, body awareness and attention awareness on ED was explored. In these analyses, the effect of both between and within person mechanisms on ED was tested (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Consistent with our hypothesis, greater both within- and between-person effect of nonjudgment and body awareness at session x predicted improvements in ED at session x\u0026thinsp;+\u0026thinsp;1. This means that when participants reported higher capacity of nonjudgment and body awareness than their personal average (i.e., higher-than-usual), and more than the total sample average, they also showed an improvement/reduction in their ED level at the following week. Similarly, greater between-person (but not within-person) effects of decentering and attention awareness at session x also predicted improvements in ED at session x\u0026thinsp;+\u0026thinsp;1. Therefore, when participants reported higher capacity of decentering and attention awareness than the total sample average, they showed improvements in their ED in the following week (see also Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Medium-to-large effects size were obtained in all models (R\u003csup\u003e2\u003c/sup\u003e: .20-.31).\u003c/p\u003e \u003cp\u003eSubsequently, both the between- and within-person effect was assessed of all mechanisms on ED in the same model (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Greater between-person effects of decentering, nonjudgment, and attention awareness, as well as greater within-person effects of body awareness in session x predicted improvements in ED at the following week (i.e., session x\u0026thinsp;+\u0026thinsp;1). The variance of the time lagged fixed effects (i.e., the four mechanisms at session x) explained 52% of the total variance of DERS in the following week, yielding a large effect size.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFull model time-lagged analysis of mechanisms and improvement in emotion dysregulation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eDERS Predicted by time-lagged Skills\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003cp\u003e(session x-1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntercept\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime (sessions)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecentering \u003csub\u003eBetween\u0026minus;person\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecentering \u003csub\u003eWithin\u0026minus;person\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonjudgment \u003csub\u003eBetween\u0026minus;person\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-5.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonjudgment \u003csub\u003eWithin\u0026minus;person\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody Awareness \u003csub\u003eBetween\u0026minus;person\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody Awareness \u003csub\u003eWithin\u0026minus;person\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttention-Awareness \u003csub\u003eBetween\u0026minus;person\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-4.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttention-Awareness \u003csub\u003eWithin\u0026minus;person\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u003csub\u003emarginal\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.52 [95% CI: .44-.60]; R\u003csup\u003e2\u003c/sup\u003e\u003csub\u003econditional\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.69 [95% CI: .65-.74]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNotes. DERS\u0026thinsp;=\u0026thinsp;Difficulties in Emotion Regulation Scale; Decentering\u0026thinsp;=\u0026thinsp;Experience Questionnaire - Decentering items [EQ]; Nonjudgment\u0026thinsp;=\u0026thinsp;Five facet Mindfulness Questionnaire \u0026ndash; Nonjudge sub-scale items [FFMQ-NJ]; Body Awareness\u0026thinsp;=\u0026thinsp;Scale Body Connection \u0026ndash; Body-Awareness sub-scale items [SBC-BA]; Attention Awareness\u0026thinsp;=\u0026thinsp;Mindful Attention Awareness Scale items [MAAS]; R\u003csup\u003e2\u003c/sup\u003e\u003csub\u003emarginal\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;the variance explained by fixed effect predictors relative to the total variance in the response; R\u003csup\u003e2\u003c/sup\u003e\u003csub\u003econditional\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;the variance explained by fixed effects plus random effects relative to the total variance in the response.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[Insert Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e here]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEffects of emotion dysregulation on mechanism of change over time\u003c/h2\u003e \u003cp\u003eWe then explored the lagged effects of ED on each mechanism of change to determine the possibility of bidirectionality (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Higher within- and between-person level of ED at session x predicted decreased capacity of decentering, nonjudgment and attention awareness at session x\u0026thinsp;+\u0026thinsp;1. However, only higher between-person level of ED at session x predicted decreased body awareness at session x\u0026thinsp;+\u0026thinsp;1. This means that when participants had a week with more emotion regulation difficulties than their personal average, they were less able to increase decentering, nonjudgment and attention awareness at the following week. In addition, when participants had more ED than the total sample average, they were also less able to increase body awareness in the following week. In all models, medium-to-large effects size were obtained (R\u003csup\u003e2\u003c/sup\u003e: .19-.30). Thus, a bidirectional temporal dynamic between the proposed mechanisms and ED was found.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDecentering moderates the association of body awareness, attention awareness, and nonjudgment with emotion dysregulation\u003c/h2\u003e \u003cp\u003eSubsequently, the moderating role of decentering as a metacognitive process on the association between nonjudgment, body awareness, attention awareness, and ED was assessed. In these analyses, the between-person effects of decentering as moderator, the within-person effects of nonjudgment, body awareness and attention awareness as predictors, and ED as outcome were used [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. First, an interaction effect was found between nonjudgment x decentering in predicting ED (b\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.41, SE\u0026thinsp;=\u0026thinsp;.09, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Simple slope analysis showed that within-person increase in nonjudgment predicted improvements in ED more strongly among participants with high decentering (b = -2.37, SE\u0026thinsp;=\u0026thinsp;.31, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) than among participants with low decentering (B\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.71, SE\u0026thinsp;=\u0026thinsp;.22, p\u0026thinsp;\u0026lt;\u0026thinsp;.01; see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSecond, an interaction effect was also found between body awareness x decentering in predicting ED (b\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.25, SE\u0026thinsp;=\u0026thinsp;.08, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01). Simple slope analysis showed that a within-person increase in body awareness predicted improvements in ED more strongly among participants with high decentering (B = -1.88, SE\u0026thinsp;=\u0026thinsp;.30, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) than among participants with low decentering (B\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.84, SE\u0026thinsp;=\u0026thinsp;.21, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001; see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThere was no significant moderating effect of decentering on the association between attention awareness and ED (b\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.09, SE\u0026thinsp;=\u0026thinsp;.09, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.31). In addition, there was no evidence that a within-person effect of decentering was moderated by the between-person effects of nonjudgment, body awareness or attention awareness (all p-value\u0026thinsp;\u0026gt;\u0026thinsp;.69).\u003c/p\u003e \u003cp\u003e[Insert Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here]\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study aimed to explore how mindfulness DBT skills training improves emotion regulation in people with BPD. A main finding was that participants who at a given week increased their capacity for nonjudgment of inner experience and body awareness more than their own personal average (i.e., within-person effects), and those who increased their capacity for decentering and attention awareness more than the total sample average (i.e., between-person effects), showed improvements in ED at the following week. Moreover, as expected, a bidirectional relationship was found. That is, when participants were more emotionally dysregulated than their own usual state, they showed less gains in decentering, nonjudgment and attention awareness at the following week. Lastly, decentering moderated the relationship between nonjudgment and body awareness with ED, such that increased nonjudgment and body awareness predicted improvements in ED more strongly in those participants with high decentering capacity compared with those participants with low decentering.\u003c/p\u003e \u003cp\u003eThe present study is an advance in identifying the possible mechanisms of change involved in a mindfulness DBT skills training as a stand-alone intervention to improve ED in BPD outpatients, using ad hoc methodology [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Previous studies reporting the mechanisms of change involved in a DBT skills training agree that greater use of behavioral skills mediates changes in ED [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Specifically, when participants use more DBT skills than their own personal average, their emotion regulation capacity improve [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. A recent study explored this question only in a DBT mindfulness skills training and also found that greater use of behavioral skills (i.e., mindfulness practice) predicted improvements in ED [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Current results extend previous findings and provide further evidence to report specifically what are the mechanisms of change involved in a mindfulness skill training.\u003c/p\u003e \u003cp\u003eSpecifically, the within-person effects of nonjudgment and body awareness predicted subsequent improvements in ED. Previous empirical studies support these findings, showing that acceptance without judgment mediated changes in psychiatric symptoms and frequency of nonsuicidal self-injury \u0026ndash;ED related outcomes\u0026ndash; following DBT skills training [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Similarly, Eisenlohr-Moul et al. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] found that fluctuations in nonjudgment of internal experience over time (i.e., at within-person level) predicted lower borderline symptoms in women with BPD features. The tendency to judge internal experience is characteristic in individuals with BPD and contributes to emotional regulation problems [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Therefore, strategies focused on improving this ability are key in the treatment of BPD [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The role of body awareness as a mechanism of change has been less studied in DBT interventions and the evidence obtained from other mindfulness-based interventions shows significant but small effects [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. However, our results support the role of body awareness as a relevant mechanism to foster emotion regulation in BPD. For example, some of the items used to assess body awareness (\"\u003cem\u003eI take my body's signals to understand how I feel\u003c/em\u003e\") highlight the importance of the body (e.g., attending to bodily sensations) to facilitate awareness of one's emotions and feelings, which is a pre-condition for regulating them [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAn additional finding in the current study was that decentering ability modulated the strength of the association between nonjudgment, body awareness, and ED, such that high decentering capacity reinforced the effect of these mechanisms on reducing ED. This result is consistent with previous studies [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] and highlights the role of decentering as a metacognitive capacity that promotes emotion regulation [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Decentering is described as a metacognitive awareness that helps us disidentify from the contents of our experience so that instead of fusing with them (e.g., \"\u003cem\u003eI am not lovable\u003c/em\u003e\"), we can perceive them as transient mental events (e.g., \"\u003cem\u003eI am having a thought of not being lovable\u003c/em\u003e\") [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Given that decentering is diminished in individuals with BPD [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], a goal of mindfulness skills in DBT is to increase meta-awareness of mental contents by enhancing the ability to detach from thoughts and sensations, and decreasing reactivity to mental events [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Furthermore, the findings support that decentering not only allows for greater meta-awareness of mental contents but also of bodily sensations, but not inversely (i.e., moderating role), suggesting that observing judgmental thought patterns and intense bodily sensations (e.g., associated with distress) from a decentered perspective may help reduce emotional reactivity [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs noted, a bidirectional temporal dynamic between the proposed mechanisms and ED was found. Interestingly, previous studies also found a bidirectional relationship between poorer psychosocial functioning and ED [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], and between mindfulness practice skills and ED [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] in people with BPD who attended DBT skill training. These antecedents suggest that when participants with BPD had a previous high level of ED, they tended to practice less and, therefore, improved less in the proposed mechanisms. One explanation for this effect is that mindfulness practice is mood-dependent [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] and therefore practicing skills is more difficult when one is emotionally dysregulated. This leads to a challenge for clinicians when intervening with individuals diagnosed with BPD who usually have pervasive patterns of ED. However, part of the effectiveness of DBT skill training is that participants are taught to express and manage difficult emotional states within a structured group setting in which the therapist models skills and provides positive feedback and reinforcement [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This encourages exposure to difficult experiences rather than avoidance or fusion with them [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In this way, patients undergoing DBT skills training may feel more capable to apply their newly learned skills to the real-world.\u003c/p\u003e \u003cp\u003eThe results of this study may have some clinical implications and allow for possible causal interpretations of the mechanisms that favor improvements in ED after mindfulness skill training. Only nonjudgment and body awareness increases were related to within-person effects, whereas increases in decentering and attention awareness were only related to between-person effects. Thus, the more attitudinal aspects of mindfulness, such as nonjudgment and body awareness, seem to be more sensitive to within-person variability, whereas the more attentional and metacognitive aspects seem more stable [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Importantly, when all four proposed mechanisms of change were included in the same model, they explained 52% of the variance of changes in ED in the following week. Thus, these mechanisms appear to complement each other and therapists could consider this information to improve the efficacy of BPD-oriented treatments. In addition, decentering capacity acted as a metacognitive process that enhances the effect of the other mechanisms on ED. This also suggests that therapists may use strategies that increase the decentering ability in BPD treatments.\u003c/p\u003e \u003cp\u003eThe present study has some limitations that should be considered when interpreting the results. First, a single-arm non-randomized trial was implemented, that limits the generalizability of our conclusions. Second, to facilitate the weekly evaluation of the participants, the 3 most representative items of each measure (i.e., mechanisms of change) was used. However, these items may not be fully representative of the overall construct and may therefore increase risk of false negatives (i.e., type II error). Third, a measure of ED was used as the outcome. However, ED can also be considered as a process that contributes to the development or maintenance of psychopathology [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. For example, a repeated measure of borderline symptoms would have enriched the results. Fourth, the sample was mostly composed of women. It is desirable that future studies consider more representative samples of men with BPD.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe present study provides preliminary evidence on the mechanisms of change underlying mindfulness skill training. Therapists could benefit from this information when treating emotion dysregulation in BPD patients by using strategies that promote decentering, nonjudgment and body awareness. Finally, understanding how mindfulness DBT skills training works can help optimize treatment for BPD.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBPD Borderline Personality Disorder ED Emotion Dysregulation DBT Dialectical Behavior Therapy SCID II Structured Clinical Interview for DSM IV axis II Disorders DIB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eR Revised Diagnostic Interview for Borderlines DERS-18 Brief Version of the Difficulties in Emotion Regulation Scale EQ Experiencing Questionnaire NJ-FFMQ Nonjudging of Inner Experience sub-scale of Five Facets Mindfulness Questionnaire BA-SBC Body Awareness of Scale Body Connection MAAS Mindfulness Attention Awareness Scale MLM Multilevel modeling REML Restricted maximum likelihood\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of Hospital de la Santa Creu i Sant Pau. Informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Centro de Investigaci\u0026oacute;n Biom\u0026eacute;dica en Red de Salud Mental (CIBERSAM) and by a grant from Instituto de Salud Carlos III [PI19/00087 and PI21/00505] and co-financed by the European Regional Development Fund (ERDF). CS was supported by the National Agency for Research and Development (ANID) / Scholarship Program / Doctorado Becas Chile [reference number 72190624]. SN was supported by a fellowship from \"La Caixa\" Foundation [ID 100010434; code: LCF/BQ/DR21/11880013].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCS, JS, JCP, designed the study. JCP and LA recruited the participants. JS and DV performed the interventions. CS and SN collected and interpreted the data analyses. All authors approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by Centro de Investigaci\u0026oacute;n Biom\u0026eacute;dica en Red de Salud Mental (CIBERSAM).\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Reviseds [Internet]. Fifth Edition. American Psychiatric Association. ; 2022 [cited 2011 Nov 10]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787\u003c/span\u003e\u003cspan address=\"https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrull TJ, Jahng S, Tomko RL, Wood PK, Sher KJ. Revised NESARC personality disorder diagnoses: gender, prevalence, and comorbidity with substance dependence disorders. J Pers Disord. 2010;24(4):412\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1521/pedi.2010.24.4.412\u003c/span\u003e\u003cspan address=\"10.1521/pedi.2010.24.4.412\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGlashan TH, Grilo CM, Skodol AE, et al. The Collaborative Longitudinal Personality Disorders Study: baseline Axis I/II and II/II diagnostic co-occurrence. Acta Psychiatr Scand. 2000;102(4):256\u0026ndash;64. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1034/j.1600-0447.2000.102004256.x\u003c/span\u003e\u003cspan address=\"10.1034/j.1600-0447.2000.102004256.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlvarez-Tom\u0026aacute;s I, Soler J, Bados A, et al. Long-Term Course of Borderline Personality Disorder: A Prospective 10-Year Follow-Up Study. J Pers Disord. 2017;31(5):590\u0026ndash;605. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1521/pedi_2016_30_269\u003c/span\u003e\u003cspan address=\"10.1521/pedi_2016_30_269\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeichsenring F, Fonagy P, Heim N, et al. Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies. World Psychiatry. 2024;23(1):4\u0026ndash;25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/wps.21156\u003c/span\u003e\u003cspan address=\"10.1002/wps.21156\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePascual JC, Mart\u0026iacute;n-Blanco A, Soler J. Twenty-Year Trends in the Psychopharmacological Treatment of Outpatients with Borderline Personality Disorder: A Cross-Sectional Naturalistic Study in Spain. CNS Drugs. 2021;35(9):1023\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s40263-021-00852-7\u003c/span\u003e\u003cspan address=\"10.1007/s40263-021-00852-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarpenter RW, Trull TJ. Components of emotion dysregulation in borderline personality disorder: a review. Curr Psychiatry Rep. 2013;15(1):335. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11920-012-0335-2\u003c/span\u003e\u003cspan address=\"10.1007/s11920-012-0335-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlenn CR, Klonsky ED. Emotion dysregulation as a core feature of borderline personality disorder. J Pers Disord. 2009;23(1):20\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1521/pedi.2009.23.1.20\u003c/span\u003e\u003cspan address=\"10.1521/pedi.2009.23.1.20\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeacsiu AD, Eberle JW, Kramer R, Wiesmann T, Linehan MM. Dialectical behavior therapy skills for transdiagnostic emotion dysregulation: a pilot randomized controlled trial. Behav Res Ther. 2014;59:40\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.brat.2014.05.005\u003c/span\u003e\u003cspan address=\"10.1016/j.brat.2014.05.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBohus M, Stoffers-Winterling J, Sharp C, Krause-Utz A, Schmahl C, Lieb K. Borderline personality disorder. Lancet. 2021;398(10310):1528\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(21)00476-1\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(21)00476-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChapman AL. Borderline personality disorder and emotion dysregulation. Dev Psychopathol. 2019;31(3):1143\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1017/S0954579419000658\u003c/span\u003e\u003cspan address=\"10.1017/S0954579419000658\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003e2018 surveillance of personality disorders (NICE guidelines CG77 and CG78)\u003c/em\u003e. London: National Institute for Health and Care Excellence (NICE); July 19, 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStoreb\u0026oslash; OJ, Stoffers-Winterling JM, V\u0026ouml;llm BA, et al. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2020;5(5):CD012955. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/14651858.CD012955.pub2\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD012955.pub2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2020 May 4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLinehan MM. Cognitive-behavioral treatment of borderline personality disorder. 558xvii. p. ed. New York, NY, US: Guilford Press; 1993. (Cognitive-behavioral treatment of borderline personality disorder).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLinehan MM. Skills training manual for treating borderline personality disorder. New York, NY, US: Guilford Press; 1993. xii, 180 p. (Skills training manual for treating borderline personality disorder).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarmona i Farr\u0026eacute;s C, Elices M, Soler J, Dom\u0026iacute;nguez-Clav\u0026eacute; E, Pomarol-Clotet E, Salvador R, Pascual JC. Effects of mindfulness training on borderline personality disorder: Impulsivity versus emotional dysregulation. Mindfulness. 2019;10(7):1243\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12671-018-1071-4\u003c/span\u003e\u003cspan address=\"10.1007/s12671-018-1071-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchmidt C, Soler J, Carmona I, Farr\u0026eacute;s C, et al. Mindfulness in Borderline Personality Disorder: Decentering Mediates the Effectiveness. Psicothema. 2021;33(3):407\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7334/psicothema2020.437\u003c/span\u003e\u003cspan address=\"10.7334/psicothema2020.437\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKazdin AE. Mediators and mechanisms of change in psychotherapy research. Annu Rev Clin Psychol. 2007;3:1\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1146/annurev.clinpsy.3.022806.091432\u003c/span\u003e\u003cspan address=\"10.1146/annurev.clinpsy.3.022806.091432\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKazdin AE. Evidence-based psychotherapies I: Qualifiers and limitations in what we know. South Afr J Psychol. 2014;44(4):381\u0026ndash;403. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0081246314533750\u003c/span\u003e\u003cspan address=\"10.1177/0081246314533750\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolmes EA, Ghaderi A, Harmer CJ, et al. The Lancet Psychiatry Commission on psychological treatments research in tomorrow's science. Lancet Psychiatry. 2018;5(3):237\u0026ndash;86. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2215-0366(17)30513-8\u003c/span\u003e\u003cspan address=\"10.1016/S2215-0366(17)30513-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang LP, Maxwell SE. On disaggregating between-person and within-person effects with longitudinal data using multilevel models. Psychol Methods. 2015;20(1):63\u0026ndash;83. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/met0000030\u003c/span\u003e\u003cspan address=\"10.1037/met0000030\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChapman AL, Owens L. Mechanisms of change in dialectical behavior therapy. In: Bedics J, editor. The handbook of dialectical behavior therapy: Theory, research, and evaluation. Elsevier Academic; 2020. pp. 51\u0026ndash;69. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/B978-0-12-816384-9.00003-8\u003c/span\u003e\u003cspan address=\"10.1016/B978-0-12-816384-9.00003-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsarnow JR, Berk MS, Bedics J, et al. Dialectical Behavior Therapy for Suicidal Self-Harming Youth: Emotion Regulation, Mechanisms, and Mediators. J Am Acad Child Adolesc Psychiatry. 2021;60(9):1105\u0026ndash;1115e4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jaac.2021.01.016\u003c/span\u003e\u003cspan address=\"10.1016/j.jaac.2021.01.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSouthward MW, Howard KP, Cheavens JS. Less is more: Decreasing the frequency of maladaptive coping predicts improvements in DBT more consistently than increasing the frequency of adaptive coping. Behav Res Ther. 2023;163:104288. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.brat.2023.104288\u003c/span\u003e\u003cspan address=\"10.1016/j.brat.2023.104288\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWyatt KP, Eberle JW, Ruork AK, Neacsiu AD. Mechanisms of change in treatments for transdiagnostic emotion dysregulation: The roles of skills use, perceived control and mindfulness. Clin Psychol Psychother. 2023;30(6):1380\u0026ndash;92. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/cpp.2879\u003c/span\u003e\u003cspan address=\"10.1002/cpp.2879\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarnicot K, Gonzalez R, McCabe R, Priebe S. Skills use and common treatment processes in dialectical behaviour therapy for borderline personality disorder. J Behav Ther Exp Psychiatry. 2016;52:147\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jbtep.2016.04.006\u003c/span\u003e\u003cspan address=\"10.1016/j.jbtep.2016.04.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchmidt C, Soler J, Vega D, Pascual JC. Practice Matters: The Role of Mindfulness Skills in Emotion Dysregulation in Borderline Personality Disorder. Manuscript submitted for publication; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eH\u0026ouml;lzel BK, Lazar SW, Gard T, Schuman-Olivier Z, Vago DR, Ott U. How Does Mindfulness Meditation Work? Proposing Mechanisms of Action From a Conceptual and Neural Perspective. Perspect Psychol Sci. 2011;6(6):537\u0026ndash;59. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1745691611419671\u003c/span\u003e\u003cspan address=\"10.1177/1745691611419671\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang YY, H\u0026ouml;lzel BK, Posner MI. The neuroscience of mindfulness meditation. Nat Rev Neurosci. 2015;16(4):213\u0026ndash;25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/nrn3916\u003c/span\u003e\u003cspan address=\"10.1038/nrn3916\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarmody J, Baer RA, Lykins LB, Olendzki E. An empirical study of the mechanisms of mindfulness in a mindfulness-based stress reduction program. J Clin Psychol. 2009;65(6):613\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/jclp.20579\u003c/span\u003e\u003cspan address=\"10.1002/jclp.20579\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFresco DM, Moore MT, van Dulmen MH, et al. Initial psychometric properties of the experiences questionnaire: validation of a self-report measure of decentering. Behav Ther. 2007;38(3):234\u0026ndash;46. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.beth.2006.08.003\u003c/span\u003e\u003cspan address=\"10.1016/j.beth.2006.08.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBernstein A, Hadash Y, Lichtash Y, Tanay G, Shepherd K, Fresco DM. Decentering and Related Constructs: A Critical Review and Metacognitive Processes Model. Perspect Psychol Sci. 2015;10(5):599\u0026ndash;617. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1745691615594577\u003c/span\u003e\u003cspan address=\"10.1177/1745691615594577\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO'Toole MS, Renna ME, Mennin DS, Fresco DM. Changes in Decentering and Reappraisal Temporally Precede Symptom Reduction During Emotion Regulation Therapy for Generalized Anxiety Disorder With and Without Co-Occurring Depression. Behav Ther. 2019;50(6):1042\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.beth.2018.12.005\u003c/span\u003e\u003cspan address=\"10.1016/j.beth.2018.12.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarpenter JK, Conroy K, Gomez AF, Curren LC, Hofmann SG. The relationship between trait mindfulness and affective symptoms: A meta-analysis of the Five Facet Mindfulness Questionnaire (FFMQ). Clin Psychol Rev. 2019;74:101785. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.cpr.2019.101785\u003c/span\u003e\u003cspan address=\"10.1016/j.cpr.2019.101785\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWupperman P, Neumann CS, Whitman JB, Axelrod SR. The role of mindfulness in borderline personality disorder features. J Nerv Ment Dis. 2009;197(10):766\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/NMD.0b013e3181b97343\u003c/span\u003e\u003cspan address=\"10.1097/NMD.0b013e3181b97343\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrantz LH, McMain S, Kuo JR. The unique contribution of acceptance without judgment in predicting nonsuicidal self-injury after 20-weeks of dialectical behaviour therapy group skills training. Behav Res Ther. 2018;104:44\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.brat.2018.02.006\u003c/span\u003e\u003cspan address=\"10.1016/j.brat.2018.02.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeifman RJ, Boritz T, Barnhart R, Labrish C, McMain SF. The independent roles of mindfulness and distress tolerance in treatment outcomes in dialectical behavior therapy skills training. Personal Disord. 2020;11(3):181\u0026ndash;90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1037/per0000368\u003c/span\u003e\u003cspan address=\"10.1037/per0000368\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEisenlohr-Moul T, Peters JR, Chamberlain KD, Rodriguez M. Weekly fluctuations in nonjudging predict borderline personality disorder feature expression in women. J Psychopathol Behav Assess. 2016;38(1):149\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10862-015-9505-y\u003c/span\u003e\u003cspan address=\"10.1007/s10862-015-9505-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrice CJ, Thompson EA. Measuring dimensions of body connection: body awareness and bodily dissociation. J Altern Complement Med. 2007;13(9):945\u0026ndash;53. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1089/acm.2007.0537\u003c/span\u003e\u003cspan address=\"10.1089/acm.2007.0537\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarmody J, Baer RA. Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. J Behav Med. 2008;31(1):23\u0026ndash;33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10865-007-9130-7\u003c/span\u003e\u003cspan address=\"10.1007/s10865-007-9130-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L. Using self-report assessment methods to explore facets of mindfulness. Assessment. 2006;13(1):27\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1073191105283504\u003c/span\u003e\u003cspan address=\"10.1177/1073191105283504\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchmitz M, Bertsch K, L\u0026ouml;ffler A, Steinmann S, Herpertz SC, Bekrater-Bodmann R. Body connection mediates the relationship between traumatic childhood experiences and impaired emotion regulation in borderline personality disorder. \u003cem\u003eBorderline Personal Disord Emot Dysregul\u003c/em\u003e. 2021;8(1):17. Published 2021 May 17. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s40479-021-00157-7\u003c/span\u003e\u003cspan address=\"10.1186/s40479-021-00157-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLutz A, Slagter HA, Dunne JD, Davidson RJ. Attention regulation and monitoring in meditation. Trends Cogn Sci. 2008;12(4):163\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.tics.2008.01.005\u003c/span\u003e\u003cspan address=\"10.1016/j.tics.2008.01.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu JL, Hamilton JL, Fresco DM, Alloy LB, Stange JP. Decentering predicts attenuated perseverative thought and internalizing symptoms following stress exposure: A multi-level, multi-wave study. Behav Res Ther. 2022;152:104017. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.brat.2021.104017\u003c/span\u003e\u003cspan address=\"10.1016/j.brat.2021.104017\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFirst MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS. Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Washington, DC: American Psychiatric Press, Inc; 2007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarrachina J, Soler J, Campins MJ, et al. Validaci\u0026oacute;n de la versi\u0026oacute;n espa\u0026ntilde;ola de la Diagnostic Interview for Bordelines-Revised (DIB-R) [Validation of a Spanish version of the Diagnostic Interview for Bordelines-Revised (DIB-R)]. Actas Esp Psiquiatr. 2004;32(5):293\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElices M, Pascual JC, Portella MJ, et al. Impact of mindfulness training on borderline personality disorder: A randomized trial. Mindfulness. 2016;7(3):584\u0026ndash;95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s12671-016-0492-1\u003c/span\u003e\u003cspan address=\"10.1007/s12671-016-0492-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVictor SE, Klonsky ED. Validation of a brief version of the Difficulties in Emotion Regulation Scale (DERS-18) in five samples. J Psychopathol Behav Assess. 2016;38(4):582\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10862-016-9547-9\u003c/span\u003e\u003cspan address=\"10.1007/s10862-016-9547-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoler J, Franquesa A, Feliu-Soler A, et al. Assessing decentering: validation, psychometric properties, and clinical usefulness of the Experiences Questionnaire in a Spanish sample. Behav Ther. 2014;45(6):863\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.beth.2014.05.004\u003c/span\u003e\u003cspan address=\"10.1016/j.beth.2014.05.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCebolla A, Garc\u0026iacute;a-Palacios A, Soler J, Guillen V, Ba\u0026ntilde;os R, Botella C. Psychometric properties of the Spanish validation of the Five Facets of Mindfulness Questionnaire (FFMQ). Eur J Psychiatry. 2012;26(2):118\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4321/S0213-61632012000200005\u003c/span\u003e\u003cspan address=\"10.4321/S0213-61632012000200005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuezada-Berumen LC, Gonz\u0026aacute;lez-Ram\u0026iacute;rez MT, Cebolla A, Soler J, Garcia-Campayo J. Body awareness and mindfulness: validation of the Spanish version of the Scale of Body Connection. Actas Esp Psiquiatr. 2014;42(2):57\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Personal Soc Psychol. 2003;84(4):822\u0026ndash;48. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/0022-3514.84.4.822\u003c/span\u003e\u003cspan address=\"10.1037/0022-3514.84.4.822\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoler J, Tejedor R, Feliu-Soler A, et al. Psychometric proprieties of Spanish version of Mindful Attention Awareness Scale (MAAS). Actas Esp Psiquiatr. 2012;40(1):19\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilks CR, Korslund KE, Harned MS, Linehan MM. Dialectical behavior therapy and domains of functioning over two years. Behav Res Ther. 2016;77:162\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.brat.2015.12.013\u003c/span\u003e\u003cspan address=\"10.1016/j.brat.2015.12.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEnders CK, Tofighi D. Centering predictor variables in cross-sectional multilevel models: a new look at an old issue. Psychol Methods. 2007;12(2):121\u0026ndash;38. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/1082-989X.12.2.121\u003c/span\u003e\u003cspan address=\"10.1037/1082-989X.12.2.121\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAiken LS, West SG. Multiple regression: Testing and interpreting interactions. Sage Publications, Inc; 1991.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStoffel MA, Nakagawa S, Schielzeth H, rptR. Repeatability estimation and variance decomposition by generalized linear mixed-effects models. Methods Ecol Evol. 2017;8:1639\u0026ndash;44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/2041-210X.12797\u003c/span\u003e\u003cspan address=\"10.1111/2041-210X.12797\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakagawa S, Schielzeth H. A general and simple method for obtaining R2 from generalized linear mixed-effects models. Methods Ecol Evol. 2013;4(2):133\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.2041-210x.2012.00261.x\u003c/span\u003e\u003cspan address=\"10.1111/j.2041-210x.2012.00261.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen J. Statistical Power Analysis for the Behavioral Sciences. 2th ed. Hillsdale, NJ: Lawrence Erlbaum Associates,; 1988.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBates D, M\u0026auml;chler M, Bolker B, Walker S. Fitting Linear Mixed-Effects Models Using lme4. J Stat Softw. 2015;67(1):1\u0026ndash;48. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.18637/jss.v067.i01\u003c/span\u003e\u003cspan address=\"10.18637/jss.v067.i01\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElices M, Pascual JC, Carmona C et al. Correction to: Exploring the relation between childhood trauma, temperamental traits and mindfulness in borderline personality disorder. \u003cem\u003eBMC Psychiatry\u003c/em\u003e. 2018;18(1):284. Published 2018 Sep 4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12888-018-1834-4\u003c/span\u003e\u003cspan address=\"10.1186/s12888-018-1834-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTreves IN, Tello LY, Davidson RJ, Goldberg SB. The relationship between mindfulness and objective measures of body awareness: A meta-analysis. Sci Rep. 2019;9(1):17386. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41598-019-53978-6\u003c/span\u003e\u003cspan address=\"10.1038/s41598-019-53978-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Published 2019 Nov 22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarpenter JK, Sanford J, Hofmann SG. The Effect of a Brief Mindfulness Training on Distress Tolerance and Stress Reactivity. Behav Ther. 2019;50(3):630\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.beth.2018.10.003\u003c/span\u003e\u003cspan address=\"10.1016/j.beth.2018.10.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElices M, Tejedor R, Pascual JC, Carmona C, Soriano J, Soler J. Acceptance and present-moment awareness in psychiatric disorders: Is mindfulness mood dependent? Psychiatry Res. 2019;273:363\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.psychres.2019.01.041\u003c/span\u003e\u003cspan address=\"10.1016/j.psychres.2019.01.041\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAldao A, Nolen-Hoeksema S, Schweizer S. Emotion-regulation strategies across psychopathology: A meta-analytic review. Clin Psychol Rev. 2010;30(2):217\u0026ndash;37. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.cpr.2009.11.004\u003c/span\u003e\u003cspan address=\"10.1016/j.cpr.2009.11.004\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"borderline-personality-disorder-and-emotion-dysregulation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bded","sideBox":"Learn more about [Borderline Personality Disorder and Emotion Dysregulation](http://bpded.biomedcentral.com)","snPcode":"40479","submissionUrl":"https://submission.nature.com/new-submission/40479/3","title":"Borderline Personality Disorder and Emotion Dysregulation","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mindfulness training, mechanisms, moderators, Emotion regulation, Borderline personality disorders, Dialectical behavior therapy","lastPublishedDoi":"10.21203/rs.3.rs-3976899/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3976899/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMindfulness skills training is a core component of Dialectical Behavior Therapy and aims to improve emotion dysregulation (ED) in people with Borderline Personality Disorder (BPD). However, the underlying mechanisms of change are not fully understood.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 75 BPD outpatients participated in a 10-week mindfulness skills training. Decentering, nonjudgment, body awareness and attention awareness was proposed as putative mechanisms. Multilevel models with a time-lagged approach were conducted to examine the temporal dynamics between these mechanisms and ED.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eGreater nonjudgment and body awareness showed within-person effects; participants who reported higher nonjudgement of inner experience and body awareness than their own personal average at a given week showed improvement in ED at the following week. Notably, decentering moderated these associations, such that increased nonjudgment and body awareness predicted improvements in ED more strongly in those participants with high decentering ability. Lastly, a bidirectional relationship between the mechanisms and ED was found; when participants were more emotionally dysregulated than their usual state, they showed less gain in the mechanisms at the following week.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eKnowing how mindfulness training works is relevant to optimize treatments. Clinicians may use strategies to increase these mechanisms when the goal is to improve emotion regulation difficulties in BPD.\u003c/p\u003e","manuscriptTitle":"How does mindfulness skills training works on emotion dysregulation in borderline personality disorder?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-04 18:47:56","doi":"10.21203/rs.3.rs-3976899/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-16T16:08:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-10T13:17:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-03T08:37:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"03a4cec5-c6c9-417f-8de9-ed6acebacb9b","date":"2024-03-21T13:40:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"740f2fe2-f615-492b-b644-a6e041c028a0","date":"2024-03-20T14:37:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-20T14:31:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-28T09:14:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-28T08:03:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"Borderline Personality Disorder and Emotion Dysregulation","date":"2024-02-21T21:27:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"borderline-personality-disorder-and-emotion-dysregulation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bded","sideBox":"Learn more about [Borderline Personality Disorder and Emotion Dysregulation](http://bpded.biomedcentral.com)","snPcode":"40479","submissionUrl":"https://submission.nature.com/new-submission/40479/3","title":"Borderline Personality Disorder and Emotion Dysregulation","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"53d1e6cc-df07-4de6-a192-f85b0cc62268","owner":[],"postedDate":"March 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-09T16:10:25+00:00","versionOfRecord":{"articleIdentity":"rs-3976899","link":"https://doi.org/10.1186/s40479-024-00265-0","journal":{"identity":"borderline-personality-disorder-and-emotion-dysregulation","isVorOnly":false,"title":"Borderline Personality Disorder and Emotion Dysregulation"},"publishedOn":"2024-09-02 16:05:04","publishedOnDateReadable":"September 2nd, 2024"},"versionCreatedAt":"2024-03-04 18:47:56","video":"","vorDoi":"10.1186/s40479-024-00265-0","vorDoiUrl":"https://doi.org/10.1186/s40479-024-00265-0","workflowStages":[]},"version":"v1","identity":"rs-3976899","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3976899","identity":"rs-3976899","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}