Relations of mindfulness facets and psychological symptoms among individuals with a diagnosis of Obsessive-Compulsive Disorder, Major Depressive Disorder and Borderline Personality Disorder Fabrizio Didonna 1,2, Roberta Rossi 3, Clarissa Ferrari 4, Luca Iani 5, Laura Pedrini 3, Nicoletta Rossi 1, Erica Xodo 2, and Mariangela Lanfredi 3 1 Unit for OCD, Department of Psychiatry, Villa Margherita Private Hospital, Vicenza, Italy 2 Italian Institute for Mindfulness, Vicenza, Italy 3 Unit of Psychiatry, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy 4 Service of Statistics, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy 5 Department of Human Sciences European University of Rome, Rome, Italy Cite this article as: Didonna, F., Rossi, R., Ferrari, C., Iani, L., Pedrini, L., Rossi, N., … & Lanfredi, M. (2018). Relations of mindfulness facets and psychological symptoms among individuals with a diagnosis of Obsessive-Compulsive Disorder, Major Depressive Disorder and Borderline Personality Disorder. Psychology and Psychotherapy: Theory, Research and Practice. doi: 10.1111/papt.12180 Corresponding author Dr. Mariangela Lanfredi Unit of Psychiatry, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, via Pilastroni 4, I-25125, Brescia, Italy; tel.: +390303501504, fax: +390303501592, email: mlanfredi@fatebenefratelli.eu ORCID ID: 0000-0001-5968-8952 ResearcherID Author Code: M-3345-2016 1     Abstract Objectives: To explore differences in mindfulness facets among patients with a diagnosis of either Obsessive-Compulsive Disorder (OCD), Major Depressive Disorder (MDD) or Borderline Personality Disorder (BPD), and healthy controls (HC), and their associations with clinical features. Design and method: One hundred and fifty-three patients and 50 HC underwent a clinical assessment including measures of mindfulness (Five Facets Mindfulness Questionnaire - FFMQ), psychopathological symptoms (Symptom Check List-90R), dissociation (Dissociative Experience Scale), alexithymia (Alexithymia Scale 20), and depression (Beck Depression Inventory II). Analysis of variance (ANOVA) and Covariance (ANCOVA) were performed to assess differences in mindfulness scores and their associations with clinical features. Results: The three diagnostic groups scored lower on all mindfulness facets (apart from FFMQ observing) compared to the HC group. OCD group had a significant higher FFMQ total score (FFMQ-TS) and FFMQ acting with awareness compared to the BPD group, and scored higher on FFMQ describing compared to BPD and MDD groups. The scores in non-judging facet were significantly lower in all the three diagnostic groups compared to the HC group. Interestingly, higher FFMQ-TS was inversely related to all psychological measures, regardless of diagnostic group. Conclusions: Deficits in mindfulness skills were present in all diagnostic groups. Furthermore, we found disease-specific relationships between some mindfulness facets and specific psychological variables. Clinical implications are discussed. Key words: Mindfulness, Obsessive-Compulsive Disorder, Major Depressive Disorder, Borderline Personality Disorder 2     Introduction Research on mindfulness and mindfulness-based interventions has increased exponentially over recent decades (Fjorback, Arendt, Ornbøl, Fink, & Walach, 2011; Grossman, Niemann, Schmidt, & Walach, 2004; Gu, Strauss, Bond, & Cavanagh, 2015; Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Salmon et al., 2004). Mindfulness is defined as a moment-to-moment non-judgmental awareness (KabatZinn, 1994), and is a set of skills that can be learned through training and regular practice. Mindfulness has received interest from clinicians and researchers because it is linked to well-being (Iani, Lauriola, Cafaro, & Didonna, 2017; Brown & Ryan, 2003), improves acceptance of symptoms that are difficult or impossible to change (Fjorback et al., 2011), enhances one’s meta-cognitive awareness (Teasdale et al., 2002), and helps patients to change their focus by emphasizing experience of the present moment (Shapiro, Carlson, Astin, & Freedman, 2006). Mindfulness is a multifaceted construct including different components related to attention, awareness, and ability to not react and not judge (Baer et al., 2008). Although several studies exploring the effects of mindfulness-based interventions on clinical outcomes conceptualized mindfulness as a unidimensional construct, recent studies pointed out the importance of assessing multiple mindfulness facets given their specific and contrasting relations to outcomes (Desrosiers, Klemanski, & NolenHoeksema, 2013; Gawrysiak et al., 2017; Hawley et al., 2017). According to Bishop et al. (2004), the processes underlying the positive effects of mindfulness are the self-regulation of attention and awareness, acceptance, and openness to experience of the present moment. By such means, mindfulness facilitates an observational stance towards internal experience, allowing people to accept their thoughts as ‘just thoughts’ rather than a literal reflection of reality (Chambers, Gullone, & Allen, 2009; Wells, 2006). Several manualized treatments have incorporated mindfulness among their techniques - such as Mindfulness-Based Stress Reduction (Kabat-Zinn, 1982, 1990), Mindfulness-Based Cognitive Therapy 3     (Segal, Williams, & Teasdale, 2013), and Dialectical Behavior Therapy (Linehan, 1993, 2014) - with beneficial effects on psychological functioning across a variety of psychiatric disorders (Bluett, Homan, Morrison, Levin, & Twohig, 2014; Cramer, Lauche, Haller, Langhorst, & Dobos, 2016; Hofmann, Sawyer, Witt, & Oh, 2010; Khoury et al., 2013; Strauss, Cavanagh, Oliver, & Pettman, 2014). Techniques similar to mindfulness have also been used in metacognitive therapy (i.e., detached mindfulness) which is aimed to modify the style of thinking and the nature of the relationship that an individual has with his thoughts (Wells, 2006), and in Acceptance and Commitment therapy, that is based on a theory of language and cognition (Hayes, Strosahl, & Wilson, 1999). Mindfulness skills may develop differently in various subgroups of individuals (Lilja et al., 2012). Low levels of mindfulness played a significant role in personality psychopathology, and was found negatively associated with Borderline Personality Disorder (BPD) features (Fossati, Vigorelli Porro, Maffei & Borroni, 2012; Shorey et al., 2016); moreover, higher levels of trait mindfulness were associated with lower levels of residual depressive symptoms, especially among individuals who have experienced five or more episodes of depression (Radford et al., 2014), and a recent study by Crowe and McKay (2016) showed that an OCD group scored significantly lower than a anxiety groups and a control group on some facets of mindfulness. In fact, mindfulness practice has been found related to improvements in core features of BPD (Chafos & Economu, 2014). Furthermore, recent studies on mindfulnessbased interventions for OCD (Hale, Strauss, & Taylor, 2013; Hawley et al., 2017; Key, Rowa, Bieling, McCabe, & Pawluk, 2017; Kumar, Sharma, Narayanaswamy, Kandavel, & Janardhan Reddy, 2016) and anxiety disorders (Evans et al. 2008; Vøllestad, Nielsen, & Nielsen, 2012; Wong et al. 2016) have shown encouraging results in terms of diagnosis-specific symptoms and comorbid depressive symptoms alleviation. Interestingly, a recent study by Hawley et al. (2017) showed that specific facets of mindfulness predicted symptom alleviation after cognitive behavior therapy. In particular, mindfulness practice may benefit OCD patients by 4     empowering them to deal with their intrusive thoughts in a healthy way and better recognize and prevent their urges to engage in compulsive behaviors (Didonna, 2009). Although research has identified positive effects of mindfulness-based interventions on health outcomes and on levels of mindfulness after treatment among individuals with a diagnosis of mental illness, few studies have examined whether or not deficits in mindfulness ability are present in a diagnostic group compared to controls (Crowe & McKay, 2016) at intake. To our knowledge, no studies compared mindfulness deficits among patients with major depression, obsessive compulsive disorder and borderline personality disorder and a healthy control group. This could be relevant in order to identify, on the one hand, the clinical population who may benefit from a mindfulness-based intervention, and, on the other hand, to better tailor mindfulness-based treatments to promote clinical improvement. We conducted a pilot study in order to explore two specific aims. Based on previous studies that conceptualized mindfulness as a multifaceted construct (e.g. Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006; Williams, Dalglesh, Karl & Kuyen, 2014), our first aim was to investigate differences in mindfulness skills, in terms both of facets and total scores, among three different diagnostic groups (OCD, MDD, and BPD) and a healthy control (HC) group. Second, due to the preliminary nature of our study, we tested whether or not there were negative associations between dispositional mindfulness and indexes of distress, dissociative symptoms, alexithymia, and depressive symptoms, as reported in previous studies (see Baer et al., 2006; de Bruin, Topper, Muskens, Bögels, & Kamphuis, 2012; Didonna & Bosio, 2012; Giovannini et al., 2014) and their differences among different diagnostic groups. Method Participants and Procedure 5     Treatment-seeking individuals were recruited from the Department of Psychiatry, Unit for Mood and Anxiety Disorders and Unit for Personality Disorders, at Villa Margherita Private Hospital, in Vicenza, Italy, and from an outpatient treatment program for OCD at the Italian Institute for Mindfulness. Eligible patients were consecutively selected and invited to participate in the study. For the clinical sample, inclusion criteria were: a primary psychiatric diagnosis of MDD, OCD, or BPD according to DSM-IV-TR (American Psychiatric Association [APA], 2000); aged 18 years or above; ability to speak Italian fluently; informed consent. Exclusion criteria were: current substance abuse; organic brain damages; regular mindfulness practice in the past year. For the HC group, inclusion criteria were: aged 18 years or above; ability to speak Italian fluently; informed consent. Exclusion criteria were: currently receiving psychiatric treatment, or history of documented major psychiatric diagnosis; current substance abuse; organic brain damages; psychiatric symptoms during the past week, as assessed with the 9 subscales of the SCL-90-R; regular mindfulness practice in the past year. All psychiatric diagnoses were obtained from patients records and confirmed by a clinician through an interview according to DSM-IV criteria for Axis I (APA, 2000). Patients with BPD were interviewed using the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II, First et al., 1997; Mazzi et al., 2003). All participants provided written informed consent to participate to the study. In accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards, informed consent provided participants with sufficiently detailed information on the purpose of the study. All participants completed self-report questionnaires, as described below. Measures Mindfulness - Dispositional mindfulness in daily life was assessed using the 39-item Five-Facet Mindfulness Questionnaire (FFMQ) (Baer et al., 2006; Didonna & Bosio, 2012). The FFMQ includes five facets rated on a 5-point Likert scale: observing, 6     describing, acting with awareness, non-judging of inner experience, and nonreactivity to inner experience. A total mindfulness score (FFMQ-TS) is produced by the sum of the five subscales, with higher scores reflecting a greater degree of mindfulness. Psychopathological symptoms – Psychological problems and psychopathological symptoms were assessed with the Symptom Check List-90-R (SCL-90-R) (Derogatis, 1977; Sarno, Preti, Prunas, & Madeddu, 2011). Items are rated on a 5point Likert scale from none (0) to extreme (4). The SCL-90-R is scored on nine symptom dimensions: 1) Somatization; 2) Obsessive-Compulsive; 3) Interpersonal Sensitivity; 4) Depression; 5) Anxiety; 6) Hostility; 7) Phobic Anxiety; 8) Paranoid Ideation; 9) Psychoticism. For the purpose of our study, we used the Global Severity Index (GSI), which is the mean value of all of the items, and is considered a measure of global psychological distress. Depressive symptoms – Depressive symptoms were assessed using the Beck Depression Inventory II (BDI-II) (Beck, Steer, & Brown, 1996; Ghisi, Flebus, Montano, Sanavio, & Sica, 2006). It is a 21-item self-report questionnaire measuring the severity of depressive symptoms in the past two weeks with higher scores reflecting higher levels of depression. Dissociative symptoms - Dissociative symptoms were assessed using the Dissociative Experience Scale (DES) (Carlson & Putnam, 1993; Mazzotti & Cirrincione, 2001). It is a 28-item questionnaire assessing the frequency and severity of a wide range of dissociative experiences using an 11-point visual analog scale (0%–100%). A general score is computed as the average of all the answers. Alexithymia – Alexithymia was assessed with the Toronto Alexithymia Scale 20 (TAS-20) (Bagby, Taylor, & Parker, 1993; Bressi et al., 1996), which is a scale 7     composed of 20 items rated on a 5-point Likert scale with higher scores indicating higher levels of alexithymia. Data analyses Descriptive statistics of socio-demographic and clinical characteristics were carried out through means and standard deviations (SDs) for continuous variables and frequencies and percentages for categorical variables. Analysis of variance (ANOVA) models were applied for comparing continuous variables among the diagnostic groups. The Gaussianity assumption of the variables was assessed by Shapiro-Wilk and Kolmogorov-Smirnov tests as well as by Q-Q plot inspection. DES score distribution showed a positive skewness and was log-transformed when analyzed as a dependent variable in the linear models. In order to evaluate the effect of dispositional mindfulness on global distress, dissociation, alexithymia and depressive symptoms for the different groups, Analysis of Covariance (ANCOVA) models were performed with SCL-90-R GSI, log-transformed DES, TAS and BDI-II as dependent variables (different models for each dependent variable) and FFMQ total and facets scores with group factor as independent variables. The interaction of Groups x FFMQ variables was also evaluated. In addition, the effect of other covariates and factors (age and sex) on the relation between clinical features and FFMQ was taken into account. The reported ANCOVA results refer to models where only significant variables were included. Adjusted R2 and partial eta squared (η2), were used as goodness of fit and effect size indexes of the ANCOVA models, respectively. In particular, R2 allows us to analyze the whole additional effect of FFMQ (total score and 5 facets scores), Groups and their interaction in explaining the dependent clinical variables. Conversely, by the partial η2, only the main effect of each variable included in the model on each clinical outcome is evaluated. Through the comparison of R2 and η2 and the significance of the covariates, a complete evaluation of the impact of both FFMQ scores (total and facets scores) as well as Groups and interaction effects on distress, 8     dissociation, alexithymia and depressive symptoms was performed. All post-hoc comparisons were evaluated by Sidak adjustments. Statistical analyses were performed using IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp; and statistical significance was set at 0.05. Results Patient characteristics The current study included a sample of 203 individuals: 153 patients (diagnostic groups: MDD group, N=50; BPD group, N=48; OCD group, N=55) and 50 healthy control subjects (HC group). One participant in the HC group was subsequently excluded by the analysis because he attained a score above the clinical cutoff criterion for the SCL-90-R Depression subscale. Socio-demographic and clinical differences between all groups are reported in Table 1. MDD patients were significantly older than the other groups. The distribution by sex was different across the four groups: we found a higher prevalence of female in the MDD, BPD and HC groups, whereas males were prevalent in OCD patients. Diagnostic groups showed higher levels of global distress, alexithymia, and depressive symptoms than the HC group. The BPD group presented more dissociative features compared with the other diagnostic groups and the HC group, while the BPD and MDD groups showed higher level of depressive symptoms than the OCD group. Insert Table 1 Differences in reported mindfulness scores for different diagnostic groups Differences among all groups in FFMQ-TS and in the five mindfulness facets, evaluated by ANOVA models, are described in Table 2. FFMQ-TS and all FFMQ facets except observing had different scores among all groups (p<.001 for all). Insert Table 2 9     Post-hoc comparison showed that the HC group had higher scores on FFMQ-TS and on all mindfulness facets, except for observing that was not significantly different among the four groups. Patients with OCD showed higher scores on FFMQ-TS and acting with awareness compared to the BPD group, and on describing compared to the BPD and MDD groups. The MDD group had higher scores than the BPD group on non-reactivity. All the three diagnostic groups showed lower scores on the nonjudging facet than the HC group, but no statistically significant difference within diagnostic groups was found. Relationships of mindfulness with indexes of global distress, dissociation, alexithymia and depressive symptoms ANCOVA modelling was performed to test relationships between mindfulness total and facets scores and SCL-90-R, GSI, DES, TAS-20, and BDI-II scores. Although all models were adjusted for age and sex, only in the models with DES as a dependent variable did one of the socio-demographic variables (sex) remain significant and merit inclusion as an independent variable (Table 3). Insert Table 3 All the associations between FFMQ facets and clinical features (SCL-90-R, GSI, DES, TAS-20 scores) were significant, except for non-reactivity with DES, observing and non-reactivity with TAS-20, and describing with BDI-II. On average, R2 indices were about 0.50 (ranging between 0.28 and 0.63), indicative of a good association and predictive value of all the independent variables (FFMQ, Groups and FFMQ x Groups interaction) in explaining the clinical outcomes. Focusing on partial eta squared and the significance of the group and interaction effects, we were able to detect three different type of associations between FFMQ facet and clinical variables: i) full associations (high η2 of the 10     FFMQ facet effect and low η2 of the other effects) indicating that the large variability of the clinical features was explained substantially by each of the mindfulness facets rather than the groups or the interaction effect; ii) partial association (quite high η2 of the FFMQ facet effect and moderate/low η2 of the other effects) indicating that the variability of clinical outcomes was explained by FFMQ facets as well as by groups and/or the interaction effect; and finally iii) weak association (η2 of the FFMQ facet effect lower than the ones of group or interaction effect) indicating a low predictive value for these mindfulness facets on these clinical dimensions and, consequently, a prevalent effect of groups (alone and by the interaction term) in explaining the outcome variability. Full association was detected for FFMQ-TS and acting with awareness with DES and TAS-20, and for non-judging with DES. It is worth to note that the strong association between acting with awareness and DES was observed in particular for the BPD group (see post-hoc analysis in Table 3). Partial associations were found between FFMQ-TS, acting with awareness and non-judging with SCL-90-R GSI; between non-judging and BDI-II; and between describing and TAS-20, where a significant interaction effect highlighted a higher association of these two variables in the MDD group rather than in the HC group. Finally, only weak associations were found between observing, describing and non-reactivity with SCL-90-R GSI; between observing, describing and DES; between non-judging and TAS-20 and between FFMQ-TS, observing, acting with awareness and non-reactivity with BDIII. Except for SCL-90-R GSI scale, all the weak associations between FFMQ facets and DES, TAS-20 and BDI-II were characterized by a prevalent effect of groups and of the interaction term highlighted by the significant post-hoc comparisons in (Table 3). Discussion 11     The first aim of this pilot study was to assess differences in mindfulness facets among a sample of treatment seeking individuals with a diagnosis of OCD, MDD or BPD and a HC group. Our findings indicated that mindfulness abilities seem to be impaired in psychiatric patients compared with HC. Indeed, we found that the diagnostic groups showed lower levels of mindfulness than the HC group in FFMQTS and on four mindfulness facets scores, indicating the presence of mindfulness deficits in the clinical sample, regardless of specific psychiatric diagnosis. Our findings, indicative of a lower dispositional mindfulness in psychiatric patients compared with HC, are in line with previous studies that reported a similar pattern in a small sample of patients with a diagnosis of BPD (Baer, Smith, & Allen, 2004), and in a currently depressed group versus a never depressed group (Solem et al., 2015). Furthermore, we found that BPD patients showed the lowest score in FFMQTS compared to the other groups, with post-hoc comparisons indicating significant differences also between BPD and OCD in the mindfulness total score (see Table 2). Consistently with our finding, a recent study with a sample of inpatients with mixed primary mental health diagnoses pointed out that mindfulness might be a unique predictor of the BPD pathology (Wupperman, Neumann, Whitman, & Axelrod, 2009) being inversely associated with BPD features. Our findings underline the value of assessing mindfulness as a multi-faceted construct in order to detect differences and similarities in mindfulness skills among a variety of diagnostic groups. In particular, we found that OCD patients reported less severe deficits in describing and acting with awareness compared to the BPD and MDD groups (see Table 2). Describing refers to labelling observed experiences, while acting with awareness entails focusing attention on one’s current activity as opposed to “acting on automatic pilot”. Interestingly, although OCD patients reported lower scores than control subjects in these two facets, in line with Crowe and McKay findings (2016), it is likely that deficits in mindfulness in patients with OCD symptoms are more related to the ability to not judge without getting caught up in thoughts and feelings, and to not react to inner experience (e.g., compulsive 12     rituals and safety behaviors). In fact, mindfulness has been used to complement exposure and response prevention techniques in order to improve individuals’ capacity to not respond to the anxiety caused by unwanted intrusive thoughts, and to learn to see them as “just thought” (Didonna, 2009; Fairfax, 2008) as opposed to reacting with experiential avoidance (Shapiro et al., 2006). Interestingly, a recent study by Hawley and colleagues (2017) found that non-reactivity predicted lower severity of OCD symptoms after a CBT treatment in a group of outpatients with a diagnosis of OCD. Not surprisingly, BPD patients reported the lowest scores in non-reactivity, and differed from HC and MDD patients. This finding may be related to the impulsive behaviors in response to distressing emotions, sensations, or events that represent well-known hallmarks of BPD (Cackowski et al., 2014), and a recent study showed that mindfulness training might improve some aspects of impulsivity in BPD (Soler et al., 2016). It is notable that the non-judging facet was found to have significantly lower scores in all the three diagnostic groups compared to the HC group. From a clinical point of view, a deficit in the ability to take a non-judging stance toward thoughts and feelings is consistent with the core aspects of MDD, BPD, and OCD symptomatology. Accepting without judgment was the only facet that increased over time after a DBT intervention, and this positive change was associated with improvements in BPD symptoms (Perroud, Nicastro, Jermann, & Huguelet, 2012). In fact, through mindfulness training, patients learn to bring nonjudgmental awareness to their emotional experience, and this may be beneficial not only in BPD, but also in MDD and OCD patients who criticize themselves for having irrational or inappropriate thoughts or emotions (Didonna, 2009; Feldman, Harley, Kerrigan, Jacobo, & Fava, 2009). Over the last years, mindfulness measures have been also considered as indexes of dysfunctions in the mentalizing or metacognitive network (Velotti et al., 2016). In the Jankowski and Holas’ metacognitive model of mindfulness (2014), they considered mindfulness as related to the highest level of metacognition. The 13     concept of mindfulness, as assessed with the FFMQ, has been considered to be related to the constructs of metacognitive beliefs as specified in the metacognitive theory (Solem et al., 2015). In line with the present results, Lysaker and colleagues (2017) showed that metacognitive capacities were differentially affected in different mental disorders (i.e., borderline personality disorder, schizophrenia and substance use disorder). The second aim of the present study was to assess the relationship between mindfulness skills and specific clinical features. Consistent with previous studies (Baer et al., 2004, 2006; de Bruin et al., 2012) using FFMQ to assess mindfulness, our exploratory analysis showed a significant negative relationship between the overall mindfulness construct and indexes of global distress, dissociative symptoms, alexithymia and depression. Moreover, our results showed significant relationships between specific mindfulness facets and clinical features. This aspect may have important clinical implications. In particular, SCL-90-R GSI scores were significantly negatively associated with mindfulness total score and with the four of the five FFMQ facets scores, with partial eta-squared values indicating a large effect for mindfulness total score, acting with awareness, and non-judging. Interestingly, the association between mindfulness facets and psychopathology was similar in all the diagnostic groups with no significant Group X FFMQ facet interaction effect. These results are in line with Baer et al. (2004, 2006), confirming that higher scores on these mindfulness facets may be associated with lowered psychopathological symptoms. One possible explanation could be that these skills help patients to move their attention from their thoughts, to interrupt or prevent several metacognitive processes, such as harsh self-judgments and hypercriticism toward self, dysfunctional beliefs or appraisals, and in general the cognitive rumination that has been identified as a key factor in the onset and maintenance of different mental disorders (Didonna, 2009; Iani & Didonna, 2017; McEvoy, Watson, Watkins, & Nathan, 2013). 14     We also found that dissociative symptoms were negatively associated with mindfulness skills. In addition to the FFMQ-TS, we found that describing, acting with awareness, and non-judging were significantly negatively associated with dissociative symptoms. Consistent with previous literature (Baer et al., 2004, 2006; Giovannini et al., 2014), the strongest relationship was detected in acting with awareness with post-hoc analysis indicating that this relation was significant for the BPD diagnostic group versus the other groups. In line with other studies (Scalabrini, Cavicchioli, Fossati, & Maffei, 2016; Lyssenko et al., 2017), the BPD patients in our sample showed higher levels of dissociative symptoms compared with the HC, OCD, and MDD patients. Indeed, this aspect is one of the core features of BPD. It is well-known that dissociative symptoms are related to impaired performance on measures of attention, executive functioning, memory, and social cognition (McKinnon et al., 2016). It is likely that acting with awareness is particularly impaired in patients with higher levels of dissociation (as highlighted by the more negative standardized coefficient among those of the FFMQ facets related to DES). A recent feasibility study on MBCT supported the hypothesis of a strong link between mindfulness, attention, and dissociative symptoms in BPD patients (Sachse, Kevile, & Feigenbaum, 2011). Interestingly, Kleindienst et al. (2011) found that high DES scores predicted poor response to DBT in female inpatients with BPD, supporting the idea that there is an effect of state dissociation on the neural correlates of those processes relevant for learning in psychotherapy (e.g., processing of emotional information and memory reconsolidation) (Kleindienst et al., 2016). Mindfulness, and in particular acting with awareness, may be an important strategy for paying attention to the present moment, and also promoting the learning process during psychotherapy. Furthermore, we found that alexithymia was negatively associated with describing, acting with awareness, and non-judging. Interestingly, the partial eta squares of the association between TAS and describing and acting with awareness are very high, indicative of a strong relation between these mindfulness facets and 15     alexithymia, although differences in describing seem to be more evident in the MDD group. This is in line with other studies in which describing had the strongest relationship with alexithymia (de Bruin et al., 2012), or showed a strong positive association with similar constructs, such as emotional intelligence (Baer et al., 2006). It could be hypothesized that the increase in the ability of describe one’s own emotions, supported by the ability to act with awareness, have an impact on the level of alexithymia, and this relationship is strongest where alexithymia is a distinctive clinical feature, such as in depression (Honkalampi, Hintikka, Saarinen, Lehtonen, & Viinamäki, 2000). Furthermore, alexithymia is a predictor of the level of depressive symptoms after psychotherapy (Günther, Rufer, Kersting, & Suslow, 2016). Mindfulness, and in particular the ability to describe, might be an important strategy to improve an important clinical aspect that contributes to perpetuate the depressive symptomatology. Finally, depressive symptoms were found to be negatively associated with non-judging, and, to a lesser extent, to non-reactivity and acting with awareness. As reported elsewhere (Peters, Eisenlohr-Moul, & Smart, 2016), acting with awareness may imply, for example, being aware that ruminative thoughts are occurring and, in turn, it may foster the use of more adaptive cognitive strategies, while non-judging and non-reactivity may lead to fewer critical thoughts about one-self and others and to fewer counterproductive safety-seeking behaviors. Furthermore, although there is an association between non-reactivity with BDI-II scores, the variability of depressive symptoms was poorly explained by non-reactivity, as could be observed from the very low partial eta square. Indeed, in this relationship the effect of interaction mindfulness facet x Groups was significant, indicating that the association was significantly different in the MDD and BPD patients with respect to OCD. It is worth noting that, in our study, self-reported levels of observing showed a significant positive relationship with indexes of global distress, dissociative symptoms, and depression. Observing refers to the ability to attend to sensory 16     stimuli, body sensations, cognitions, and emotions and is considered to be adaptive when it indicates a tendency to notice a wide range of internal and external stimuli, rather than focusing selectively on the unpleasant ones (Baer et al., 2008). Conversely, the ability to observe could be misunderstood and associated with a maladaptive mechanism of excessive focused and selective attention, maintaining for example, rumination processes. It could be hypothesized that more practice and training could be needed to make this ability adaptive and useful in the management of clinical symptoms. Indeed, Baer et al. (2008) found that observing was positively associated to psychological symptoms among college students without meditation experience, while it was negatively related among individuals with prior meditation practice. In line with this hypothesis, it should be noted that our control and diagnostic groups included individuals without specific experience in meditation. In our study, acting with awareness and non-judging were found negatively associated with all tested clinical variables (level of distress, dissociation, alexithymia, and depression). According to the metacognitive processes model of decentering proposed by Bernstein et al. (2015) mindfulness and other decenteringrelated constructs reflect a common mental phenomenon subserved by three interrelated metacognitive processes: meta-awareness, disidentification from internal experience, and reduced reactivity to thought content. The third-wave cognitive behavior therapies including mindfulness or mindfulness focused procedures (e.g., cognitive-defusion or detached mindfulness) in their intervention packages aimed to reduce reactivity to thought content by directing attention to present moment experiences rather than thought content. Mindfulness involves developing flexible awareness (Baer et al., 2003) or, in other words, facilitate development of metacognitive insight (Chambers et al., 2009). In this sense, our study showed that in this process two facets of mindfulness, namely, acting with awareness and nonjudging, could play an important role in mental health and may be relevant in predicting clinical features among different diagnostic groups. 17     Finally, it is worth noting that deficits in mindfulness scores were found in all diagnostic groups and this is in line with recent literature positing mindfulness as a therapeutic approach for transdiagnostic mental processes (Baer, 2007). However, the choice of specific mindfulness techniques could take into account the specific deficits in mindfulness skills that vary in relevance across mental disorders (Harvey, Watkins, Mansell, & Shafran, 2004; Teasdale, Segal, & Williams, 2003). Our results raise the question as to whether mindfulness-based interventions could be effectively implemented in clinical settings, taking into account different patterns of mindfulness skills and their impact on disease-specific maladaptive cognitive strategies or symptomatology. Strengths and limitations The present study presents both strengths and limitations. The main strength is the inclusion of different diagnostic groups that allowed assessment not only of the presence of mindfulness deficits in clinical samples, but also of whether different diagnostic groups exhibited different patterns of mindfulness skills compared to a HC group. Our study was based on a consecutive non-probabilistic convenience sample. Although this methodology ensured a good sample size, a random sample is needed to ensure a generalization of our findings. Furthermore, these preliminary results could be a first step to hypothesize mindfulness-based treatments focused on specific mindfulness deficits. In terms of limitations, in the present study, diagnoses (except for BPD diagnoses) were not assessed through structured diagnostic interviews and, therefore, diagnostic reliability might be reduced. However, it should be noted that diagnoses following the DSM IV criteria were made by expert clinicians who also observed the patients and followed their treatment phase for a relatively long period. Some clinical data were collected from patients’ records, for this reason limited information of the sample were available, for example lack of information about length of illness or comorbidity were found. Moreover, data collection relied 18     exclusively on self-report measures and due to the exploratory nature of the study we chose to collect a few symptoms measures that were previously found associated to mindfulness in other clinical samples. Furthermore, we selected a single measure meant to operationalize mindfulness and each of the psychological variables explored in the study. Due to the complexity of the mindfulness construct and of the clinical features examined in the study, a more detailed assessment should be included in future studies. Moreover, we did not assess psychometric properties of the FFMQ in our specific clinical sample. However, we did adopt a 5-factor structure solution, which is supported by previous research in clinical and nonclinical samples. The cross-sectional nature of the study does not allow to make inferences about causality. A further issue is that dispositional mindfulness might change over time, longitudinal studies should investigate its stability and confirm associations with clinical variables at different time points. Finally, further studies with larger sample sizes should detect to what extent the relationships between mindfulness and clinical variables may be ascribed to other socio-demographic or clinical variables, such as illness duration or baseline symptoms’ severity. Conflict of Interest: The authors declare that they have no conflict of interest. References American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders IV-Tr. Washington DC: American Psychiatric Association. Baer, R. A. (2007). Mindfulness, Assessment, and Transdiagnostic Processes. Psychological Inquiry, 18(4), 238-271. http://dx.doi.org/10.1080/10478400701598306. Baer, R. A., Smith, G. T., & Allen, K. B. (2004). Assessment of mindfulness by selfreport: the Kentucky inventory of mindfulness skills. Assessment, 11(3), 191-206. doi: 10.1177/1073191104268029. Baer, R. A., Smith, G. T., Hopkins J., Krietemeyer, J., & Toney L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13(1), 27-45. doi: 10.1177/1073191105283504. 19     Baer, R. A., Smith, G. T., Lykins, E., Button, D., Krietemeyer, J., Sauer S, … & Williams G. M. G. (2008). Construct validity of the five facet mindfulness questionnaire in meditating and non-meditating samples. Assessment, 15(3), 329342. doi: 10.1177/1073191112446654. Bagby, R. M., Taylor, G. J., & Parker, J. D. A. (1993). The twenty-item Toronto Alexithymia Scale-II: Convergent, discriminant, and concurrent validity. Journal of Psychosomatic Research, 38(1), 33-40. Beck, A. T., Steer, R. A., Brown, G. K. (1996). BDI-II Beck Depression Inventory, Second Edition, Manual. San Antonia: The Psychological Corporation. Bernstein, A., Hadash, Y., Lichtash, Y., Tanay, G., Shepherd, K., & Fresco D. M. (2015). Decentering and Related Constructs: A Critical Review and Metacognitive Processes Model. Perspectives on Psychological Science, 10(5), 599–617. doi: 10.1177/1745691615594577. Bishop, S. R., Lau, M., Shapiro, S. L., Carlson, L., Anderson, N. D., Carmody, J., … & Devings, G. (2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11(3), 230–241. doi: 10.1093/clipsy.bph077. Bluett, E. J., Homan, K. J., Morrison, K. L., Levin M. E., & Twohig, M. P. (2014). Acceptance and commitment therapy for anxiety and OCD spectrum disorders: an empirical review. Journal of Anxiety Disorders, 28(6), 612-624. doi: 10.1016/j.janxdis.2014.06.008. Bressi, C., Taylor, G., Parker, J., Bressi, S., Brambilla, V., Aguglia, E., … & Invernizzi, G. (1996). Cross validation of the factor structure of the 20-item Toronto Alexithymia Scale: an Italian multicenter study. Journal of Psychosomatic Research, 41(6), 551-559. https://doi.org/10.1016/S00223999(96)00228-0. Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84(4), 822–848. http://dx.doi.org/10.1037/0022-3514.84.4.822. Cackowski, S., Reitz, A. C., Ende, G., Kleindienst, N., Bohus, M., Schmahl, C., & Krause-Utz, A. (2014). Impact of stress on different components of impulsivity in borderline personality disorder. Psychological Medicine, 44(15), 3329-3340. doi: 10.1017/S0033291714000427. Carlson, E. B., & Putnam, F. W. (1993). An Update on the Dissociative Experiences Scale. Dissociation. Progress in the Dissociative Disorders, 6(1), 16-27. Chafos, V. H., & Economou, P. (2014). Beyond borderline personality disorder: the mindful brain. Social Work, 59(4), 297-302. https://doi.org/10.1093/sw/swu030. Chambers, R., Gullone, E., & Allen, N. B. (2009). Mindful emotion regulation: An integrative review. Clinical Psychology Review, 29(6), 560-572. doi: 10.1016/j.cpr.2009.06.005. Cramer, H., Lauche, R., Haller, H., Langhorst, J., & Dobos, G. (2016). Mindfulnessand Acceptance-based Interventions for Psychosis: A Systematic Review and Meta-analysis. Global Advances in Health and Medicine, 5(1), 30-43. doi: 10.7453/gahmj.2015.083. 20     Crowe, K., & McKay, D. (2016). Mindfulness, Obsessive–Compulsive Symptoms, and Executive Dysfunction. Cognitive Therapy and Research, 40, 627–644. doi: 10.1007/s10608-016-9777-x. de Bruin, E. I., Topper, M., Muskens, J. G., Bögels, S. M., & Kamphuis, J. H. (2012). Psychometric properties of the Five Facets Mindfulness Questionnaire (FFMQ) in a meditating and a non-meditating sample. Assessment, 19(2), 187197. doi: 10.1177/1073191112446654. Derogatis, L. R. (1977). SCL-90. Administration, scoring & procedures manual-I for the (revised) version and other instruments of the psychopathology rating scale series. Baltimore, MD: Johns Hopkins University School of Medicine. Desrosiers, A., Klemanski, D. H., & Nolen-Hoeksema, S. (2013). Mapping mindfulness facets onto dimensions of anxiety and depression. Behaviour Therapy, 44(3), 373-384. doi: 10.1016/j.beth.2013.02.001. Didonna, F. (2009). Clinical Handbook of Mindfulness. New York: Springer Didonna, F., & Bosio, V. (2012). Misurare le abilità di Mindfulness: uno studio di validazione della versione italiana del Five Facet Mindfulness Questionnaire. Psicoterapia Cognitivo-Comportamentale, 18(3), 261-284. Evans, S., Ferrando, S., Findler, M., Stowell, C., Smart, C., & Haglin, D. (2008). Mindfulness-based cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disorders, 22(4), 716-721. https://doi.org/10.1016/j.janxdis.2007.07.005 Fairfax, H. (2008). The use of mindfulness in obsessive compulsive disorder: suggestions for its application and integration in existing treatment. Clinical Psychology and Psychotherapy, 15(1), 53-59. doi: 10.1002/cpp.557. Feldman, G., Harley, R., Kerrigan, M., Jacobo, M., & Fava, M. (2009). Change in emotional processing during a dialectical behavior therapy-based skills group for major depressive disorder. Behaviour Research and Therapy, 47(4), 316-321. doi: 10.1016/j.brat.2009.01.005. First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. S. (1997). Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Washington, D.C.: American Psychiatric Press, Inc. Fjorback, L. O., Arendt, M., Ornbøl, E., Fink P., & Walach, H. (2011). Mindfulnessbased stress reduction and mindfulness-based cognitive therapy: a systematic review of randomized controlled trials. Acta Psychiatrica Scandinavica, 124(2), 102–119. doi: 10.1111/j.1600-0447.2011.01704.x. Fossati, A., Vigorelli Porro, F., Maffei, C., Borroni, S. (2012). Are the DSM-IV personality disorders related to mindfulness? An Italian study on clinical participants. Journal of Clinical Psychology, 68(6), 672-83. doi: 10.1002/jclp.21848. Gawrysiak, M.J., Grassetti, S.N., Greeson, J.M., Shorey, R.C., Pohlig, R., & Baime, M.J. (2017). The many facets of mindfulness and the prediction of change following mindfulness-based stress reduction (MBSR). Journal of Clinical Psychology. doi: 10.1002/jclp.22521. Ghisi, M., Flebus, G. B., Montano, A., Sanavio, E., & Sica, C. (2006). Beck 21     Depression Inventory-BDI-II. Manuale. Firenze: O.S. Giovannini, C., Giromini, L., Bonalume, L., Tagini, A., Lang, M., & Amadei, G. (2014). The Italian Five Facet Mindfulness Questionnaire: A Contribution to its Validity and Reliability. Journal of Psychopathology and Behavioral Assessment, 36(3), 415-423. doi: 10.1007/s10862-013-9403-0. Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction and health benefits. A meta-analysis. Journal of Psychosomatic Research, 57(1), 35-43. doi: 10.1016/S0022-3999(03)00573-7. Gu, J., Strauss, C., Bond, R., & Cavanagh, K. (2015). How do mindfulness-based cognitive therapy and mindfulness-based stress reduction improve mental health and wellbeing? A systematic review and meta-analysis of mediation studies. Clinical Psychology Review, 37, 1-12. doi: 10.1016/j.cpr.2015.01.006. Günther, V., Rufer, M., Kersting, A., & Suslow, T. (2016). Predicting symptoms in major depression after inpatient treatment: the role of alexithymia. Nordic Journal of Psychiatry, 70(5), 392-398. doi: 10.3109/08039488.2016. Hale, L., Strauss, C., & Taylor, B. L. (2013). The effectiveness and acceptability of mindfulness-based therapy for obsessive compulsive disorder: a review of the literature. Mindfulness, 4(3), 75–82. doi: 10.1007/s12671-012-0137-y. Harvey, A. G., Watkins, E. R., Mansell, W., & Shafran, R. (2004). Cognitive behavioural processes across psychological disorders: A transdiagnostic approach to research and treatment. Oxford: Oxford University Press. Hawley, L. L., Rogojanski, J., Vorstenbosch, V., Quilty, L.C., Laposa, J. M., & Rector, N. A. (2017). The structure, correlates, and treatment related changes of mindfulness facets across the anxiety disorders and obsessive compulsive disorder. Journal of Anxiety Disorder, 49, 65-75. doi: 10.1016/j.janxdis.2017.03.003. Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1-25. https://doi.org/10.1016/j.brat.2005.06.006. Hayes, S. C., Strosahl, K. D. & Wilson, K. G. (1999). Acceptance and commitment therapy: an experimental approach to behaviour change. New York: Guilford. Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78(2), 169-183. doi: 10.1037/a0018555. Honkalampi, K., Hintikka, J., Saarinen, P., Lehtonen, J., & Viinamäki, H. (2000). Is alexithymia a permanent feature in depressed patients? Results from a 6-month follow-up study. Psychotherapy and Psychosomatics, 69(6), 303-308. https://doi.org/10.1159/000012412. Jankowski, T., & Holas, P. (2014). Metacognitive model of mindfulness. Consciousness and Cognition, 28, 64-80. doi: 10.1016/j.concog.2014.06.005. 22     Kabat-Zinn, J. (1982). An out-patient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry, 4(1), 33-47. Kabat-Zinn, J. (1990). Full catastrophe living: using the wisdom of your body and mind to face stress, pain and illness. New York: Delacorte. Kabat-Zinn J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. New York: Hyperion Books. Key, B. L., Rowa, K., Bieling, P., McCabe,R., Pawluk, E. J. (2017). Mindfulnessbased cognitive therapy as an augmentation treatment for obsessive-compulsive disorder. Clinical Psychology and Psychotherapy, 1–12. doi: 10.1002/cpp.2076. Khoury, B., Lecomte, T., Fortin, G., Masse, M., Therien, P., Bouchard, V., … & Hofmann S. G. (2013). Mindfulness-based therapy: a comprehensive metaanalysis. Clinical Psychology Review, 33(6), 763-771. doi: 10.1016/j.cpr.2013.05.005. Kleindienst, N., Limberger, M. F., Ebner-Priemer, U. W., Keibel-Mauchnik, J., Dyer, A., Berger, M., … & Bohus, M. (2011). Dissociation predicts poor response to Dialectial Behavioral Therapy in female patients with Borderline Personality Disorder. Journal of Personality Disorders, 25(4), 432-447. doi: 10.1521/pedi.2011.25.4.432. Kleindienst, N., Priebe, K., Görg, N., Dyer, A., Steil, R., Lyssenko, L., … & Bohus, M. (2016). State dissociation moderates response to dialectical behavior therapy for posttraumatic stress disorder in women with and without borderline personality disorder. European Journal of Psychotraumatology, 7:30375. doi: 10.3402/ejpt.v7.30375. Kumar, A., Sharma, M. P., Narayanaswamy, J. C., Kandavel, T., & Janardhan Reddy, Y. C. (2016). Efficacy of mindfulness-integrated cognitive behavior therapy in patients with predominant obsessions. Indian Journal of Psychiatry, 58(4), 366-371. doi: 10.4103/0019-5545.196723. Iani, L., & Didonna, F. (2017). Mindfulness e benessere psicologico: il ruolo della regolazione delle emozioni [Mindfulness and psychological well-being: The role of emotion regulation]. Giornale Italiano di Psicologia, 2, 317-322. doi: 10.1421/87338 Iani, L., Lauriola, M., Cafaro, V., & Didonna, F. (2017). Dimensions of mindfulness and their relations with. psychological well-being and neuroticism. Mindfulness, 8(3):664-676. doi: 10.1007/s12671-016-0645-2. Liljia, J. L., Lundh, L. G., Josefsson, T., & Falkenström, F. (2012). Observing as an Essential Facet of Mindfulness: A Comparison of FFMQ Patterns in Meditating and Non-Meditating Individuals. Mindfulness, 4(3), 203–212. Linehan, M. (1993). Cognitive Behavioural Treatment for Borderline Personality Disorder. New York: Guilford Press. Linehan, M. M. (2014). DBT® skills training manual. New York: Guilford Publications. 23     Lysaker, P.H., George, S., Chaudoin-Patzoldt, K.A., Pec, O., Bob, P., Leonhardt, B.L., Vohs, J.L., James, A.V., Wickett, A., Buck, K.D., Dimaggio. G. (2017). Contrasting metacognitive, social cognitive and alexithymia profiles in adults with borderline personality disorder, schizophrenia and substance use disorder. Psychiatry Research, 257:393-399. doi: 10.1016/j.psychres.2017.08.001. Lyssenko, L., Schmahl, C., Bockhacker, L., Vonderlin, R., Bohus, M., & Kleindienst, N. (2017). Dissociation in Psychiatric Disorders: A Meta-Analysis of Studies Using the Dissociative Experiences Scale. American Journal of Psychiatry, 175(1), 37-46. doi: 10.1176/appi.ajp.2017.17010025. Mazzi, F., Morosini, P., De Girolamo, G., & Guaraldi, G. P. (Eds), (2003). Structured Clinical Interview for DSM-IV Axis II Disorders (Italian version). Firenze: Organizzazioni Speciali. Mazzotti, E., & Cirrincione, R. (2001). La Dissociative Experiences Scale, esperienze dissociative in un campione di studenti italiani [The Dissociative Experiences Scale, dissociative experiences in a sample of Italian students]. Giornale Italiano di Psicologia, 1, 179–192. McEvoy, P. M., Watson, H., Watkins, E. R., & Nathan, P. (2013). The relationship between worry, rumination, and comorbidity: evidence for repetitive negative thinking as a transdiagnostic construct. Journal of Affective Disorders, 151(1), 313-320. doi: 10.1016/j.jad.2013.06.014. McKinnon, M. C., Boyd, J. E., Frewen, P. A., Lanius, U. F., Jetly, R., Richardson, J. D., & Lanius, R. A. (2016). A review of the relation between dissociation, memory, executive functioning and social cognition in military members and civilians with neuropsychiatric conditions. Neuropsychologia, 90, 210-234. doi: 10.1016/j.neuropsychologia.2016.07.017. Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed anxiety/depressive symptoms. Journal of Abnormal Psychology, 109(3), 504-511. http://dx.doi.org/10.1037/0021-843X.109.3.504. Peters, J. R., Eisenlohr-Moul, T. A, & Smart, L. M. (2016). Dispositional mindfulness and rejection sensitivity: The critical role of nonjudgment. Personality and Individual Differences, 1(93), 125-129. doi: 10.1016/j.paid.2015.06.029. Perroud, N., Nicastro, R., Jermann, F., & Huguelet, P. (2012). Mindfulness skills in borderline personality disorder patients during dialectical behavior therapy: preliminary results. International Journal of Psychiatry in Clinical Practice, 16(3), 189-196. doi: 10.3109/13651501.2012.674531. Radford, S., Eames, C., Brennan, K., Lambert, G., Crane, C., Williams, J. M., … & Barnhofer, T. (2014). Trait mindfulness as a limiting factor for residual depressive symptoms: an explorative study using quantile regression. PLoS One, 9(7):e100022. doi: 10.1371/journal.pone.0100022. Sachse, S., Keville, S., & Feigenbaum, J. A. (2011). A feasibility study of mindfulness-based cognitive therapy for individuals with borderline personality 24     disorder. Psychology and Psychotherapy, 84(2), 184-200. doi: 10.1348/147608310X516387. Salmon, P., Sephton, S. E., Weissbecker, I., Hoover, K, Ulmer, C., & Studts, J. (2004). Mindfulness meditation in clinical practice. Cognitive and Behavioral Practice, 11(4), 434-446. https://doi.org/10.1016/S1077-7229(04)80060-9. Sarno, I., Preti, E., Prunas, A., & Madeddu, F. (2011). SCL-90-R. Symptom Checklist-90-R. Firenze: Giunti O. S. Scalabrini, A., Cavicchioli, M., Fossati, A., & Maffei, C. (2016). The Extent of Dissociation in Borderline Personality Disorder: A Meta-Analytic Review. Journal of Trauma & Dissociation, 18(4), 522-543. doi: 10.1080/15299732.2016.1240738. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. Second Edition. New York: Guilford. Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of mindfulness. Journal of Clinical Psychology, 62(3), 373-386. doi: 10.1002/jclp.20237. Shorey, R. C., Elmquist, J., Wolford-Clevenger, C., Gawrysiak, M. J., Anderson, S., & Stuart, G. L. (2016). The relationship between dispositional mindfulness, borderline personality features, and suicidal ideation in a sample of women in residential substance use treatment. Psychiatry Research, 238, 122-128. doi: 10.1016/j.psychres.2016.02.040. Solem, S., Hagen, R., Wang, C. E., Hjemdal, O., Waterloo, K., Eisemann, M., & Halvorsen, M. (2015). Metacognitions and Mindful Attention Awareness in Depression: A Comparison Of Currently Depressed, Previously Depressed and Never Depressed Individuals. Clinical Psychology & Psychotherapy, 24(1), 94102. doi: 10.1002/cpp.1983. Soler, J., Elices, M., Pascual, J. C., Martín-Blanco, A., Feliu-Soler, A., Carmona, C., & Portella, M. J. (2016). Effects of mindfulness training on different components of impulsivity in borderline personality disorder: results from a pilot randomized study. Borderline Personality Disorder and Emotion Dysregulation, 3, 1. doi: 10.1186/s40479-015-0035-8. Strauss, C., Cavanagh, K., Oliver, A., & Pettman, D. (2014). Mindfulness-based interventions for people diagnosed with a current episode of an anxiety or depressive disorder: a meta-analysis of randomised controlled trials. PLoS One, 9(4):e96110. doi: 10.1371/journal.pone.0096110. Teasdale, J.D., Moore, R.G., Hayhurst, H., Pope, M., Williams, S., & Segal, Z.V. (2002). Metacognitive awareness and prevention of relapse in depression: empirical evidence. Journal of Consulting and Clinical Psychology, 70(2), 27587. http://dx.doi.org/10.1037/0022-006X.70.2.275. Teasdale, J. D., Segal, Z. V., & Williams, J. M. G. (2003). Mindfulness Training and Problem Formulation. Clinical Psychology: Science and Practice, 10(2), 157– 160. doi: 10.1093/clipsy/bpg017. 25     Velotti, P., Garofalo, C., D'Aguanno, M., Petrocchi, C., Popolo, R., …, & Dimaggio, G. (2016). Mindfulness moderates the relationship between aggression and Antisocial Personality Disorder traits: Preliminary investigation with an offender sample. Comprehensive Psychiatry, 64, 38-45. doi: 10.1016/j.comppsych.2015.08.004. Vøllestad, J., Nielsen, M. B., & Nielsen, G. H. (2012). Mindfulness- and acceptancebased interventions for anxiety disorders: a systematic review and meta-analysis. British Journal of Clinical Psychology, 51, 239–260. doi: 10.1111/j.20448260.2011.02024.x. Wells, A. (2006). Detached mindfulness in cognitive therapy: A metacognitive analysis and ten techniques. Journal of Rational-Emotive and Cognitive-Behavior Therapy, 23(4), 337–355. doi: 10.1007/s10942-005-0018-6. Williams, M. J., Dalgleish, T., Karl, A., Kuyken, W. (2014). Examining the factor structures of the five facet mindfulness questionnaire and the self-compassion scale. Psychological Assessment, 26(2): 407-418. doi: 10.1037/a0035566. Wong, S. Y., Yip, B. H., Mak, W. W., Mercer, S., Cheung, E. Y., Ling, C. Y., … & Ma, H. S. (2016). Mindfulness-based cognitive therapy v. group psychoeducation for people with generalised anxiety disorder: randomised controlled trial. British Journal of Psychiatry, 209(1), 68-75. doi: 10.1192/bjp.bp.115.166124. Wupperman, P., Neumann, C. S., Whitman, J. B., & Axelrod, S. R. (2009). The role of mindfulness in borderline personality disorder features. Journal of Nervous Mental Disease, 197(10). doi: 10.1097/NMD.0b013e3181b97343. 26