Who Can Benefit From DBT?

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Recent research has demonstrated that dialectical behavior therapy (DBT) works for treating adolescent, young adult, and adult populations diagnosed with borderline personality disorder (BPD) (Rizvi SL et al, Prof Psychol-Res Pr 2013;44(2)73–80), though data pertaining to its superiority over other treatments remain mixed.

Psychologist Marsha Linehan reported that the therapy was superior to “community treatment by experts” (Linehan MM et al, Arch Gen Psychiatry 2006;63(7):757–766). However, a 2012 study reported no statistically significant differences between one-year treatment using DBT or psychodynamically-informed treatment by experts (McMain et al, Am J Psychiatry 2012;169(6):650–661). Further, the study also reported no statistically significant differences between DBT or general psychiatric management at a two-year follow-up. Despite this, it is clear that DBT remains a viable and successful treatment option for this difficult-to-treat population.

In randomized controlled trials (RCTs), DBT has shown effectiveness in the treatment of borderline personality disorder, eating disorders, PTSD, ADHD, bipolar disorder, and depression. DBT has also been shown in RCTs to reduce hopelessness, self-injury, substance use, suicidal behaviors, and anger. In adolescent samples, results from uncontrolled studies have demonstrated effectiveness in disorders such as oppositional defiant disorder (ODD), trichotillomania, and in reducing impulsivity (MacPherson HA et al, Clin Child Fam Psychol Rev 2013;16(1):59–80).

Eating Disorders Studies

In an RCT of concurrent eating and substance use disorders in women, there was a significant decrease in eating disordered and substance abuse behavior among participants in DBT (Courbasson C et al, Clin Psychol Psychother 2012;19(5): 434–449). In fact, due to the high levels of drop-out and disordered behavior in the control group, as well as clinical and ethical obligations, the treatment-as-usual was discontinued and that group was offered DBT treatment.

The 2013 Rizvi et al overview study of DBT, on adaptations of DBT in the treatment of bulimia nervosa and binge eating disorder (BED) (without co-morbid BPD), found that DBT was superior to a wait-list control condition in the reduction of symptoms, and reported improvements in anger, eating concerns, and body image (Rizvi SL et al, op.cit).

However, since research has been mixed in the long-term effectiveness of DBT on eating disorders, understanding the moderating factors in this treatment is important and further studies continue. One study examined the moderators of DBT for BED and found that individuals with higher baseline pathology (personality disorder and eating disorder) tend to respond better to the modified DBT treatment than those with lower levels of pathology (Robinson HR and Safer DL, Int J Eat Disord 2012;45(4):597–602).

Substance Abuse Studies

A 2011 study reported positive results in assessing the effectiveness of DBT in decreasing substance dependence and increasing emotion regulation in a sample of women diagnosed with BPD and substance abuse (Axelrod S R et al, Am J Drug Alcohol Abuse 2011;37(1): 37–42). However, another study reported a decrease in self-harm behaviors, impulsivity, and alcohol use initially, but demonstrated no significant difference with treatment–as-usual conditions at the six-month follow-up (van den Bosch LM et al, Behav Res Ther 2005;43(9):1231–1241). No studies have been done, as yet, on populations with substance dependence and no BPD diagnosis.

A Small PTSD Study

Patients with both PTSD and BPD can often be the most difficult to treat, keep in treatment, and see results in the reduction of symptoms. In an open trial design, a modified version of DBT with prolonged exposure (PE) was applied to a population of suicidal and self-injuring women diagnosed with PTSD, BPD and/or imminent serious, intentional self-injury (Harned MS et al, Behav Res Ther 2012;50(6):381–386). DBT plus PE demonstrated significant reductions in PTSD symptoms. Suicidal ideation, trauma-related guilt cognitions, shame, anxiety, depression, and social adjustment appeared improved as well. Treatment drop-out was low. A major drawback of this study is its small sample size (13 participants).

Adolescents and Young Adults

A 2013 comprehensive report found that DBT for adolescents with BPD who also exhibited suicidal ideation, suicide behavior, and non-suicidal self-injury (NSSI), resulted in significant improvements in depression, hopelessness, and general functioning, and reductions in hospitalizations, NSSI, suicide behavior, violent incidents, dissociation, and anger (MacPherson HA et al, op.cit).

TCRBH’s Take: There is little question that DBT is an effective treatment for borderline personality disorder. And research support for its effectiveness in the treatment of other conditions is growing. However, the available data do not, at this time, clearly establish DBT as superior to other specialized (as opposed to treatment-as-usual) approaches.

Ongoing and future research that directly compares DBT with other approaches and that carefully examines specific types of outcome (eg, suicidal behavior, quality of interpersonal relationships, maintenance of therapeutic effects) should further help identify which types of individuals might benefit most from DBT treatment.