Bohus, M., Kleindienst, N., Hahn, C., Müller-Engelmann, M., Ludäscher, P., Steil, R., Fydrich, T., Kuehner, C., Resick, P. A., Stiglmayr, C., Schmahl, C., & Priebe, K. (2020). Dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) compared with cognitive processing therapy (CPT) in complex presentations of PTSD in women survivors of childhood abuse: A randomized clinical trial. JAMA Psychiatry, 77(12), 1235–1245. https://doi.org/10.1001/jamapsychiatry.2020.2148

Summary by: Gaya Julia Alt

Childhood abuse (CA) significantly increases the risk of developing posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD). Standard psychotherapy and Cognitive Behavior Therapy have shown limited effectiveness for complex PTSD and BPD related to CA. Even Dialectical Behavior Therapy (DBT), the most common treatment for BPD, is less effective when PTSD co-occurs. Moreover, most trauma treatments are adapted from adult-onset PTSD. One commonly used treatment is Cognitive Processing Therapy (CPT), a trauma-focused cognitive therapy that focuses on changing dysfunctional trauma-related beliefs and emotions.  However, it is not known whether this type of treatment is also suitable for those who are struggling with CA related PTSD and BPD symptoms.  

Some researchers argue that phase-based treatments, which teach emotion regulation before addressing traumatic memories, are more appropriate for this population, while others believe standard trauma-focused therapies are sufficient. DBT-PTSD was developed as a phase-based approach tailored for CA-related PTSD and BPD, integrating cognitive behavioral therapy, compassion-focused therapy, and acceptance and commitment principles.  

The aim of this study was to compare the effectiveness of DBT-PTSD with CPT in women suffering from CA-related PTSD and BPD. Conducted between 2014 and 2016 at three sites in Germany, the study involved 131 women, with an average age of 36 (SD = 11.1) who suffered from PTSD resulting from childhood sexual or physical abuse and met at least three BPD criteria.  

First, the participants were diagnosed with PTSD and BPD. Then, the participants were randomly assigned to two groups: the CPT treatment group (n = 58) and the DBT-PTSD treatment group (n = 73). Additionally, all the participants received individual therapy. Participants' conditions were assessed at baseline and at 3, 6, 9, 12, and 15 months of post-treatment.  

The primary dependent variables were symptomatic remission, defined as absence of DSM-5 criteria for PTSD; reliable improvement, measured by a change in the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) score; and reliable recovery, defined as a combination of significant improvement along with symptomatic remission. In addition, the researchers examined Global Assessment of Functioning, PTSD checklist for DSM-5, BPD rating scales by the Borderline Symptom List (BSL), specific behavior measurement of the BSL (self-harm, high-risk behaviors, or consumption of drugs), Beck Depression Inventory–II, and the number and duration of dissociation.

To analyze the data, a power analysis was first performed to determine the sample size. For quantitative variables, mixed linear models were conducted, and for categorical variables, chi-square and Fisher's exact tests were conducted. 

The main results showed a significant improvement in both groups' CAPS-5 scores. Between-group comparison indicated that DBT-PTSD was more effective than CPT showing greater improvements in symptomatic remission and reliable recovery, although early remission was higher in the CPT group. Secondary results showed greater improvement in PTSD symptoms in the DBT-PTSD group, with a reduction in dissociation duration and intensity, significant improvements in BSL scores, significant improvements in behavior aspects of the BSL, and in the depressive symptoms.

In conclusion, DBT-PTSD was found to be more effective than CPT for individuals with childhood abuse-related PTSD and BPD, particularly in those with emotional dysregulation. The strengths of the study are randomization, and good training for therapists. The limitations of the study include the focus on a specific population, women with PTSD and BPD who suffer from emotional dysregulation.