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

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: Liron Saban

Introduction

Childhood abuse increases the risk of PTSD and BPD. Existing PTSD therapies may not be efficient for complex cases involving emotional dysregulation. DBT-PTSD was developed to solve these issues with a phase-based approach.

Methods

Trial Design and Participants

The study conducted at three university outpatient clinics in Germany. Women with PTSD linked to childhood abuse and at least three BPD criteria were included. 193 participants were randomized (98 DBT-PTSD; 95 CPT).

Interventions

• DBT-PTSD: Phase-based therapy incorporating DBT principles, trauma-focused CBT, and compassion-focused elements.
• CPT: Standard cognitive processing therapy adjusted to the study format.

Diagnostic Procedures

PTSD diagnosed with CAPS-5. BPD and other disorders diagnosed via structured interviews. High interrater reliability was reported.

Outcome Measures

• Primary: CAPS-5 score at 15 months.
• Secondary: PTSD Checklist, BSL-23, Beck Depression Inventory, Global Assessment of Functioning, and Dissociation Tension Scale.

Assessments and Missing Data

Evaluations at 0, 3, 6, 9, 12, and 15 months. Used multiple imputation methods for missing data.

Statistical Analysis

Mixed linear models and additional categorical analyses (remission, reliable improvement, recovery).

Results

Patient Flow

955 screened; 193 included in analysis. Dropout: 39% in CPT vs. 25.5% in DBT-PTSD (significant).

Treatment Integrity

Both groups showed good adherence and therapist competence.

Primary Outcome

CAPS-5 scores improved significantly in both groups. DBT-PTSD showed a significantly greater reduction (effect size d = 0.33, P = .02).

Secondary Outcomes

DBT-PTSD outperformed CPT in:

• PTSD symptom checklist scores (d = 0.57).
• Dissociation (duration and intensity).
• Borderline symptoms and self-harming behaviors.
• Depression severity (small advantage).
  Functional gains were moderate and similar in both groups.

Discussion

DBT-PTSD was more effective than CPT in treating complex PTSD symptoms in women with childhood abuse history. Lower dropout rates and better remission and recovery rates were observed with DBT-PTSD.

Strengths

The randomized controlled trial design is a strength, as it minimizes bias and ensures a high level of internal validity. Both treatment arms (DBT-PTSD and CPT) were delivered by well-trained therapists, ensuring consistency and treatment fidelity.

Limitations

Possible developer allegiance bias. Generalizability limited to adult women with severe PTSD and BPD traits. Long-term outcomes were not assessed.

Conclusions

Both DBT-PTSD and CPT are effective, but DBT-PTSD is superior for complex PTSD in women with childhood abuse and emotional dysregulation. Further research is needed to assess broader applicability and long-term efficacy.