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Cited by 265Posttraumatic Stress Disorder ResearchPersonality Disorders and PsychopathologyChild Abuse and Trauma

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

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Bohus, Martin, Kleindienst, Nikolaus, Hahn, Christopher, Müller-Engelmann, Meike, Ludäscher, Petra, Steil, Regina, Fydrich, Thomas, Kuehner, Christine +4 more·2020·JAMA Psychiatry
DOI 10.1001/jamapsychiatry.2020.2148PMC PMC7376475
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Abstract

Importance: Childhood abuse significantly increases the risk of developing posttraumatic stress disorder (PTSD), often accompanied by symptoms of borderline personality disorder (BPD) and other co-occurring mental disorders. Despite the high prevalence, systematic evaluations of evidence-based treatments for PTSD after childhood abuse are sparse. Objective: To compare the efficacy of dialectical behavior therapy for PTSD (DBT-PTSD), a new, specifically designed, phase-based treatment program, against that of cognitive processing therapy (CPT), one of the best empirically supported treatments for PTSD. Design, Setting, and Participants: From January 2014 to October 2016, women who sought treatment were included in a multicenter randomized clinical trial with blinded outcome assessments at 3 German university outpatient clinics. The participants were prospectively observed for 15 months. Women with childhood abuse-associated PTSD who additionally met 3 or more DSM-5 criteria for BPD, including affective instability, were included. Data analysis took place from October 2018 to December 2019. Interventions: Participants received equal dosages and frequencies of DBT-PTSD or CPT, up to 45 individual sessions within 1 year and 3 additional sessions during the following 3 months. Main Outcomes and Measures: The predefined primary outcome was the course of the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) score from randomization to month 15. Intent-to-treat analyses based on dimensional CAPS-5 scores were complemented by categorical outcome measures assessing symptomatic remission, reliable improvement, and reliable recovery. Results: Of 955 consecutive individuals assessed for eligibility, 193 were randomized (DBT-PTSD, 98; CPT, 95; mean [SD] age, 36.3 [11.1] years) and included in the intent-to-treat analyses. Analysis revealed significantly improved CAPS-5 scores in both groups (effect sizes: DBT-PTSD: d, 1.35; CPT: d, 0.98) and a small but statistically significant superiority of DBT-PTSD (group difference: 4.82 [95% CI, 0.67-8.96]; P = .02; d, 0.33). Compared with the CPT group, participants in the DBT-PTSD group were less likely to drop out early (37 [39.0%] vs 25 [25.5%]; P = .046) and had higher rates of symptomatic remission (35 [40.7%] vs 52 [58.4%]; P = .02), reliable improvement (53 [55.8%] vs 73 [74.5%]; P = .006), and reliable recovery (34 [38.6%] vs 52 [57.1%]; P = .01). Conclusions and Relevance: These findings support the efficacy of DBT-PTSD and CPT in the treatment of women with childhood abuse-associated complex PTSD. Results pertaining to the primary outcomes favored DBT-PTSD. The study shows that even severe childhood abuse-associated PTSD with emotion dysregulation can be treated efficaciously. Trial Registration: German Clinical Trials Register: DRKS00005578.

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Crossref · 10.1001/jamapsychiatry.2020.2148

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68 of 68 references verified0 citation errors · 0 not checkable

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  • Only DBT-PTSD resulted in reduced dissociation, depression, and BPD symptoms.

    “Both treatments resulted in reductions in PTSD symptoms, but those improvements and PTSD remission and reliable change were greater in DBT-PTSD and only DBT-PTSD resulted in reduced dissociation, depression, and BPD symptoms.”

    From Complex PTSD and borderline personality disorder (2021) · cites this paper as [9]

    The Secondary Outcomes section reports reduced dissociation duration in both groups, as well as improvements in depression and borderline symptom scores with CPT. Only the decline in dissociation intensity was significant exclusively for DBT-PTSD, so the claim that only DBT-PTSD reduced all three types of symptoms is contrary to the reported results. Page numbers were not provided in our copy. (LLM, conf=0.91)

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  • The three most extensively tested approaches to PTSD psychotherapy (EX, CT, and EMDR) have been systematically integrated with DBT.

    “Thus, the three most extensively tested approaches to PTSD psychotherapy (EX, CT, and EMDR) have been systematically integrated with DBT.”

    From Complex PTSD and borderline personality disorder (2021) · cites this paper as [9]

    The Interventions section (page not available) says DBT-PTSD supplements standard DBT with trauma-focused cognitive-behavioral interventions. The paper also describes adding prolonged exposure to standard DBT, but our copy does not say that EMDR was integrated with DBT or identify EX, CT, and EMDR as the three most extensively tested approaches. (LLM, conf=0.88)

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  • Mindfulness and acceptance-based approaches have shown promise as alternative interventions to trauma-focused therapies for PTSD.

    “Mindfulness and acceptance-based approaches have shown promise as alternative interventions to trauma-focused therapies for PTSD.”

    From Group-Based Acceptance and Commitment Therapy for PTSD in a HMO Psychiatry Clinic: An Open Trial (2024) · cites this paper as Borhus et al., 2020

    The Interventions section says DBT-PTSD incorporates techniques from acceptance and commitment therapy, and the Primary Outcome section reports greater PTSD symptom improvement with DBT-PTSD than with CPT in women with complex childhood-abuse–associated PTSD. But DBT-PTSD also incorporates trauma-focused cognitive-behavioral interventions. The trial therefore does not establish mindfulness or acceptance-based approaches on their own as alternatives to trauma-focused therapies for PTSD generally. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Both DBT-PTSD and CPT resulted in reductions in PTSD symptoms.

    “Both treatments resulted in reductions in PTSD symptoms, but those improvements and PTSD remission and reliable change were greater in DBT-PTSD and only DBT-PTSD resulted in reduced dissociation, depression, and BPD symptoms.”

    From Complex PTSD and borderline personality disorder (2021) · cites this paper as [9]

  • Improvements in PTSD symptoms, PTSD remission, and reliable change were greater in DBT-PTSD than CPT.

    “Both treatments resulted in reductions in PTSD symptoms, but those improvements and PTSD remission and reliable change were greater in DBT-PTSD and only DBT-PTSD resulted in reduced dissociation, depression, and BPD symptoms.”

    From Complex PTSD and borderline personality disorder (2021) · cites this paper as [9]

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Cites

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Research works printed but not linked: 1

  1. Hayes SC, Strosahl KD, Wilson KG. Acceptance and Commitment Therapy: The Process And Practice of Mindful Change. Guilford Press; 2011.

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Authors
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.
Affiliations
  • Harvard University (US)
  • Heidelberg University (DE)
  • Institute of Psychology, Goethe University Frankfurt am Main, Frankfurt, Germany
  • Goethe University Frankfurt (DE)
  • Humboldt-Universität zu Berlin (DE)
  • Duke Medical Center (US)
  • AWP Berlin, Berlin, Germany
Corresponding author
Bohus, Martin
ORCID
Venue
JAMA Psychiatry
Publisher
American Medical Association (AMA)
Published
2020-12-01
Volume
77
Issue
12
Pages
1235
ISSN
2168-622X (ISSN-L)
DOI
10.1001/jamapsychiatry.2020.2148
PMC
PMC7376475
OpenAlex
W3044324912
Cited by
265
References
67
Citations by year
2026: 53 · 2025: 46 · 2024: 47 · 2023: 38 · 2022: 43 · 2021: 33 · 2020: 5
FWCI
11.91
Type
journal article
Language
en
Open access
Locations
  • JAMA Psychiatry (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
Bundesministerium für Bildung und Forschung (01KR1303A, BMBF 01KR1303A, grant BMBF 01KR1303A)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
  • Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
  • Social Sciences › Psychology › Clinical Psychology › Child Abuse and Trauma
Keywords
post-traumatic stress disorder, cognitive processing therapy, childhood abuse, women, borderline personality disorder, comorbid mental disorders, treatment efficacy, symptom remission, CAPS-5, individual psychotherapy, trauma-focused psychotherapy, neuroticism, women's mental health services, Germany, United States
MeSH terms
Adverse Childhood Experiences, Dialectical Behavior Therapy, Adult, Female, Humans, Middle Aged, Remission Induction, Stress Disorders, Post-Traumatic, Cognitive Behavioral Therapy, Outcome Assessment, Health Care, Adult Survivors of Child Abuse, Young Adult, Patient Acuity

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