Transdiagnostic applications of DBT for adolescents and adults

May combine two claims.

Several strategies relevant to substance use were added to existing DBT skills, including alternate rebellion, observing urges, building a life worth living, adaptive denial, burning bridges, and eliminating cues.

“Several strategies relevant to substance use were added to the existing DBT skills to address the challenges pertinent to individuals with SUDs (Dimeff & Linehan, 2008).”

• cites Dimeff & Linehan, 2008Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

This change was adopted because empirical evidence suggests that a number of clients with SUDs also have significant social anxiety, which prevents them from engaging fully in group sessions.

“This change was adopted because empirical evidence (see Dimeff, Rizvi, Brown & Linehan, 2000) suggests that a number of clients with SUDs also have significant social anxiety, which prevents them from engaging fully in group sessions.”

• cites Dimeff, Rizvi, Brown & Linehan, 2000 sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

The essence of DBT lies in the therapist's skillful blending of acceptance- and change-based strategies.

“The essence of DBT lies in the therapist's skillful blending of acceptance-and change-based strategies (Linehan, 1993).”

• cites Linehan, 1993Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Empirical evidence for DBT demonstrates that the treatment is effective not only for reducing suicide and NSSI, but also associated psychological difficulties such as depression and trauma symptoms.

“Moreover, the empirical evidence for DBT demonstrates that the treatment is effective not only for reducing the major treatment targets of suicide and NSSI, but also associated psychological difficulties, such as depression and trauma symptoms (Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004).”

• cites Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S4 (based).

The three DBT modifications with the strongest empirical support are for substance use, eating disorders, and trauma.

“Although a thorough review of each of these adaptations is beyond the scope of the current paper, in the pages that follow we review three of the DBT modifications that have the strongest empirical support (i.e., for substance use, eating disorders, and trauma).”

May combine two claims.

Other research supports use of DBT with adolescents diagnosed with eating disorders, bipolar disorder, and oppositional defiant disorder.

“Other research supports the use of DBT with adolescents diagnosed with the following Axis I disorders: eating disorders (Salbach-Andrae et al., 2009), bipolar disorder (Goldstein, Axelson, Birmaher, & Brent, 2007), and oppositional defiant disorder (Nelson-Gray et al., 2006).”

• cites Salbach-Andrae et al., 2009 sourceNot checked — no full text of the source
• cites Goldstein, Axelson, Birmaher, & Brent, 2007 sourceNot checked — no full text of the source
• cites Nelson-Gray et al., 2006 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Eating disorders including anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified are often chronic conditions associated with high levels of impairment and psychological comorbidity.

“Eating disorders (EDs), including anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and eating disorder not otherwise specified (EDNOS), are often chronic conditions associated with high levels of impairment and psychological comorbidity.”

Classified as probably not a substantial claim.

DBT is designed to mitigate pervasive dysregulation by teaching skills to disrupt and replace harmful compensatory behaviors with more effective coping strategies.

“As such, the treatment is designed to mitigate this pervasive dysregulation by teaching skills to disrupt and replace these harmful compensatory behaviors with more effective coping strategies.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Standard DBT is a principle-based treatment that includes weekly individual therapy, as-needed between-session coaching, weekly group-based skills training, and weekly consultation team meetings for therapists.

“Standard DBT is a principle-based treatment that includes weekly individual therapy, as-needed between-session coaching, weekly group-based skills training, and weekly consultation team meetings for therapists (for a description of modes, targets, and stages of treatment, see Linehan, this issue).”

• cites Linehan, this issueNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

In adolescents, suicide and NSSI are commonly observed not only in BPD, but also in bipolar disorder, depression and anxiety disorders, PTSD, and conduct disorder.

“For example, in adolescents, suicide and nonsuicidal self-injury (NSSI) are commonly observed not only in the context of BPD, but also in bipolar disorder (Goldstein et al., 2007), depression and anxiety disorders (Lewinsohn, Rohde, & Seeley 1996), PTSD (Giaconia, Reinherz, Silverman, Pakiz, Frost, & Cohen, 1995), and conduct disorder (Lewinsohn et al., 1995).”

• cites Goldstein et al., 2007 sourceNot checked — no full text of the source
• cites Lewinsohn, Rohde, & Seeley 1996 sourceNot checked — no full text of the source
• cites Giaconia et al., 1995 sourceNot checked yet

  Checked before — its earlier verdict is held back until a new check runs.

May combine two claims.

Because DBT targets problematic emotions and behaviors that occur across a range of psychological disorders, it is broadly applicable as a transdiagnostic treatment strategy.

“Because DBT targets problematic emotions and behaviors that occur across a range of psychological disorders, it is broadly applicable as a transdiagnostic treatment strategy (see Ritschel, Miller, & Taylor, 2013).”

• cites Ritschel, Miller, & Taylor, 2013Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• AssumptionRests on an assumption: Emotion dysregulation is the common element across most psychological disorders.

May combine two claims.

Independent of a BPD diagnosis, empirical literature supports use of DBT for treatment-resistant depression, eating disorders, and depression in older adults with mixed personality features.

“Independent of a BPD diagnosis, empirical literature supports the use of DBT for individuals with treatment-resistant depression (Harley, Sprich, Safren, Jacobo, & Fava, 2008), eating disorders (Safer, Telch, & Agras, 2001;Telch, Agras, & Linehan, 2001), and depression in older adults with mixed personality features (Lynch et al., 2007).”

• cites Harley, Sprich, Safren, Jacobo, & Fava, 2008 sourceNot checked — no full text of the source
• cites Safer, Telch, & Agras, 2001 sourceNot checked — no full text of the source
• cites Lynch et al., 2007Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

DBT-SUD uses the same treatment modalities as standard DBT: weekly individual therapy, skills-training group, coaching calls, and therapist participation in weekly consultation team meetings.

“Dialectical behavioral therapy for substance use disorders uses the same treatment modalities as standard DBT: clients are required to attend weekly individual therapy as well as skills-training group.Coaching calls and therapist participation in weekly consultation team meetings are also part of the treatment.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Another modification in DBT-SUD involves splitting the usual 150-minute skills group into a 90-minute skills group and a 30-minute individual skills consultation.

“Finally, another modification in DBT-SUD involves splitting the usual 150-minute skills group into a 90-minute skills group and a 30-minute individual skills consultation.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

DBT is often associated with treatment of borderline personality disorder, which is characterized by emotional, behavioral, cognitive, intrapersonal, and interpersonal dysregulation.

“DBT is often associated with the treatment of borderline personality disorder (BPD), which is characterized by emotional, behavioral, cognitive, intrapersonal, and interpersonal dysregulation (Linehan, 1993a).”

• cites Linehan, 1993aNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Classified as probably not a substantial claim. May combine two claims.

Because substance use is conceptualized as a form of behavioral dyscontrol, and not explicitly as a means of self-injury, it falls under quality of life interfering behavior in the treatment target hierarchy, unless drugs were taken as an intentional means to die by suicide, in which case it becomes the number one treatment target.

“Because substance use is conceptualized as a form of behavioral dyscontrol, and not explicitly as a means of self-injury, it falls under quality of life interfering behavior in the treatment target hierarchy (unless, of course, drugs were taken as an intentional means to die by suicide, in which case it becomes the number one treatment target).”

• AssumptionThe authors state this as an assumption: Substance use functions to modulate painful emotions and negative mood states.

May combine two claims.

DBT-SUD differs from relapse prevention, motivational interviewing, and 12-step approaches in being a comprehensive and integrated treatment with equal emphases on abstinence and harm reduction, requiring significant time commitment, and viewing substance abuse as a learned behavior rather than a disease.

“Nevertheless, DBT-SUD differs from these approaches in that it is a comprehensive and integrated treatment with equal emphases on abstinence and harm reduction (compared to RP), requires significant time commitment (compared to MI), and views substance abuse as a learned behavior rather than a disease (compared to 12-step approaches).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The ultimate goal of DBT-SUD is attaining clear mind, in which clients no longer use substances and simultaneously prepare for the possibility of slipping back to abusing drugs.

“Similar to the standard DBT goal of achieving greater amounts of time in wise mind, the ultimate goal of DBT-SUD is attaining clear mind, in which clients no longer use substances and simultaneously prepare for the possibility of slipping back to abusing drugs (McMain, Sayrs, Dimeff, & Linehan, 2007).”

• cites McMain, Sayrs, Dimeff, & Linehan, 2007Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Classified as probably not a substantial claim.

DBT has been reconceptualized as broadly applicable for individuals who have difficulties regulating emotion.

“Since the publication of the original treatment manual, DBT has been reconceptualized as a treatment that is broadly applicable for individuals who have difficulties regulating emotion.”

May combine two claims.

In some cases, drug use may be treated as a behavior that leads to imminent risk or a therapy-interfering behavior; in these cases, substance use takes priority in individual therapy.

“In some cases, however, drug use may be treated as a behavior that leads to imminent risk (e.g., drug overdose) or a therapy-interfering behavior (e.g., missing sessions due to substance use, coming to sessions under the influence).In these cases, substance use takes priority in individual therapy.”

May combine two claims.

DBT is an empirically supported treatment originally developed for chronically suicidal adults.

“Dialectical behavior therapy (DBT) is an empirically supported treatment that was originally developed for chronically suicidal adults.”

• Also stated in: § INTRODUCTION · plain

  “Dialectical Behavior Therapy ([DBT]; Linehan, 1993) is an evidencebased treatment that was originally developed for chronically suicidal adults.”

• cites Linehan, 1993Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

DBT-SUD employs many strategies shown successful in other substance abuse treatments, and extant literature underscores many commonalities between DBT-SUD and more established substance abuse treatments.

“More specifically, DBT-SUD employs many of the strategies that have been shown to be successful in other substance abuse treatments; in fact, extant literature underscores many commonalities between DBT-SUD and more established substance abuse treatments (McMain, Sayrs, Dimeff, and Linehan, 2007).”

• cites McMain, Sayrs, Dimeff, and Linehan, 2007Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Classified as probably not a substantial claim.

DBT offers a multi-modal, comprehensive, and flexible treatment approach that can be used transdiagnostically with both adults and adolescents who have a range of emotion regulation difficulties.

“Dialectical behavior therapy offers a multi-modal, comprehensive, and flexible treatment approach that can be used transdiagnostically with both adults and adolescents who have a range of emotion regulation difficulties.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Studies suggest that 15% to 40% of clients with BN attempt suicide, and there is a strong association between AN and completed suicide.

“Studies suggest that 15% to 40% of clients with BN attempt suicide (Dulit, Fyer, Leon, Brodsky, & Frances, 1994); similarly, there is a strong association between AN and completed suicide (Wisniewski, Safer, & Chen, 2007).”

• cites Dulit, Fyer, Leon, Brodsky, & Frances, 1994 sourceNot checked — no full text of the source
• cites Wisniewski, Safer, & Chen, 2007Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Individuals with BPD tend to meet criteria for at least one additional diagnosis; on average, a person diagnosed with BPD meets criteria for approximately four additional disorders.

“First, individuals with BPD tend to meet criteria for at least one additional diagnosis; on average, a person diagnosed with BPD meets criteria for approximately four additional disorders (Hamed et al., 2008)”

• cites Hamed et al., 2008Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Insistence on absolute abstinence helps prolong the period between drug use episodes, whereas relapse prevention helps to decrease the frequency and intensity of relapse following a period of abstinence.

“Whereas insistence on absolute abstinence helps prolong the period between drug use episodes, relapse prevention helps to decrease the frequency and intensity of relapse following a period of abstinence (McMain, Sayrs, Dimeff & Linehan, 2007).”

• cites McMain, Sayrs, Dimeff & Linehan, 2007Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Classified as probably not a substantial claim.

DBT-SUD rests on the concept of dialectical abstinence.

“Just as the dialectical balance between acceptance and change is the foundation of standard DBT, DBT-SUD rests on the concept of dialectical abstinence.”

Classified as probably not a substantial claim. May combine two claims.

Wisniewski and Kelly adapted the biosocial theory of DBT, positing that in addition to having a biological susceptibility to emotion dysregulation, clients with EDs are also susceptible to a nutrition-related vulnerability that affects the body's ability to regulate hunger cues.

“To improve understanding about the etiology of eating disorders, Wisniewski and Kelly (2003) adapted the biosocial theory of DBT.They posited that in addition to having a biological susceptibility to emotion dysregulation, clients with EDs are also susceptible to a nutrition-related vulnerability that affects the body's ability to regulate hunger cues.”

• cites Wisniewski and Kelly (2003) sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The concept of dialectical abstinence relates specifically to objective binge eating; its aim is to encourage clients to commit to completely abstain from objective binge eating while at the same time acknowledging that if a binge episode occurs, they can return to the goal of abstinence from overeating and feeling out of control.

“As in DBT-SUD, the concept of dialectical abstinence relates specifically to objective binge eating; its aim is to encourage clients to commit to completely abstain from objective binge eating while at the same time acknowledging that if a binge episode occurs, they can return to the goal of abstinence from overeating and feeling out of control.”

May combine two claims.

An integrated treatment combining standard DBT with the DBT Prolonged Exposure Protocol has been developed and evaluated to address the constellation of symptoms of suicidal and self-injuring clients with BPD and PTSD.

“DBT researchers have developed and evaluated an integrated treatment to address the challenges in treating the constellation of symptoms of suicidal and self-injuring clients with BPD and PTSD (Harned, Korslund, Foa, & Linehan, 2012;Harned, Korslund, & Linehan, in press;Harned & Linehan, 2008).”

• cites Harned, Korslund, Foa, & Linehan, 2012 sourceNot checked yet

  Not checked in the free run.

• cites Harned, Korslund, & Linehan, in pressNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Harned & Linehan, 2008Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

As a principle-driven therapy, DBT lends itself to addressing multiple co-occurring problems as well as the relationships between them.

“As a principle-driven therapy, DBT lends itself to addressing these multiple problems as well as the relationships between the problems.”

May combine two claims.

Radically open DBT was designed to be a transdiagnostic treatment that focuses on problems associated with emotional overcontrol.

“One of the newest adaptations to standard DBT is radically open DBT (RO-DBT; see Lynch et al., this volume;Lynch et al., 2007), which was designed to be a transdiagnostic treatment that focuses on problems”

• cites Lynch et al., 2007Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Effective treatment requires two foci: current factors that maintain the dissociative behavior with development of emotion regulation skills and exposure to current cues for negative emotion, and in vivo and imaginal exposure to the index trauma undertaken after the individual has learned skills to manage negative affect.

“The authors note that effective treatment requires two foci: (1) current factors that maintain the dissociative behavior and the associated development of emotion regulation skills and exposure to current cues for negative emotion; and (2) in vivo and imaginal exposure to the index trauma, which is undertaken after the individual has learned skills to manage negative affect”

• cites Wagner, Rizvi, and Harned (2007) sourceNot checked — no full text of the source

May combine two claims.

In the pilot randomized controlled trial comparing standard DBT to DBT-PE, a majority of completers in the combined therapy (60% to 100%) showed significant improvement in all measured areas at follow-up, while a much lower percentage of standard DBT participants (20%) maintained sustained, significant improvement.

“Notably, the pilot randomized controlled trial (RCT) compared standard DBT to DBT-PE and found that a majority of completers in the combined therapy (60% to 100%) showed significant improvement in all of the above-mentioned areas at follow up, while a much lower percentage of participants in standard DBT (20%) maintained sustained, significant improvement.”

• cites Harned, Korslund, & Linehan, in pressNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Comprehensive DBT is an intensive treatment requiring considerable training for therapists and a sizable commitment from clients.

“As we have noted elsewhere (Ritschel, Miller, & Taylor, 2013), comprehensive DBT is an intensive treatment requiring considerable training for therapists and a sizable commitment from clients”

• cites Ritschel, Miller, & Taylor, 2013Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

The integrated DBT-PE treatment is feasible to implement and leads to large and significant improvements in suicidal ideation, NSSI, symptoms of PTSD, dissociation, shame, anxiety, depression, trauma-related guilt cognitions, and global functioning.

“Case studies (Harned & Linehan, 2008), an open trial (Harned, Korslund, Foa, & Linehan, 2012) and more recently, a pilot randomized controlled trial (Harned, Korslund, & Linehan, in press) have suggested that the integrated DBT-PE treatment is feasible to implement and leads to large and significant improvements in suicidal ideation, NSSI, symptoms of PTSD, dissociation, shame, anxiety, depression”

• cites Harned & Linehan, 2008Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Harned, Korslund, Foa, & Linehan, 2012 sourceNot checked yet

  Not checked in the free run.

• cites Harned, Korslund, & Linehan, in pressNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S2 (checkable).

DBT is an ideal treatment to be modified for transdiagnostic applications.

“Due in large part to the flexible integration of acceptance and changebased strategies, DBT is an ideal treatment to be modified for transdiagnostic applications.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

The emphasis of DBT on commitment strategies and therapist support inherent in the consultation team are noteworthy aspects that make DBT relevant in helping this historically difficult-to-treat population.

“The emphasis of DBT on commitment strategies and therapist support inherent in the consultation team are noteworthy aspects that make DBT relevant in helping this historically difficult-to-treat population.”

Probably not a substantial claim: may not pass S2 (checkable).

Avenues exist to further expand the transdiagnostic reach of DBT by incorporating evidence-based treatments for additional comorbid diagnoses such as panic disorder.

“Moreover, avenues exist to further expand the transdiagnostic reach of DBT by incorporating evidence-based treatments for additional comorbid diagnoses, such as panic disorder.”

Classified as probably not a substantial claim. May combine two claims.

The transdiagnostic flexibility of DBT makes it a viable treatment option for individuals with a primary diagnosis of an ED who do not respond well to traditional CBT as well as for individuals who meet criteria for both BPD and an ED.

“The transdiagnostic flexibility of DBT makes it a viable treatment option for individuals with a primary diagnosis of an ED who do not respond well to traditional CBT as well as for individuals who meet criteria for both BPD and an ED.”

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

Personal threats in the form of physical, sexual, and emotional abuse constitute an invalidating environment and are likely to contribute to pervasive emotion regulation difficulties and ineffective compensatory regulation strategies.

“For example, personal threats in the form of physical, sexual, and emotional abuse constitute an invalidating environment and are likely to contribute to pervasive emotion regulation difficulties and ineffective compensatory regulation strategies.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Around two-thirds of individuals with BPD have experienced physical or emotional abuse in childhood.

“Wagner, Rizvi, and Harned (2007) estimated that around two-thirds of individuals with BPD have experienced physical or emotional abuse in childhood”

• cites Wagner, Rizvi, and Harned (2007) sourceNot checked — no full text of the source

May combine two claims.

Examples of therapy-interfering behaviors in DBT-ED include not completing food diary cards, difficulties focusing in session due to being overly hungry or glucose deficient, falling below an agreed-upon weight range, purging that negatively affects medication absorption, and lying about weight.

“Examples of therapyinterfering behaviors in DBT-ED include not completing food diary cards, difficulties focusing in session due to being overly hungry or glucose deficient, falling below an agreed-upon weight range, purging that negatively affects medication absorption, and lying about weight either directly or through surreptitious means (e.g.water loading prior to weigh-in).”

• cites Wisniewski, Safer, & Chen, 2007Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Heightened threat arousal in overcontrolled individuals is associated with increased sympathetic nervous system activity and decreased facial muscle activity, resulting in blank or scowling facial expressions that increase the likelihood of social rejection and isolation.

“This arousal is associated with increased sympathetic nervous system activity and decreased activity of the facial muscles, resulting in blank or scowling facial expressions that tend to increase the likelihood of social rejection and isolation.”

Probably not a substantial claim: may not pass S3 (load-bearing).

ED behaviors are considered to be life threatening when they pose an imminent risk of threat either to the patient or another person.

“As Wisniewski, Safer, and Chen (2007) highlight, ED behaviors are considered to be life threatening when they pose an imminent risk of threat either to the patient or another person.”

• cites Wisniewski, Safer, and Chen (2007)Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Quality-of-life-interfering behaviors specific to ED include restricting, binge eating, vomiting, excessive exercise, diet pill abuse, and other weight-related compensatory behaviors.

“Finally, quality-of-life-interfering behaviors specific to ED include restricting, binge eating, vomiting, excessive exercise, diet pill abuse, and other weight-related compensatory behaviors (Wisniewski, Safer, & Chen, 2007).”

• cites Wisniewski, Safer, & Chen, 2007Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Empirically-supported treatments such as CBT are estimated to be effective for only about half of individuals who seek treatment for BN and for an even smaller percentage of clients with AN.

“Empirically-supported treatments such as cognitive behavior therapy (CBT) are estimated to be effective for only about half of individuals who seek treatment for BN (Whittal, Agras, & Gould, 1999) and for an even smaller percentage of clients with AN (Fairburn & Harrison, 2003).”

• cites Whittal, Agras, & Gould, 1999 sourceNot checked — no full text of the source
• cites Fairburn & Harrison, 2003 sourceNot checked — no full text of the source

May combine two claims.

Excessive inhibition increases the risk for interpersonal difficulties, social isolation, and persistent mental health problems.

“While emotional control is emphasized and valued in many societies and cultures, excessive inhibition has been shown to increase the risk for interpersonal difficulties, social isolation, and persistent mental health problems (Lynch et al., this volume).”

• cites Lynch et al., this volumeNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.