DBT an Option for PTSD Treatment Following Childhood Abuse

Martin Bohus, MD, PhD

Childhood abuse will often have reverberating effects later in adulthood, leading to therapy for post-traumatic stress disorder (PTSD).

However, there is some debate over what form of therapy is most effective in this patient population.

A team in the US and Germany, led by Martin Bohus, MD, PhD, Institute of Psychiatric and Psychosomatic Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, compared the efficacy of dialectical behavior therapy for PTSD (DBT-PTSD) with cognitive processing therapy (CPT).

DBT-PTSD is a new, specifically designed, phase-based treatment program, while CPT is one of the best empirically supported treatment for PTSD.

It is well-known that childhood abuse increases the risk of developing PTSD, which can be accompanied by symptoms of borderline personality disorder and other co-occurring mental disorders. However, there is sparse evidence of systematic evaluations of evidence-based treatments for PTSD following childhood abuse.

In the multicenter, randomized clinical trial with blinded outcome assessments, the investigators examined 955 women who sought treatment between January 2014 and October 2016 at 3 German university clinics.

A total of 193 participants were randomized (DBT-PTSD, n = 98; CPT, n = 95; mean age, 36.3 years) and included in the intent-to-treat analyses.

Each individual was prospectively followed for 15 months and women with childhood abuse-associated PTSD who additionally met 3 or more DSM-5 criteria for borderline personality disorder, including affective instability, were included.

Each patient received equal dosages and frequencies of DBT or CPT, with up to 45 individual sessions within 1 year and 3 additional sessions during the following 3 months.

The investigators sought predefined primary outcomes of the course of the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) score from randomization to month 15. The team complemented intent-to-treat analyses based on dimensional CAPS-5 scores by categorical outcome measures assessing symptomatic remission, reliable improvement, and reliable recovery.

The researchers found both therapy options significantly improved CAPS-5 scores (effect sizes: DBT-PTSD: d, 1.35; CPT: d, 0.98). However, there was a small, but statistically significant superiority of DBT (group difference: 4.82 [95% CI, 0.67-8.96]; P = .02; d, 0.33).

Participants undergoing dialectical behavior therapy were also less likely to drop out early than individuals in the cognitive processing therapy group (37 [39.0%] vs 25 [25.5%]; P = .046). The DBT group also had higher rates of symptomatic remission [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).

“These findings support the efficacy of DBT-PTSD and CPT in the treatment of women with childhood abuse—associated complex PTSD,” the authors wrote. “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.”

The study, “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,” was published online in JAMA Psychiatry.