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n Biomedica en Red de Salud Mental, CIBERSAM, St. Antoni M. Claret, 167, 08025 Barcelona, Spain
Department of Psychiatry, Santa Creu i Sant Pau Hospital, Centro de Investigacio
Department of Epidemiology, Santa Creu i Sant Pau Hospital, St. Antoni M. Claret, 167, 08025 Barcelona, Spain
`noma de Barcelona, Barcelona 08025, Spain
Universitat Auto
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 14 July 2008
Received in revised form
4 December 2008
Accepted 20 January 2009
Dialectical behaviour therapy (DBT) has proven to be an effective treatment in borderline personality
disorder (BPD). However, the effectiveness in BPD of DBT skills training (DBT-ST) alone is not known. This
study aimed at comparing the efcacy of DBT-ST and standard group therapy (SGT) for outpatients with
BPD. Sixty patients meeting the DSM-IV diagnostic criteria for BPD, as assessed by two semi-structured
diagnostic interviews, were included in a 3-month, single-blind randomised controlled trial. A total of 13
weekly group psychotherapy sessions of 120 min of either SGT or DBT-ST were conducted. Assessments
were carried out every 2 weeks by two blinded evaluators. Observer-rater, self-report scales and behavioural reports were used as outcome measures. DBT-ST was associated with lower dropout rates, 34.5%
compared to 63.4% with SGT. It was superior to SGT in improving several mood and emotion areas, such as:
depression, anxiety, irritability, anger and affect instability. A reduction in general psychiatric symptoms
was also observed. Three-months weekly DBT-ST proved useful. This therapy was associated with greater
clinical improvements and lower dropout rates than SGT. DBT-ST seems to play a role in the overall
improvement of BPD seen with standard DBT intervention. It allows straightforward implementation in
a wide range of mental health settings and provides the additional advantage that it is cost effective.
2009 Elsevier Ltd. All rights reserved.
Keywords:
Dialectical behaviour therapy
Borderline personality disorder
Controlled trial
Introduction
People with borderline personality disorder (BPD) are regular
users of emergency services and may often require admission to
hospital. They will likely need long psychotherapies and require
more medications than other personality disorder or major
depression patients (Bender et al., 2006; Lieb, Zanarini, Schmahl,
Linehan, & Bohus, 2004). Moreover, BPD is associated with a high
prevalence of self-injurious behaviour and an incidence of
completed suicide of up to 10%, a rate over 50 times higher than
that in the general population. This results in a high consumption of
healthcare resources (American Psychiatric Association, 2001; Lieb
et al., 2004; Paris, 2002; Stone, 1998) and non-health care costs are
even higher (Van Asselt, Dirksen, Arntz, & Severens, 2007).
0005-7967/$ see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.brat.2009.01.013
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meetings are attended by all the therapists using DBT and they are
held weekly. These meetings aim to provide support for therapists,
maintain motivation and adherence to the treatment model, and
help to prevent burn out.
Although several studies have introduced modications in the
application of the original design, these adaptations have adjusted
DBT to other settings, such as BPD inpatients (Bohus et al., 2004) or
to other disorders, such as binge eating disorder (Telch, Agras, &
Linehan, 2001).
One study using this standard DBT treatment for BPD (Lindenboim, Comtois, & Linehan, 2007) focused especially on the
group component. The authors examined the type and frequency
of skills practised by patients receiving one year of standard DBT as
a part of a clinical trial (Linehan et al., 2006). This study addressed
several questions regarding the skills in standard DBT treatment. In
contrast with what is traditionally expected concerning compliance in BPD patients, they reported using some skills regularly,
a minimum of at least one skill on most days. The average was
more than four skills per day during the one year of treatment. This
skills practice increased over the course of treatment, especially in
the rst months of the therapy. Another nding of interest was
that patients preferred to use skills aimed at acceptance rather
than change. Although it seems clear that the group mode of DBT
in BPD may be partially responsible for the positive outcomes
reported in this setting, there is no evidence that DBT-ST treatment
is an efcacious intervention without the individual DBT therapy
mode. In a nonpublished study, Linehan et al. (Linehan, 1993a)
assigned a subgroup of BPD patients receiving non-DBT individual
therapy to DBT-ST. The results suggested that adding DBT-ST to
non-DBT individual therapy was no more effective than non-DBT
individual therapy, and less effective than individual DBT plus
DBT-ST treatment. Only one controlled study has been published
(Springer, Lohr, Buchtel, & Silk, 1996) to date. It compares contentreduced DBT-ST to a non-psychotherapeutic discussion group.
Subjects in both groups signicantly improved in most change
measures although no signicant between-group differences were
found. The ndings from this study are limited because treatment
was short (13 weekdays), the sample characteristics were not
homogenous (inpatients with different personality disorders),
diagnosis was made by means of a self-reported questionnaire, and
considerable modications were introduced in the standard
content of DBT skills training (e.g. the Mindfulness module was not
taught).
Skills training is an essential element in DBT treatment in view of
the skills decit underlying BPD. It can be conceptualised as a set of
abilities to manage emotional instability and has been adapted to
and tested in other diagnoses. In a controlled study that compared
an adapted 20-session DBT-ST to waiting list condition in binge
eating disorder (Telch et al., 2001), the intervention was associated
with a decrease in binge eating behaviour immediately post treatment and at 6-months follow-up. Similarly, DBT-ST plus medication
and scheduled telephone coaching have been successfully adapted
to treat older depressed patients and have been associated with an
improvement in depressive symptoms compared with medication
(Lynch, Morse, Mendelson, & Robins, 2003).
Although skills training is thought to play an important role in
DBT treatment, is frequently used by BPD patients and have
proved to be useful in other disorders such as binge eating
disorder or depression, they are not adequately been tested in BPD
patients. The aim of this randomised controlled clinical trial was to
evaluate whether skills training, one of the four modes of DBT
intervention, was sufcient to induce an observable improvement
in people with BPD in comparison with standard group therapy
(SGT) administered over the same number of hours in a 3-month
period.
Method
Participants
A total of 63 patients were included (participants were recruited
from outpatient facilities and emergency service). Inclusion criteria
consisted of: 1) meeting the DSM-IV diagnostic criteria for BPD as
assessed by two semi-structured diagnostic interviews: the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II;
Gomez-Beneyto et al., 1994) and the Revised Diagnostic Interview
for Borderlines (DIB-R; Barrachina et al., 2004); 2) age between 18
and 45 years; 3) no comorbidity with schizophrenia, drug-induced
psychosis, organic brain syndrome, alcohol or other psychoactive
substance dependence, bipolar disorder, mental retardation, or
major depressive episode in course; 4) Clinical Global Impression of
Severity (CGI-S; Guy, 1976) score 4; 5) no current psychotherapy.
This study was approved by the clinical research ethics review
board at our centre. After giving a full description of the study,
written informed consent was obtained from all participants.
Study design and procedure
This was a single-centre, randomised, single-blind, two-group
clinical trial. Blocks of four generated using the SPSS software
program served for the randomisation to DBT-ST or SGT.
Subjects included in the study had two interview visits to
establish a pre-intervention baseline. No therapeutic intervention
was carried out in this phase. All participants were then randomised to DBT-ST or SGT group psychotherapy intervention
(13 weekly sessions). During the therapy period, participants were
evaluated every 2 weeks by experienced psychiatrists. Subjects
were instructed not to disclose any information about the group
(topics, group members or therapists) to maintain blind conditions.
Both interventions, DBT-ST and SGT, consisted of thirteen psychotherapy sessions of 120 min each, conducted by 2 therapists (a male
and a female) for each group, in groups of 911 participants. During
the study, participants did not receive any other individual or group
psychotherapy. The two therapies were conducted at different
times to avoid participants meeting the members of the other
group. The DBT format used was adapted from the standard version
(Linehan, 1993a, 1993b), applying one of the four modes of intervention: skills training. DBT-ST included all the original skills. These
skills can be divided into those that promote change, interpersonal
effectiveness and emotional regulation skills, and those that
promote acceptance, mindfulness and distress tolerance skills.
Interpersonal effectiveness: training in interpersonal problem
solving and assertion. It deals with learning strategies to ask for
what one needs, to say no to requests when appropriate, and to
achieve interpersonal goals, while taking care of relationships and
self-respect.
Emotion regulation: learning skills to decrease labile affect. It
includes learning to identify, label and describe emotions, using
mindfulness on emotion experience, reducing vulnerability to
negative emotions, increasing the occurrence of positive emotions,
and acting in an opposite manner to motivational tendency associated with negative emotion.
Mindfulness: developing attentional control, nonjudgemental
awareness and sense of true self. Participants learn to simply
observe and then describe events, thoughts, emotions and body
sensations, and fully participate in their actions and experiences in
a non-evaluative manner, focusing on one thing at a time and
reorienting attention when distracted.
Distress tolerance: focusing on acceptance of painful emotions
without trying to change them. The module is divided into crisis
survival skills which are short-term strategies to tolerate a stressful
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Allocated to UGT : 30
Drop out : 10
3 Inpatient hospitalization
7 Patient decision
Drop out : 19
6 Inpatient hospitalization
13 Patient decision
Retention : 65.5%
Retention : 36.6%
MIXED procedure of SPSS. We determined the appropriate covariance structure using Akaikes and Schwarzs information criteria. The
method used was restricted maximum likelihood, and the normality
for residuals was evaluated with a KolmogorovSmirnov test.
All tests were performed using a two-sided approximation, and
with a signicance level set at 0.05. All analyses were performed
using SPSS 15.0 software.
Results
Patient demographics and baseline clinical characteristics
From a total of 114 subjects evaluated, 63 met the inclusion
criteria. Patient ow and reason for dropout are presented in Fig. 1.
Three patients dropped out of the study during baseline visits.
A total of sixty subjects were randomised (1:1). As shown in Table 1,
there were no signicant differences between the two groups in
terms of demographic variables, pharmacological treatment or
clinical severity. One patient in the DBT-ST group was excluded
from the analysis as she did not attend any psychotherapy sessions
Table 1
Demographic and clinical variables at baseline.
Variable
DBT-ST
N
Female sex*
Completed Study*
23
19
79.3
65.5
26
11
86.7
36.6
ns.
.027
72.4
82.8
51.7
51.7
22
24
14
9
73.3
80
46.7
30
ns.
ns.
ns.
ns.
SD
6.55
4.89
5.46
5.58
.88
.91
.79
17.38
11.56
Mean (Range)
29.97 (2139)
19.23 (1227)
19.17 (1127)
14.23 (731)
2.45 (1.373.65)
7.2 (69)
4.9 (47)
77.33 (60102)
47.23 (1964)
SD
5.63
4.20
4.46
5.83
.60
.99
.71
11.33
12.09
p
ns.
ns.
ns.
ns.
ns.
ns.
ns.
ns.
ns.
Pharmacological Treatment
Antidepressants
21
Benzodiazepines
24
Antipsychotics
15
Mood Stabilizers
15
Age
HRSD
HRSA
BPRS
SCL90-R (GSI)
DIB-R
CGI-BPD (global)
BI
BDI
Mean (Range)
28.45 (1941)
17.83 (829)
20.28 (1234)
15 (832)
2.34 (.633.63)
7.52 (69)
4.71 (47)
70 (3399)
46.08 (2166)
SGT
Note: Continuous variables were compared using t-tests. Proportions (*) were
compared using Chi-square tests. P values are 2-tailed.
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Table 2 presents a summary of the mean pre- and post-intervention measurements for those patients that completed the study
and the signicant group time interactions on intent to treat HLM
analysis. The DBT-ST group showed a signicant improvement in
more psychopathology scales.
In the HLM analysis of differences between DBT-ST and SGT
groups, the former showed a greater decrease in depression,
anxiety and general psychiatric symptoms compared with the SGT
group. The difference between treatment groups in HRSD was,
F(37.93) 4.59, p .001, as can be observed in Fig. 3. The HRSA
scale and the BPRS scale also showed signicant differences
between groups, F(39.97) 2.45, p .034, and F(32.95) 2.90,
p .018, respectively (see Table 2).
Regarding the SCL90-R, HLM analysis showed statistically
signicant differences in the psychoticism subscale, F(21.92) 3.95,
p .034, and in the BDI irritability subscale, F(17.72) 4.37,
p .028. A greater decrease was detected in the DBT-ST condition.
Both treatment conditions showed signicant reductions in
CGI-BPD global severity scores. However, no signicant differences
were displayed between groups in HLM analysis. In this measure,
several specic sub-scales, such as: anger, F(38.69) 3.26, p .008,
emptiness, F(37.47) 2.80, p .019, and affect instability,
F(37.65) 3.74, p .004, had a signicantly greater reduction in
DBT-ST compared to SGT. No differences were seen in the other
scales (BI) or behavioural reports (number of self-harm behaviours,
suicides or emergency visits) used in the study.
100
Percent survival
DBT
SGT
50
0
1
10
11
12
13
and failed to complete any assessments. Fifty-nine patients initiated the experimental phase.
Efcacy
Patients were considered dropout if they directly expressed
their intention to dropout, if they failed to attend three or more
consecutive group sessions, or if they required psychiatric inpatient
hospitalisation. This latter criterion was used as it might compromise attendance to the group session on more than one occasion
and because it normally implies signicant changes in medication.
Signicant differences were observed in time to dropout, Hazard
Ratio .67, p .029, CI 1.132.33 (Fig. 2). Ten DBT patients (34.5%)
and 19 SGT patients (63.4%) failed to complete the study, c2 (1,
N 59) 4.911, p .027. Both groups were similar in needs for
inpatient hospitalisation but they differed signicantly in dropout
related to patient decision, c2 (1, N 59) 3.860, p .049. We did
not observe signicant differences regarding the mean number of
attended sessions between the two groups.
Discussion
In this study we found that DBT-ST was associated with higher
retention rates than SGT. Patients treated with DBT-ST had almost
a 30% greater probability of completing treatment than the SGT
group and only half the number of dropouts. Participant retention
procedures in DBT rely mainly on individual therapy and telephone
consultation and previous studies have reported good retention
rate in DBT interventions (over 70%). By means of DBT-ST intervention over three months we obtained a retention rate of 65.5%,
similar to that in study where DBT-ST was accompanied with
telephone consultation (Soler et al., 2005). Behavioural therapies
Table 2
Pre- and post-intervention measures and signicant interactions on HLM analysis.
Scales
DBT-ST
SGT
Pre-treatment
Post-treatment
Mean
SD
Mean
17.05
19.63
13.74
3.83
5.20
4.13
11.11
13.00
8.74
9.63
7.06
1.02
1.61
8.38
6.75
SCL90-R
GSI
Interpersonal Sensitivity
Hostility
Psychoticism
2.47
23.81
15.93
22.00
.85
8.32
6.23
9.04
2.09
18.50
13.00
16.37
CGI-BPD
Global
Unstable relations
Impulsivity
Suicide
Affect Instability
Anger
Emptiness
CGI -Global Improv-Patient
4.78
5.06
4.67
3.17
5.39
3.89
4.66
4.18
.80
1.21
1.45
1.38
0.77
1.18
1.53
.75
3.50
4.22
3.61
2.44
3.61
3.11
4.33
3.27
HRSD-17
HRSA
BPRS
BDI
Irritability
Indirect Hostility
Pre-treatment
SD
Post-treatment
HLM
Mean
SD
Mean
SD
20.67
22.67
15.89
3.67
3.57
6.73
16.00
16.56
11.89
5.78
5.00
4.40
.001
.034
.018
3.34
1.88
9.71
8.29
0.48
0.75
9.86
7.57
0.90
1.27*
.028
.787
1.07*
10.05*
8.59*
11.09*
2.69
27.42
18.57
19.28
.51
5.06
4.50
7.27
2.50
26.00
15.85
22.28
.86
8.34
8.17
9.19
.458
.364
.978
.034
4.89
4.78
5.00
3.00
5.22
4.22
4.78
4.42
.33
0.83
1.32
0.70
0.44
1.20
1.78
.78
4.44
4.44
4.11
2.55
4.66
3.88
5
3.57
.52*
0.72
0.60*
0.88
0.70
0.78
1.50
1.13
.218
.125
.095
.077
.004
.008
.019
.832
3.99**
5.46**
5.06**
1.20**
0.80*
0.97*
1.24*
1.19**
1.02*
1.57
.90*
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20
18
16
HRSD Score
14
12
10
8
6
DBT-ST
SGT
4
2
0
Baseline
11
13
Experimental Period
Fig. 3. HSRD expected mean scores from baseline during the study. In the HLM
analysis of differences between DBT-ST and SGT groups. Note: HLM analysis (F 4,59,
p .001).
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Research and Therapy (2009), doi:10.1016/j.brat.2009.01.013