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Original Investigation
July 22, 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

Author Affiliations
  • 1Institute of Psychiatric and Psychosomatic Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
  • 2McLean Hospital, Harvard Medical School, Boston, Massachusetts
  • 3Institute of Psychology, Goethe University Frankfurt am Main, Frankfurt, Germany
  • 4Department of Psychology, Faculty of Life Sciences, Humboldt University, Berlin, Germany
  • 5Department of Psychiatry and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
  • 6Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
  • 7AWP Berlin, Berlin, Germany
  • 8Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
  • 9Department of Psychiatry and Psychotherapy, Charité–Universitätsmedizin Berlin, Berlin, Germany
JAMA Psychiatry. Published online July 22, 2020. doi:10.1001/jamapsychiatry.2020.2148
Key Points

Question  Is dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) superior to cognitive processing therapy (CPT) in reducing the severity of complex presentations of posttraumatic stress disorder associated with childhood abuse?

Findings  In this randomized clinical trial, treatments with DBT-PTSD and CPT both created large and significant improvements in PTSD severity, with improvement more pronounced under DBT-PTSD. The proportions achieving symptomatic remission were 58% in DBT-PTSD vs 41% in CPT, a significant difference.

Meaning  In this trial, patients with severe childhood abuse–associated complex posttraumatic stress disorder highly improved under both DBT-PTSD and CPT, with DBT-PTSD being superior to CPT.

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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