DBT-PTSD Reduces Risk Behaviors Related to Complex Trauma

Frontiers in Psychiatry | 2025, Vol. 16, 1538267.

Inpatient dialectical behavior therapy combined with trauma-focused therapy for PTSD and borderline personality disorder symptoms: study design of the naturalistic trauma therapy study

Annemieke C. Kamstra - Research Department, GGZ Friesland, Leeuwarden, Netherlands; Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands

Sybolt O. de Vries - Research Department, GGZ Friesland, Leeuwarden, Netherlands

Maarten F. Brilman - Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands

Petty Vasilev - Research Department, GGZ Friesland, Leeuwarden, Netherlands

Manna Alma - Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, Netherlands

Antoinette D. I. van Asselt - Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands

Mia De Wolf - Research Department, GGZ Friesland, Leeuwarden, Netherlands

Robert A. Schoevers - Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands

Frederike Jörg - Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands

Introduction: Childhood traumatization can result in physical and mental health problems in adulthood, such as post-traumatic stress disorder (PTSD), which negatively influences quality of life and social functioning. Although evidence based trauma treatments benefit clients with PTSD after childhood abuse and comorbid personality disorders, they are less effective than in clients who were traumatized in adulthood, and drop-out is substantial. The current study aims to assess the effects of inpatient dialectical behavior therapy combined with prolonged exposure (DBT-PTSD) on severity of PTSD, dissociation, parasuicidal behavior and borderline personality disorder (BPD) in clients with severe PTSD and comorbid psychiatric disorders. Secondary outcomes are social functioning, quality of life, borderline and cluster C personality disorder symptoms as treatment predictors, treatment trajectories, clients’ experiences and health economic consequences.

Methods: The naturalistic, longitudinal Trauma Therapy Study is conducted from January 2019 until May 2025 in a mental healthcare center in the Netherlands. Clients with severe PTSD and comorbid conditions who are referred to inpatient DBT-PTSD are included into the study. Based on power analyses a total sample size of N=56 is needed. Measurements take place before the waiting list period, at pre- and posttreatment and at six- and twelve-months follow-up. Clients fill in a daily DBT-PTSD diary, which gives insight into individual symptom trajectories.

Results: Statistical analyses include two-sided paired samples t-tests, linear mixed model analyses and cost-effectiveness analyses. Qualitative interviews are conducted within two years posttreatment and analyzed using a phenomenological approach. We correct for chance capitalization by using a conservative α-level of.01. Multiple imputation is used to handle missing data.

Discussion: Research on the effects of integrated treatment programs for clients with severe PTSD and co-morbid conditions is scarce. This study extends current knowledge on the effects of inpatient DBT-PTSD on PTSD and BPD symptoms, clients’ social functioning and quality of life. In addition, it provides insight into individual symptom trajectories and experiences, inspiring future treatment improvements for clients with severe psychopathology.

DBT-PTSD, study protocol, dialectical behavior therapy, post-traumatic stress disorder, parasuicidal behavior, borderline personality disorder, cost-effectiveness, Dialectical, Bio-social, Adaptations, Validation, Cognitive-behavioral, Suicidality, Mindfulness, Consultation, Exposure, Implementation

“Several groups have studied a combination of PE and DBT, [Dialectical Behaviour Therapy (DBT) and Prolonged Exposure (PE)] to make PTSD treatment accessible for clients with complex psychopathology, including high-risk behavior, and to address the needs of clients with chronic PTSD after childhood sexual abuse. A systematic review and meta-analysis of inpatient and outpatient treatments that combine DBT and PE finds that PTSD and depressive symptoms decrease… To improve our knowledge about client characteristics that may predict treatment outcome in DBT-PTSD, it is important that other personality disorders are also taken into account. In addition, obtaining a better insight into client perspectives and experiences with DBT-PTSD may also help improve this treatment…The primary aim of this longitudinal, within-subjects study is to assess the effect of inpatient DBT-PTSD on PTSD severity in clients with severe PTSD and comorbid disorders. Secondary outcomes are dissociation, parasuicidal behavior, comorbid BPD symptoms, social functioning and quality of life. We hypothesize that PTSD, dissociation, parasuicidal behavior and BPD symptoms will decrease significantly after DBT-PTSD, in contrast to no significant changes after the waiting list period. Since DBT-PTSD offers training and therapy beyond trauma-focused treatment, we hypothesize improvements in quality of life and social as well” (p. 2- 3).

“With a qualitative semi-structured interview, we study clients’ experiences with DBT-PTSD… We use the DBT-PTSD diary to assess symptom trajectories and the individual differences herein between clients… During data collection and analysis, data files are only accessible for the research nurses during data collection. After terminating data collection, the researchers involved in the project can access the anonymized data file. The only exception are the qualitative interviews, which the interviewing researchers (PV and AK) can access during the study… Further, we will use linear mixed model analyses to study the effects of DBT-PTSD on social functioning and quality of life over time.” (p. 7- 8).

“We hypothesize that when PTSD symptoms decrease, improvements on the other variables will follow. To test this hypothesis, we will include PTSD symptoms as a time-varying covariate with a two week lag in our linear mixed models. Second, we study the degree to which clients invest in their treatment, operationalized by the DBT-PTSD diary items: ‘time spent on therapeutic assignments’ (in minutes) and ‘exposure assignments carried out’ (yes/no), as predictors of treatment outcome… We hypothesize that clients who are motivated and invest in their treatment, by doing more exposure assignments and spending more time on therapeutic assignments, will benefit more from DBTPTSD. To test this hypothesis, we will split the sample in half to compare clients with the highest and lowest scores on homework and exposure assignments during the first four weeks and over the whole course of treatment… A qualitative study will be conducted to better understand clients’ (short- and long-term) experiences with inpatient DBT-PTSD. We include clients in this part of the study, based on maximum variation sampling (age, gender, region of residence, treatment year) and expect to reach data saturation with approximately 15 participants…

…The study is carried out by researchers who were not involved in the design of the treatment program, which enhances the objective evaluation and generalizability of DBT-PTSD. Finally, the qualitative study may lead to important insights into client perspectives on treatment effects and helpful ingredients of DBT-PTSD." (p. 8- 10).

“In conclusion, the Trauma Therapy Study aims to extend the evidence base of inpatient DBT-PTSD for clients with severe PTSD and co-morbid psychiatric symptoms as a consequence of a traumatic history in a day-to-day healthcare setting. Beside extending nomothetic knowledge, (group level knowledge), idiographic knowledge is gained by including qualitative interviews and diary data. Perspectives of clients who participated in DBT-PTSD can inspire improvements to the treatment program” (p. 10).

“This paper describes the design of a naturalistic study aimed at examining short and long term effects of inpatient DBT-PTSD. It will provide information about the effects on PTSD, dissociation, parasuicidal behavior, borderline symptomatology, social functioning, health-related quality of life and cost-effectiveness. It is the first study that includes both the severity of BPD and cluster C personality disorders as predictors of treatment effects. Another novel aspect is the qualitative study of clients experiences with DBT-PTSD. Finally, the use of diary data will show individual symptom trajectories and whether clients’ investment into their treatment in terms of homework predicts their treatment results…

In an RCT, outpatient Cognitive Processing Therapy and outpatient DBT-PTSD were both effective in reducing PTSD symptoms in women with a history of childhood abuse. DBT-PTSD led to greater remission and recovery rates and less drop-out compared to Cognitive Processing Therapy (respectively 25.5% vs. 39.0%). The inpatient variant of DBT-PTSD has a shorter, intensive treatment program. Compared to a waiting list group in which TAU was continued DBT-PTSD was effective in reducing PTSD symptoms. In an observational study DBT-PTSD outperformed an inpatient treatment that included trauma-focused treatment on PTSD, dissociation and disturbances in self-organization” (p. 9).

“Insight into individual symptom trajectories may inform clinicians to adjust future treatments more timely. Growing evidence of effective treatments for this client group and knowledge of prognostic factors, gives both clients and involved clinicians the opportunity to choose the most appropriate treatment through shared decision-making” (p. 10).

“This inpatient, modular DBT-PTSD treatment program of 12 weeks largely follows the original protocol developed by Bohus and colleagues… Protocol modifications include the addition of four exposure sessions (total 16) and systemic therapy. In general, the treatment consists of three phases and has both fixed and optional modules. In phase 1 (weeks 1 - 2) clients identify values they find important in life and goals they wish to work on during and after finishing the treatment. They also learn to recognize their avoidance mechanisms, determine their index trauma and acquire DBT skills. Trauma-focused therapy is the main focus of phase 2 (weeks 3 - 10). The individual psychotherapy consists primarily of PE, but has elements of cognitive therapy as well. Also, therapists can, after consultation with their client and the treatment team, use EMDR when that seems appropriate. In the third phase (weeks 11-12) the objective is to help clients accept trauma-related elements of their personal history and focus on how they wish to pick-up their daily lives after finishing treatment. Enhancing self-acceptance and selfcompassion are integrated throughout the treatment program…

To study the effects of DBT-PTSD on social functioning, we use the Work and Social Adjustment Scale (WSAS). The WSAS measures impaired functioning due to a disorder and contains five items/domains (work, home management, social leisure activities, private leisure activities and maintaining close relationships). Reliability and validity were demonstrated. We operationalize functional recovery with a score of ≤10 on the Work and Social Adjustment Scale” (p. 4- 5).

As always, please join the discussion below if you have thoughts or comments to add!

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