DBT vs. CPT for PTSD for abused women

[DynamicDidactic]

Thought this may be an interesting study for the PTSD and DBT folk on the forum

Dialectical Behavior Therapy for PTSD vs Cognitive Processing Therapy in Women Survivors of Childhood Abuse

This randomized clinical trial compares the efficacy of 2 therapies for childhood abuse–associated posttraumatic stress disorder in women by randomizing participants to receive dialectical behavior therapy for posttraumatic stress disorder or cognitive processing therapy.

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[Ollie123]

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.

(emphasis added)

This seems like stacking the deck a bit and makes the results fairly ho-hum (at least to me).

That said, I do not know what proportion of the general PTSD population has > 3 BPD symptoms. If a majority or even a sizable minority (even if our usual "better accounted for by..." diagnostic copout attributes it to PTSD - this has more profound implications.

If this is not in the literature, someone let me know and we can publish it together. I've got a national dataset with N > 35,000 that probably captures enough PTSD I think we could meaningfully run this analysis and I think it would only take me like 10 minutes to do. Don't get too excited, would need to verify all the variables needed are in there.

 

[WisNeuro]

Yeah, Ollie, I was just wondering about the overlap. Also, if you want a co-author, all my pubs are out the door and I do have a PTSD publishing background Even if it is about 5 years since my last PTSD pub, anyway.

 

[psych.meout]

Somewhat related, but is C-PTSD really a thing or is it just PTSD with comorbid BPD or BPD traits?

 

[DynamicDidactic]

I’m wondering if the BPD symptoms are associated more with child abuse than trauma more broadly. Meaning, I don’t there is a relationship btw BPD symptoms and trauma from car accidents. But, maybe, child abuse.

 

[futureapppsy2]

I’m wondering if the BPD symptoms are associated more with child abuse than trauma more broadly. Meaning, I don’t there is a relationship btw BPD symptoms and trauma from car accidents. But, maybe, child abuse.

Generally, the research shows that the link between BPD and childhood abuse victimization, which was originally conceptualized to be very strong, is much weaker than we thought and a significant proportion of people with BPD (I want to say ~50%?) have no trauma history.

 

[psych.meout]

Generally, the research shows that the link between BPD and childhood abuse victimization, which was originally conceptualized to be very strong, is much weaker than we thought and a significant proportion of people with BPD (I want to say ~50%?) have no trauma history.

Isn't that why many DBT manuals now conceptualize it more broadly as "invalidation," which can include various forms of child abuse and also childhood environments that aren't stereotypically abusive, but where their emotional needs and expression are ignored, dismissed, etc.?

 

[cara susanna]

Generally, the research shows that the link between BPD and childhood abuse victimization, which was originally conceptualized to be very strong, is much weaker than we thought and a significant proportion of people with BPD (I want to say ~50%?) have no trauma history.

Generally it's been found to be 33%.

Somewhat related, but is C-PTSD really a thing or is it just PTSD with comorbid BPD or BPD traits?

Based on my understanding and review of the available literature - it's not really a thing, no. I don't think it's always cormobid PTSD and BPD, though. It's probably sometimes cormobid PTSD and BPD or BPD traits, and sometimes just PTSD with a little different of a symptom profile. But, regardless, so far there is not really any good evidence that "complex" trauma histories predict these symptoms or that C-PTSD is distinct enough to warrant a separate diagnosis or diagnostic subcategory.

Regarding the article linked in the thread, I have a few thoughts. First, CPT is not meant to be 45 sessions (even the new version that's specifically targeted at childhood sexual abuse is 24 sessions). I can't even imagine what you'd do for 45 sessions. Even if they tried to match the dosage and frequency, DBT is structured as a more intensive treatment compared to CPT. I wonder if that influenced the results. Second, I also agree with Ollie that the diagnostic criteria sort of "stacked the deck." Emotion dysregulation is a very good predictor of BPD. We also know that people with BPD generally don't respond as well to traditional CBT, which CPT basically is.

What I'd REALLY be interested in is a study comparing DBT + PE to just PE. Of course, 45 sessions of PE sounds absolutely awful.

 

[DynamicDidactic]

Generally, the research shows that the link between BPD and childhood abuse victimization, which was originally conceptualized to be very strong, is much weaker than we thought and a significant proportion of people with BPD (I want to say ~50%?) have no trauma history.

Citation please. Not questioning it but would love to see the article.

 

[cara susanna]

Citation please. Not questioning it but would love to see the article.

Here's the citation for the study that found ~33%

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Mary Zanarini also has done a lot of work on the development of BPD and cautions about overemphasizing trauma as a causal factor in BPD.

 

[DynamicDidactic]

Here's the citation for the study that found ~33%

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Mary Zanarini also has done a lot of work on the development of BPD and cautions about overemphasizing trauma as a causal factor in BPD.

Is that an accurate citation? The study found this:

Seventy-six percent of this group reported a history of some type of childhood sexual abuse.

And cites research indicating that there is a difference between abuse rates for inpatients with BPD and without.

 

[DynamicDidactic]

@cara susanna bump

 

[EmotRegulation]

I supervise a clinical placement in a domestic violence shelter so this is interesting to me, and not all that surprising. The women we see, many of whom have childhood abuse as well as domestic violence as adults, have tons of emotion regulation issues, and although they are open to talking about their traumas, I can count on one hand the number who have successfully made it through CPT in the last 4 years. Dropout rates in this study for CPT were substantial. I also expect that this population (based on my anecdotal experience, mind you) often has significant ongoing relational difficulties including subsequent abusive relationships, and DBT is going to address those more directly.

 

[cara susanna]

Is that an accurate citation? The study found this:


And cites research indicating that there is a difference between abuse rates for inpatients with BPD and without.

Huh, I could have sworn it was 66%. Guess my memory isn't as good as I thought. Sorry. But even 76% still leaves a pretty big chunk of people without abuse histories.

Also, while hitting the literature on this topic I found this very interesting study: APA PsycNet

I supervise a clinical placement in a domestic violence shelter so this is interesting to me, and not all that surprising. The women we see, many of whom have childhood abuse as well as domestic violence as adults, have tons of emotion regulation issues, and although they are open to talking about their traumas, I can count on one hand the number who have successfully made it through CPT in the last 4 years. Dropout rates in this study for CPT were substantial. I also expect that this population (based on my anecdotal experience, mind you) often has significant ongoing relational difficulties including subsequent abusive relationships, and DBT is going to address those more directly.

From my experience, people with PTSD secondary to domestic violence don't respond as well to traditional PTSD EBPs. I think it's because there's so much more to it than just the traumatic event(s). Edward Kubany actually developed a separate protocol for domestic violence PTSD called cognitive trauma therapy (CTT).

 

[DynamicDidactic]

Interesting stuff. I have always thought our understanding of BPD etiology is very lacking. I am not particular in support of the relationship between abuse and BPD and the DBT model of invalidation is overly broad for my tastes (and, again, not very well researched).

However, from a treatment perspective, it seems to be a particular unique set of problems that I think is well suited for DBT.