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

Key PointsQuestionIs 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? FindingsIn 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. MeaningIn 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. 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. ImportanceChildhood 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. ObjectiveTo 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 ParticipantsFrom 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. InterventionsParticipants 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 MeasuresThe 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. ResultsOf 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 RelevanceThese 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 RegistrationGerman Clinical Trials Register: DRKS00005578