NU671 Unit 7 DBT Evidence Summary for a Young Man Example

Built Mostly on Women, Offered to a Man: An Evidence Summary on Dialectical Behavior Therapy for a 26-Year-Old With Borderline Personality Disorder and Repeated Self-Harm

[Student Name]

Purdue University Global

NU671: PMHNP Psychopathological Disorders and Psychotherapy

Unit 7 Evidence Summary

[Instructor Name]

[Date]

The patient is composite; details are bracketed. The studies are real and cited.

The Referral

Mr. [J.] is a [26]-year-old warehouse supervisor referred after his third emergency department visit this year for cutting his forearms, and one overdose of [12] acetaminophen tablets after an argument with his girlfriend. He describes intense anger that comes and goes within hours, a long pattern of unstable relationships, chronic emptiness and fear of being left. He meets criteria for borderline personality disorder. The referral asks whether he should be placed on the waiting list for the local dialectical behavior therapy program, which runs a weekly skills group, individual therapy and phone coaching for a year.

The Question

For adults with borderline personality disorder and recurrent self-harm, does dialectical behavior therapy reduce self-harm, suicide attempts and symptom severity compared with other treatment, and how well does that evidence apply to a young man?

The Trials

1. Linehan (1991). The first randomized trial compared a year of dialectical behavior therapy with treatment as usual in chronically parasuicidal women with borderline personality disorder. It reported fewer and less medically severe parasuicidal acts and fewer inpatient days with the new therapy (Linehan et al., 1991). The trial was small and included only women.

2. Linehan (2006). This trial compared a year of dialectical behavior therapy with community treatment by experts, a demanding comparison that controlled for therapist expertise and allegiance, followed by a year of follow-up. Participants were [101] women with recent suicidal or self-injurious behavior. Those receiving dialectical behavior therapy were half as likely to make a suicide attempt, needed fewer hospitalizations for suicidal ideation, had fewer psychiatric hospitalizations and emergency visits, and were less likely to drop out (Linehan et al., 2006). The authors concluded that the effect could not be explained by general factors of expert psychotherapy. Again, all participants were women.

3. McMain (2009). This Canadian trial randomized [180] patients with borderline personality disorder and at least two episodes of self-harm to a year of dialectical behavior therapy or general psychiatric management, a structured approach delivered by psychiatrists with expertise in the disorder. Both groups improved substantially in self-harm, emergency use, borderline symptoms, depression and anger, and there were no significant differences between groups on any outcome (McMain et al., 2009). The sample included men, though fewer than women. The best-designed comparison with a structured alternative found no advantage for dialectical behavior therapy, which changes the question from whether it works to whether it works better than other good care.

The Systematic Review

A Cochrane review of psychological therapies for borderline personality disorder included [75] randomized trials with [4,507] participants, predominantly female, with mean ages from about [15] to [46]. Dialectical behavior therapy was the subject of about a third of the trials. Compared with treatment as usual, it reduced borderline symptom severity, self-harm and impairment in psychosocial functioning. The certainty of evidence was rated low for these findings (Storebø et al., 2020).

What the Evidence Supports

Taken together, the evidence supports three conclusions. First, dialectical behavior therapy reduces self-harm and borderline symptoms compared with usual care, with low-certainty evidence from many trials. Second, it reduced suicide attempts compared with expert community treatment in one well-controlled trial of women. Third, a structured, disorder-specific alternative, general psychiatric management, produced similar results in a large trial.

Where the Support Thins for Mr. [J.]

Three gaps affect how directly the evidence applies to him.

1. Sex. The key early trials enrolled only women, and the review describes its trials as predominantly female. There is little direct evidence about whether men respond differently to the therapy, whether they engage with a skills group that is mostly female, or whether outcomes such as anger and aggression, which may be more prominent in some men, change as much.

2. Setting. The trials were conducted in specialized programs with trained therapists and consultation teams. The local program may differ in fidelity.

3. Certainty. The review rated the evidence as low certainty, partly because of risk of bias and small samples. Findings may change as more trials are done.

These gaps do not mean the therapy will not help him. They mean the confidence one can place in the evidence is lower for him than for a woman of similar age and severity.

How the Program Could Adapt for Him

If he joins the program, three adjustments may help him engage. The first concerns the group. A skills group in which he is the only man can feel exposing, and he may drop out early for reasons that have little to do with the therapy itself. Asking the program whether another man is enrolled, or whether he could join a cohort with more mixed membership, is a practical step. The second concerns the targets. His self-harm follows anger in relationships more than sadness, so the emotion regulation and interpersonal effectiveness modules may matter more to him than distress tolerance alone, and his individual therapist can weight the diary card toward anger episodes. The third concerns the language used. He describes himself as someone who "handles things" and dislikes the word therapy; framing the program as skills training for strong emotions may make it more acceptable.

How Progress Will Be Judged

The evidence gaps make local monitoring more important. His self-harm episodes, emergency visits and anger outbursts will be counted monthly, alongside a borderline symptom scale at intake and every three months. If he is receiving general psychiatric management first, the same measures will be used, so the team can see whether the switch to the full program adds anything for him. Monitoring of this kind cannot close the evidence gap, but it can tell the team whether the treatment is working for this man, which is the question the trials could not answer.

Recommendation

Mr. [J.] should be offered dialectical behavior therapy, with an honest explanation that most of the research involved women, and his engagement and outcomes should be monitored closely. Because the local waiting list is [five] months, he should not wait without treatment. General psychiatric management, which matched dialectical behavior therapy in the McMain trial and can be delivered by the outpatient psychiatric team, is a reasonable way to begin now, with a safety plan, a clear crisis pathway and attention to the relationship stresses that precede his self-harm. If he engages well and continues to self-harm, the case for moving him into the full program when a place opens is strengthened.

References

Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48(12), 1060-1064. https://doi.org/10.1001/archpsyc.1991.01810360024003

Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., Korslund, K. E., Tutek, D. A., Reynolds, S. K., & Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757-766. https://doi.org/10.1001/archpsyc.63.7.757

McMain, S. F., Links, P. S., Gnam, W. H., Guimond, T., Cardish, R. J., Korman, L., & Streiner, D. L. (2009). A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. American Journal of Psychiatry, 166(12), 1365-1374. https://doi.org/10.1176/appi.ajp.2009.09010039

Storebø, O. J., Stoffers-Winterling, J. M., Völlm, B. A., Kongerslev, M. T., Mattivi, J. T., Jørgensen, M. S., Faltinsen, E., Todorovac, A., Sales, C. P., Callesen, H. E., Lieb, K., & Simonsen, E. (2020). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews, 2020(5), Article CD012955. https://doi.org/10.1002/14651858.CD012955.pub2