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Dialectical Behavior Therapy in the Treatment of Comorbid Borderline

Personality Disorder and Eating Disorder in a Naturalistic Setting: A Six-Year
Follow-up Study

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Dialectical Behavior Therapy in the
Treatment of Comorbid Borderline
Personality Disorder and Eating Disorder
in a Naturalistic Setting: A Six-Year
Follow-up Study
María V. Navarro-Haro, Verónica
Guillén Botella, Laura Badenes-Ribera,
Luis Borao & Azucena García-Palacios

Cognitive Therapy and Research

ISSN 0147-5916

Cogn Ther Res

DOI 10.1007/s10608-020-10170-9

1 23
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 Author's personal copy
Cognitive Therapy and Research
https://doi.org/10.1007/s10608-020-10170-9

ORIGINAL ARTICLE

Dialectical Behavior Therapy in the Treatment of Comorbid Borderline

Personality Disorder and Eating Disorder in a Naturalistic Setting:
A Six‑Year Follow‑up Study
María V. Navarro‑Haro1,2 · Verónica Guillén Botella3 · Laura Badenes‑Ribera4 · Luis Borao1 ·
Azucena García‑Palacios5,6

Accepted: 16 October 2020

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Background Dialectical Behavior Therapy (DBT) has shown evidence of its effectiveness in the treatment of borderline
personality disorder (BPD) and eating disorders (EDs) separately, and there is preliminary evidence for co-occurrent BPD
and EDs. However, the long-term effectiveness of DBT for this specific population is still unknown. The main goal of this
study was to assess long-term treatment effectiveness in people diagnosed with BPD and ED.
Methods Participants (N = 109) had previously received a 6-month treatment during a clinical trial (DBT = 64 vs. Treatment
as Usual, Cognitive Behavior Therapy; TAU CBT = 45). Outcome measures (emotional eating, depressive symptoms, anger,
emotion regulation, impulsiveness, and resilience) were evaluated prospectively at 4- and 6-year follow-ups.
Results There was a statistically significant improvement in most study outcomes from pre-treatment to the follow-ups in
the DBT condition, and in depression, resilience and trait anger in the TAU CBT. No statistically significant between-group
differences were found. Nonetheless, a high percentage of participants showed a clinically significant improvement over
time in the DBT condition.
Conclusions Findings of this study contribute to determinate the long-term treatment effectiveness of DBT for people with
BPD and ED in routine psychotherapeutic practice. Longitudinal studies with larger sample sizes are needed to confirm
these results.

Keywords Personality disorders · Borderline personality disorder · Eating disorders · Dialectical behavior therapy ·
Cognitive-behavior therapy · Naturalistic setting

2
* María V. Navarro‑Haro Instituto de Investigación Sanitaria de Aragón, Zaragoza,
mvnavarro@unizar.es Spain
3
Verónica Guillén Botella Dept. Personalidad, Evaluación Y Tratamientos
veronica.guillen@uv.es Psicológicos, Universidad de Valencia, Av. Blasco Ibañez 21,
46010 Valencia, Spain
Laura Badenes‑Ribera
4
Laura.Badenes@uv.es Dept. Metodología de Las Ciencias del Comportamiento,
Universidad de Valencia, Valencia, Spain
Luis Borao
5
lborao@gmail.com Dpt. Psicología Básica, Clínica y Psicobiología, Universitat
Jaume I, Avda Vicent Sos Baynat s/n, 12071 Castellon, Spain
Azucena García‑Palacios
6
azucena@uji.es Ciber Fisiopatología Obesidad Y Nutrición (CB06/03
Instituto Salud Carlos III, Spain), Madrid, Spain
1
Dept. Psicología Y Sociología, Universidad de Zaragoza,
Calle Cdad. Escolar, S/N, 44003 Teruel, Spain

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Vol.:(0123456789)
 Author's personal copy
Introduction
Borderline Personality Disorder (BPD) and Eating Disor-
ders (EDs) comorbidity in adulthood has been associated
with more severe distortions in eating attitudes, a higher
number of hospitalizations, and non-suicidal and suicidal
behaviors (e.g. Ben-Porath et al. 2009; Chen et al. 2009).
Moreover, a diagnosis of ED has been suggested as a
predictor of early treatment dropout in individuals with
BPD (Carmona et al. 2018). Recent studies indicate a high
prevalence of comorbid BPD and ED symptoms in sam-
ples with eating disorders (ED), including interpersonal
difficulties, an unstable self‐image, marked impulsivity,
and emotion dysregulation (e.g., Martinussen et al. 2017;
Newton 2019). A 10-year follow-up study of the course of
EDs in people diagnosed with BPD found that, although
baseline comorbid ED remitted at the 10-year follow-up,
diagnostic migration of EDs was common in the long term
(Zanarini et al. 2010). Given common migrations from
one ED to another (Fairburn and Bohn 2005) and shared
etiological factors in individuals with co-occurrent BPD
and ED, transdiagnostic treatment approaches such as Dia-
lectical Behavior Therapy (DBT; Linehan 1993a, b) have
been considered adequate treatments for BPD and ED psy-
chopathologies (Treasure and Schmidt 2002).
Standard DBT (Linehan 1993a, b; Linehan et al.
2015) is an outpatient comprehensive multicomponent
intervention developed for people with extreme emotion
dysregulation and recurrent suicidal behavior and con-
sists of 4 weekly components: individual therapy, group
skills training, therapist consultation team, and as-needed
between-session telephone coaching. Strategies drawn
from cognitive and behavioral interventions (e.g., behav-
ioral assessment, contingency management, exposure, and
skills training) to dialectics and the acceptance strategies
(e.g. validation and mindfulness), that are used across all
four DBT components.
DBT has been suggested as an efficacious interven-
tion for a wide range of disorders with symptoms that are
functionally similar to those of BPD (e.g. substance use
disorder, anxiety disorders, eating disorders), and emotion
dysregulation has been proposed as the core etiological
and transdiagnostic factor (Neacsiu et al. 2014). Although
more research is needed, DBT is currently the psychologi-
cal treatment for BPD with the most evidence supporting
it (Stoffers et al 2012), and there is also some evidence of
DBT adaptations to treat EDs without BPD (e.g. Bankoff
et al. 2012; Ben-Porath et al. 2020). Specifically, a recent
review (Ben-Porath et al. 2020) reported that the Stan-
ford Model (Chen and Safer 2010; Safer et al. 2017) has
the most rigorous and numerous studies demonstrating
its efficacy and effectiveness for people diagnosed with
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Cognitive Therapy and Research
Binge Eating Disorder (BED). The Stanford Model dif-
fers from the standard DBT program in a number of ways:
only a single modality of treatment is used, group DBT
for BED instead of individual therapy, treatment consists
of 20 sessions, and DBT skills training is reduced to three
modules (for more information see Chen and Safer 2010,
p. 299). The review also informed that there is not enough
evidence about the efficacy of DBT in treating Bulimia
Nervosa (BN) and Anorexia Nervosa (AN) (Ben-Porath
et al. 2020).
Evidence about DBT for BPD and ED comorbidity is
still in its infancy. An open trial conducted in Germany
evaluated an adapted 3-month DBT plus an added cogni-
tive behavioral module specific to EDs in a large sample
of inpatients (n = 24) with BPD and EDs (BN and AN).
The results showed significant improvements in self-rated
eating-related complaints and general psychopathology, as
well as global psychosocial functioning at post-treatment
and 15-month follow-up. (Kröger et al. 2010). Further-
more, in a non-randomized controlled trial, Standard DBT
was compared to Treatment as Usual Cognitive Behavior
Therapy (TAU CBT) for BPD and ED comorbid features.
Participants (N = 118) were women diagnosed with BPD and
ED [AN, BN, and Eating Disorder Not Otherwise Speci-
fied (EDNOS)], assigned to one of the two treatment condi-
tions (DBT = 71; TAU CBT = 47). DBT, compared to TAU
CBT, showed a greater decrease in dysfunctional behaviors
used to regulate emotions (e.g. substance abuse, impulsive
spending, unprotected sex, etc.), non-suicidal self-injuries,
and depressive symptoms, as well as a greater increase in
cognitive reappraisal and global functioning (Navarro-Haro
et al. 2018). Neither of these studies presented long-term
follow-up results.
Regarding long-term outcomes of standard DBT for adults
with BPD, to our knowledge, follow-up studies have con-
sisted of a maximum of 2-year periods (e.g. Linehan et al.
2006; McMain et al. 2012). However, a shorter version of
DBT for BPD was evaluated long term in a 10-year follow-
up study conducted in Spain. Participants were BPD outpa-
tients (N = 64) who had participated in a previous clinical trial
comparing olanzapine plus DBT vs. placebo plus DBT for
12 weeks (Soler et al. 2005). Significant improvements were
reported on BPD domains (affect, impulse action patterns, and
interpersonal relationships), as well as significant decreases in
BPD criteria, self-harm, and suicidal behavior, but social and
occupational functioning continued to be impaired over time,
and there was still comorbidity with other mental disorders
(Álvarez-Tomás et al. 2017). Furthermore, several longitudinal
studies have evaluated the course of BPD after treatment, but
they have not controlled for the treatment approach. Findings
indicated that over a period of 10–16 years, BPD was asso-
ciated with low rates of relapse and high rates of remission
of BPD acute symptoms (e.g. self-harm, suicide attempts),
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Cognitive Therapy and Research
but less remission of temperamental symptoms (e.g., chronic
anger, intolerance of aloneness) and severe and persistent
impairments in social functioning (e.g. Gunderson et al. 2011;
Zanarini et al. 2016). Results of these studies are consistent
with the long-term research conducted in Spain.
To our knowledge, there are no published studies with long-
term outcomes comparing Standard DBT (including the four
treatment modes: individual psychotherapy, skills training,
phone calls, and a consultation team) to other interventions
specifically for the treatment of comorbid BPD and ED. There-
fore, the main purpose of this study was to compare long-
term treatment outcomes of Standard DBT vs. TAU CBT for
individuals with BPD and ED (AN, BN, and EDNOS) in a
naturalistic setting. Given DBT focus on transdiagnostic emo-
tion dysregulation, we expected DBT to be more effective than
TAU CBT during the follow-up periods in decreasing clinical
outcomes related to emotion dysregulation (depression, anger,
emotional eating, expressive suppression, and impulsivity) and
increasing adaptive emotion regulation strategies (cognitive
reappraisal).
Methods
Participants
Participants were recruited from three private outpatient and
day-hospital clinics in the Valencian community (Spain).
These clinics receive referrals from heterogeneous practice
settings ranging from private practice to the public mental
health system. Before starting the treatment, advisors of the
clinics carried out a screening process to assess whether par-
ticipants met the inclusion/exclusion criteria for the study.
Inclusion criteria were: (1) meeting the DSM-IV diagnostic
criteria for BPD, as assessed by the Structured Clinical Inter-
view for the DSM-IV Axis II Disorders (SCID-II; First et al.
1997); (2) meeting the DSM-IV diagnostic criteria for an eat-
ing disorder (BN, AN, or EDNOS), assessed by the clinician
using the Structured Clinical Interview for the DSM-IV Axis
I Disorders (SCID-I; First et al. 1996). Only diagnoses scored
as full threshold on the SCID-I were considered; and (3) age
18 years or older. Exclusion criteria were: (1) a diagnosis of
psychotic disorder and/or bipolar I disorder; (2) alcohol or
other substance dependence; or (3) organic disease that could
interfere with the psychological treatment. Characteristics of
the sample that participated in the follow-up are described in
the results section.
Study Design and Procedure
The current research is a prospective study with long-term
outcomes of the previous pre-post clinical controlled trial
(Navarro-Haro et al. 2018).
The previous study was a multiple site, non-randomized,
controlled trial conducted in a naturalistic setting, and it was
approved by the clinical research ethics review board of the
clinical center. Moreover, the research project was funded
by a national agency and went through an ethical review
process. Written informed consent was obtained from all
the participants. The complete procedure for the clinical trial
can be found in the cited study. A summary of the clinical
trial procedure is presented as follows.
Ten clinicians with training and experience in structured
interviews for personality and eating disorders assessed
whether patients met the diagnosis of BPD and ED and
ensured that the inclusion criteria were met. Then, the
researchers informed eligible participants about the study
goal. If they agreed to participate, they signed an informed
consent and were assigned to one of the two treatment condi-
tions (Standard DBT = 64 vs. Cognitive Behavior Therapy;
TAU CBT = 45). Assignment to the treatment conditions
was conducted based on two main criteria: (1) therapist
trained in DBT and (2) type of treatment setting (outpatient
or day hospital). Therefore, participants who were assigned
to DBT-trained therapists (according to the therapist’s work-
load) received DBT, and those who were assigned to thera-
pists not trained in DBT received TAU CBT. Number of
participants from the different settings (outpatient or day
hospital) was equivalent between conditions.
Regarding therapists, ten clinicians participated in the
study (five of them administered DBT, and the other five
administered TAU CBT). One of the DBT therapists (author
A G-P) had received training in DBT and DBT adherence
coding at the University of Washington from Dr. Linehan’s
team and trained the other four therapists in DBT. Training
consisted of 40 h of DBT seminars and supervised practice
over the course of 6 months. The therapists conducting TAU
CBT had received training in CBT for BN (Wilson et al.
1997) and AN (Garner et al. 1997) protocols. They were
also supervised during the 6 months of the treatment by the
senior clinicians of the center, who had more than 25 years
of experience in clinical practice and research in CBT.
Follow‑up Study
The current follow-up study had two time periods. The out-
come measures were followed prospectively for 6 years after
the interventions, with two assessment points: 4 years (T2)
and 6 years (T3). Participants in the follow-up assessment
points were contacted via email to answer a survey (using
Survey Monkey, following the ethical standards) that con-
tained the study measures described below. Before filling
out the measures, participants were given a description of
the study and a consent form. Participants who were not
reached by email were contacted by phone by the clinic’s
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 Author's personal copy
consultants and if they agreed to participate, completed the
questionnaires over the phone.
Instruments
Pre‑intervention
The demographic and clinical characteristics of the sam-
ple were assessed using the BPD Clinical Data Inventory
(García-Palacios 2005, unpublished manuscript). The BPD
clinical data inventory is a clinical document that was
designed by our research team and used by the clinician
to gather relevant and specific demographic and clinical
information. The demographic information collected was:
age, marital status (single, in a relationship, married, or
divorced), education level (no formal education, elementary,
middle, higher), and employment status (student, unskilled
worker, skilled worker, unemployed, housewife, disability,
sick leave/retired). Clinical information selected for this
study included: multiaxial diagnosis (DSM-IV-TR, APA
2000), previous psychological treatment, use of substances,
frequency of maladaptive eating behaviors, dysfunctional
impulsive behaviors (e.g. impulsive sex, etc.), non-suicidal
self-injuries in the past week, and frequency of suicide
attempts and hospitalization in the past 6 months.
Main Outcome Measures
The outcome measures selected for the follow-up were those
that allowed the four time periods to be compared. The main
outcome measures for this study were: depression, impulsiv-
ity, anger, emotional eating, emotional regulation strategies,
and resilience. Participants were assessed using standardized
and validated self-report measures, as follows.
Depression The Beck Depression Inventory-II (BDI-II;
Beck et al. 1996, Spanish version; Sanz et al. 2003) is one of
the most widely used self-report measures to assess depres-
sive symptoms. It contains 21 items answered on a Likert-
type response scale ranging from 0 to 3. Scores range from 0
to 63, with higher scores reflecting greater depressive symp-
tomatology. Internal consistency for clinical population was
0.89 for the Spanish version (Sanz et al. 2005), which is
similar to the alpha found in other studies (e.g. Aasen 2001;
Hunt et al. 2003).
Emotion Regulation The Emotion Regulation Questionnaire
(ERQ, Gross and John 2003, Spanish version; Cabello et al.
2013) is a self-report measure to evaluate two commonly
used emotion regulation strategies: cognitive reappraisal
and expressive suppression. It contains 10 items with a Lik-
ert-type response scale ranging from 1 (strongly disagree) to
7 (strongly agree) and it is divided into two subscales: cog-
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Cognitive Therapy and Research
nitive reappraisal (6 items) and expressive suppression (4
items). Cognitive reappraisal is a form of cognitive change
that involves construing a potentially emotion-eliciting situ-
ation in a way that changes its emotional impact. Expressive
suppression is a type of response modulation that involves
inhibiting ongoing emotion-expressive behaviors. Scores
range from 10 to 70 for the whole scale: 6–42 for cognitive
reappraisal and 4–28 for Expressive suppression. Gross and
John (2003) found adequate psychometric properties for this
measure, with alpha reliabilities of 0.79 for reappraisal, 0.73
for suppression. The Spanish version presented adequate
internal consistency (α = 0.75 for suppression, and α = 0.79
for reappraisal; Cabello et al. 2013).
Impulsivity The Barratt Impulsiveness Scale (BIS-11; Bar-
rat 1995; Spanish version; Oquendo et al. 2001) is one of
the most commonly administered self-reports for the assess-
ment of impulsiveness (a multidimensional personality trait
related to the control of emotions and behavior; Barratt et al.
2004) in both general and clinical settings. The BIS-11 con-
sist of 30 items with 4 response options. Higher mean scores
indicate greater impulsiveness. Exploratory component
analysis of the items identified three subscales: Attentional
Impulsiveness, Motor Impulsiveness, and Non-planning
Impulsiveness. For this study, only the total score was used.
Alpha coefficients for the total BIS total score ranged from
0.79 to 0.83 in clinical populations (Patton et al. 1995), and
the total score has shown high predictive validity in assess-
ing high-risk behaviors in both adults and adolescents (e.g.
Salvo and Castro 2013; Stanford et al. 2009; von Diemen
et al. 2007). The reliability of the total score for the Spanish
version was also high (α = 0.81; Oquendo et al. 2001).
Anger The State-Trait Anger Expression Inventory-2
(Spielberger 1999; Spanish version; Tobal et al. 2001) is
one of the most widely used self-report measures to assess
the experience, expression, and control of anger in research
and clinical settings. The STAXI-2 comprises 49 items with
a Likert-type 4-point response scale, and it is divided into
three scales: (a) how angry the examinee currently feels
(state), (b) how angry the examinee generally feels (trait),
and (c) how the examinee reacts when angry (control). In
this study, only the state anger and trait anger scales were
used. The state anger scores range from 15 to 60; and the
trait anger scores range from 10 to 40. The internal con-
sistency of the STAXI-2 showed Cronbach’s alphas for the
scales ranging from 0.73 to 0.93 (Spielberger 1999). The
Spanish validation of the scale also showed good internal
consistency (Cronbach’s alpha of 0.89 for state anger and
0.82 for trait anger; Tobal et al. 2001).
Emotional Eating The Emotional Eating Scale (EES;
Arnow et al. 1995) asks participants to rate the extent to
 Author's personal copy
Cognitive Therapy and Research
which different feelings lead them to feel an urge to eat,
using a 5-point scale ranging from “no desire to eat” to “an
overwhelming urge to eat”. Higher scores indicate a greater
desire/urge to eat in response to a specific feeling. This scale
has 25 items divided into 3 subscales: Anger/Frustration,
Anxiety, and Depression. All three subscales correlated
highly with measures of binge eating, providing evidence of
the “emotional eating” construct. Only the total score was
used in this study. The original coefficient alpha for the total
scale ranged from 0.81 (Arnow et al. 1995) to 0.93 (Waller
and Osman 1998), indicating acceptable internal consist-
ency. The adaptation of this scale for children and adoles-
cents has been validated in the Spanish population, showing
good internal consistency (Perpiñá et al. 2011).
Resilience The Resilience Scale (RS; Wagnild and Young
1993) is a self-report measure of the extent individual resil-
ience, conceptualized as a positive personality characteristic
that enhances successful adaptation when facing adversity
(Gail and Heather 1993). The current study used the short-
ened 15-item version (RS15), with Likert-type responses
on a 7-point scale ranging from disagree to agree. Possible
scores range from 15 to 105, and higher mean scores indi-
cate greater perceived resilience. A preliminary factor anal-
ysis of the RS15 showed a unidimensional global resilience
factor, with factor loadings ranging from 0.52 to 0.75. Its
15 items accounted for 44% of the variance (Neill and Dias
2001). Both the original RS and RS15 have shown good
internal consistency, reporting Cronbach’s alphas of around
0.90 (Gail and Heather 1993; Neill and Dias 2001). The RS
has shown good internal consistency in Spanish clinical
samples (α = 0.88) (Becoña Iglesias et al. 2013).
Interventions
The interventions conducted during the pre-post study are
described briefly (for a more extended description, see Nav-
arro-Haro et al. 2018).
Standard Dialectical Behavior Therapy (DBT) (Line-
han, 1993a, b; Linehan et al. 2015) included four inter-
vention modes: individual psychotherapy, skills training,
phone calls, and a consultation team. Individual psycho-
therapy was provided in one-hour weekly sessions with the
aim of improving awareness and reducing specific prob-
lem behaviors. Individual therapy followed the principles
and target hierarchy of standard DBT (Linehan 1993a, b).
Skills training consisted of weekly group sessions last-
ing approximately 2 h. The aim of the skills training was
to increase skills related to acceptance and awareness
(mindfulness, distress tolerance) and to behavioral change
(emotion regulation and interpersonal effectiveness). This
training lasted 24 sessions, and contents were taken from
Linehan’s 1993b manual and its version translated into
Spanish (Linehan 2003). The phone coaching mode was
applied to generalizing skills to daily life and learning
how to ask for help in crisis situations. The consultation
team met weekly with the aim to support the therapists and
ensure adherence to the treatment program.
Treatment as usual is a cognitive behavioral program
(TAU CBT) focused mainly on addressing ED psycho-
pathology (education of the disorder, self-monitoring,
establishing regular eating, reducing dysfunctional eat-
ing behaviors, and changing misinterpretations of body
image). The TAU CBT program included components of
CBT for BN (Wilson et al. 1997) and AN (Garner et al.
1997). The program also targeted other symptoms that are
more related to the personality psychopathology (self-
harm, substance use, etc.), using CBT strategies. In order
to match the dose of therapy received in the two treatment
conditions, participants in TAU CBT received one weekly
individual therapy session lasting one hour and one weekly
group session lasting approximately two hours. The TAU
CBT was adapted to a group format by the clinical team.
The treatment programs lasted 6 months. The DBT
program was adapted to 6 months, instead of 12 months,
to match the TAU CBT’s length and because research
applying DBT for 6 months shows good outcomes (e.g.
Brassington and Krawitz 2006; McMain et al. 2017).
The main difference between the two treatments is that
the DBT program focused on emotion dysregulation and
included acceptance-based strategies, whereas the CBT
TAU program aimed to change eating psychopathology
and related symptoms (e.g. perfectionism). Dysfunctional
eating behaviors in DBT are conceptualized as attempts
by individuals to mitigate emotions when experiencing
affective dysregulation and nutritional vulnerability caused
by caloric deprivation or indulgence (Bankoff et al. 2012).
Most of the participants received pharmacological
treatment (87%) during the pre-post trial. Medication was
constant during the study in most cases, and medication
changes were made in exceptional cases. There is still not
enough evidence about pharmacological treatment for
BPD (i.e., Stoffers, et al. 2010), therefore medication was
co-adjutant or auxiliary (Linehan 1993a, b, p. 105) to the
psychological treatment, the primary treatment based on
clinical guidelines for BPD (e.g. American Psychological
Association; APA; 2006). Participants in outpatient and
day hospital settings received the assigned treatment con-
dition (DBT or TAU CBT), but the individuals attending
the day hospital also attended other ancillary therapeutic
activities that were part of the day hospital routine (e.g.
normalization of eating habits). Both DBT and CBT pro-
grams accept auxiliary treatments as a complement to their
protocols.
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Statistical Analysis
The baseline sociodemographic and clinical characteristics
of participants were described using means (and standard
deviations) for the continuous variables, and frequencies
(and percentages) for the categorical variables. To compare
significant baseline differences in sociodemographic and
clinical characteristics between the DBT and TAU CBT con-
ditions, Chi-square statistics were performed on categorical
variables, whereas Student’s t tests were used for continuous
variables.
Changes in outcome measures from pre-treatment to
the follow-ups (T0–T1, T0–T2 and T0–T3), and during the
follow-up period (T1–T2, and T2–T3), were evaluated sepa-
rately for each treatment condition using one factor repeated
measures ANOVA. The Greenhouse–Geisser correction was
used if Mauchly’s test indicated a violation of the sphericity
assumption. Furthermore, to reduce chances of type 1 statis-
tical errors, Bonferroni adjustment for multiple comparisons
was applied to the p-values. The mean and the standard devi-
ation were used to summarize the results at each time point.
To investigate if changes in outcome measures across the
four time points (intrasubject factor: pre-treatment, post-
treatment, and 4- and 6-years follow-ups) differed signifi-
cantly between the two treatment conditions (intersubject
factor: DBT vs. TAU CBT), mixed factor repeated ANOVA
tests for the two factors (intrasubject and intersubject fac-
tors) were conducted. Treatment condition, time and the
interaction between treatment condition and time (treat-
ment condition × time) were included as fixed effects in the
model for each of the outcome’s measures. The interaction
of treatment condition × time tested if changes over time dif-
fered significantly between the DBT and TAU CBT groups.
Previously, the assumption of homogeneity of covariance
was examined using Box’s M test and, the most robust cri-
terion, Pillai’s trace, was used (instead of Wilk’s lambda)
to evaluate the multivariate significance of the interaction
(Tabachnick and Fidell 2007). The effect size was measured
using partial eta squared (η2). Considering Cohen’s guide-
lines, 0.01 was interpreted as a small effect, 0.06 a medium
effect and 0.14 a large effect (Cohen 1988).
Finally, reliable change for the outcome measures from
pre-treatment to the follow-ups (T0–T1, T0–T2 and T0–T3),
and during the follow-up periods (T1–T2, and T2–T3), was
also calculated separately for each treatment condition using
the Reliable Change Index (RCI) by Jacobson and Truax’s
(1991). The RCI determines if the change observed within
each patient is likely to be in excess of change that could be
accounted for measurement error alone. In practical terms,
the RCI indicates whether a given difference score reflects
a statistically reliable treatment effect. Thus, the RCI exam-
ined the percentage of participants that made significant and
clinically meaningful change at various time periods during
13
Cognitive Therapy and Research
the treatment, for each treatment condition. Calculation of
the RCI resulted in a z-score (standard score). A reliable
change at a 95% confidence level was achieved for values
equal or higher than ±1.96.
All statistical analyses were computed using SPSS ver-
sion 22.0 software for Windows. All tests were performed
using a two-sided approach, with a significance level set at
0.05.
Missing Data
As normally occurs in longitudinal research, not all par-
ticipants reported information at all the time points. Partici-
pants were assessed four times: before the treatment (T0;
n = 109), after the treatment (T1; n = 69), 4 years later (T2;
n = 15), and 6 years later (T3; n = 15). Missing values were
less than 5% at T0, less than 38% at T1, and 83.5% at T2
and T3. As recommended (Graham 2009; van Ginkel et al.
2020), missing data were multiple imputed, one of the best
methods currently available to deal with missingness. We
employed multiple imputation in SPSS to create and analyze
imputed datasets (m = 100) using the main outcome meas-
ures (Graham et al. 2007). In addition, we also included
auxiliary variables in the missing data model (Allison 2001;
Collins et al. 2001). Consistent with suggestions by Hardt
et al. (2012), the number of auxiliary variables included in
the imputation could not exceed 1/3 of the number of com-
pleters. Thus, we included five auxiliary variables used at
pre-treatment: (1) frequency of maladaptive eating behaviors
in the past week, (2) frequency of dysfunctional impulsive
behaviors in the past week, (3) frequency of hospitalization
in the past 6 months, (4) frequency of non-suicidal self-inju-
ries in the past week, and (5) frequency of suicide attempts
in the past 6 months. The comparison of the original and
imputed databases of outcomes at pre-treatment revealed
no significant sample differences in the analyzed variables.
Thus, the results from the imputed database were reported.
Results
Participants’ Characteristics
One hundred nine women (age 27.38 ± 8.81 years) partici-
pated in the study. Table 1 presents participants’ charac-
teristics at pretreatment for the total sample and by treat-
ment condition. The majority of the participants were single
(67%), had mid-level education or less (74.3%), and had an
EDNOS (60.7%). There were no statistically significant dif-
ferences at baseline between the two treatment conditions
on any of the sociodemographic or psychological outcomes.
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Cognitive Therapy and Research

Table 1  Demographic and clinical characteristics of the participants at pre-treatment (baseline)

Total sample (N = 109) DBT (n = 64) TAU CBT (n = 45) Test p

Age, mean (SD) 27.38 (8.81) 28.23 (9.12) 26.22 (8.33) t = 1.16 .248
Marital status, n (%) χ2 = 3.49 .480
Single 73 (67) 45 (70.3) 28 (62.2)
In a relationship 6 (5.5) 3 (4.7) 3 (6.7)
Married 11 (10.1) 5 (7.8) 6 (13.3)
Divorcied 13 (11.9) 9 (14.1) 4 (8.9)
Not reported 6 (5.5) 2 (3.1) 4 (8.9)
Education level, n (%) χ2 = 3.87 .276
No formal education 3 (2.8) 2 (3.1) 1 (2.2)
Elementery education 25 (22.9) 19 (29.7) 6 (13.3)
Middle education 53 (48.6) 28 (43.8) 25 (55.6)
Higher education 23 (21.1) 14 (21.9) 9 (20)
Not reported 5 (4.6) 1 (1.6) 4 (8.9)
Employment status, n (%) χ2 = 9.83 .132
Student 31 (28.4) 19 (29.7) 12 (26.7)
Unskilled worker 7 (6.4) 5 (7.8) 2 (4.4)
Skilled worker 11 (10.1) 9 (14.1) 2 (4.4)
Unemployed 9 (8.3) 4 (6.3) 5 (11.1)
Housewife 6 (5.5) 5 (7.8) 1 (2.2)
Disability 4 (3.7) 1 (1.6) 3 (6.7)
Sick leave 5 (4.6) 5 (7.8) 0 (0.0)
Not reported 36 (33) 16 (25) 20 (44.4)
Axis I primary disorder, n (%) χ2 = 1.20 .550
Bulimia nervosa 24 (22.6) 16 (25) 8 (17.8)
Anorexia nervosa 18 (16.5) 9 (14.1) 9 (20)
Eating disorder not otherwise specified 67 (61.5) 39 (60.9) 28 (62.2)
Axis II primary disorder, n (%)
Bordeline personality disorder 109 (100) 64 (100) 45 (100)
Substance use, n (%) χ2 = 0.003 .957
Yes 48 (44) 29 (45.3) 19 (42.2)
No 41 (37.6) 25 (39.1) 16 (35.6)
Not reported 20 (18.3) 10 (15.6) 10 (22.2)
Previous psychological treatment, n (%) χ2 = 0.97 .324
Yes 69 (63.3) 40 (62.5) 29 (64.4)
No 23 (21.1) 16 (25) 7 (15.6)
Not reported 17 (15.6) 8 (12.5) 9 (20)
GAF (EJE V), mean (SD) 48.73 (13.59) 49.25 (13.29) 47.8 (14.26) t = 0.47 .64
Hospitalization (last 6 months), mean (SD) 1.25 (2.29) 1.12 (2.18) 1.45 (2.45) t = −0.66 .513
Suicide attempt (last 6 months), mean (SD) 0.60 (1.20) 0.68 (1.38) 0.45 (0.85) t = 0.87 .386
NSSI (last 6 months) 1.82 (4.13) 2.23 (5.02) 1.18 (1.97) t = 1.14 .256
Disfunctional behavior (last week), mean (SD) 4.24 (2.29) 4.36 (2.28) 4.05 (2.32) t = −0.61 .539
Disfunctional eating beahavior (last week), mean (SD) 1.40 (1) 1.38 (0.95) 1.41 (1) t = −0.12 .903
BDI-II, mean (SD) 28.96 (15.06) 30.53 (15.69) 26.75 (13.99) t = 1.28 .204
ERQ, mean (SD)
Cognitive reappraisal 20.67 (7.54) 19.98 (7.46) 21.61 (7.62) t = −1.09 .278
Expressive suppression 13.06 (5.97) 13.33 (5.89) 12.68 (6.11) t = 0.55 .582
Resilience 52.27 (20) 51.11 (20.53) 53.91 (19.34) t = −0.71 .481
Impulsivity 42.01 (10.05) 43.54 (9.83) 39.38 (10.05) t = 1.80 .076
STAXI, mean (SD)
State 25.14 (12.04) 25.41 (12.62) 24.76 (11.30) t = 0.28 .781
Trait 27.12 (7.41) 27.15 (7.43) 27.07 (7.46) t = 0.06 .950
Emotinal eating, mean (SD) 50.11 (24.38) 51.94 (25.82) 47.48 (22.16) t = 0.92 .361

13
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Table 1  (continued)
DBT Dialectical Behavior Therapy, TAU Treatment As Usual, t Student t test, χ2 Chi square test, p statistical significance, N number of partici-
pants, SD standard deviation, GAF Global Assessment of Functioning, BDI-II Beck Depression Inventory, ERQ Emotion Regulation Question-
naire, STAXI State-Trait Anger Expression Inventory-2
Attrition Bias Assessment
As is common in longitudinal research, not all the partici-
pants supplied data at the four time points. Main treatment
outcome data were obtained for 69 participants at post-
test (DBT = 38, TAU CBT = 31) and for 15 participants
in the first and second follow-up periods (DBT = 10, TAU
CBT = 5). The TAU CBT condition retained fewer partici-
pants at post-treatment and in the follow-up periods than the
DBT condition, but these differences were not statistically
significant (p = 0.310; p = 0.501; respectively).
To assess attrition bias, we compared participants who
dropped out of the study (T0–T3; n = 93) with those who
completed all the time points (T0–T3; n = 16) on the mean
scores on the primary outcomes at pre-treatment, using Stu-
dent’s t test for independent samples. No statistically sig-
nificant differences between completers and dropouts were
found on depression (t = −1.35, p = 0.181), cognitive reap-
praisal of emotion regulation (t = 0.92, p = 0.359), expressive
suppression of emotion regulation (t = −1.03, p = 0.305),
resilience (t = 1.28, p = 0.202), impulsivity (t = −0.52,
p = 0.605), or trait anger (t = −0.18, p = 0.858). There were
statistically significant differences between completers
and dropouts at pre-treatment on emotional eating scores
(t = −3.98, p < 0.001) and state anger (t = −1.85, p = 0.075),
although the difference in state anger scores was only mar-
ginally significant. Thus, we performed the analyses on the
imputed database.
Pre–post Analysis for Each Treatment
Pre–post analyses were performed based on the imputed
database. Tables 2 and 3 display means and standard devia-
tions for the outcome measures at pre-treatment, post-treat-
ment, and follow-up periods for the DBT and TAU CBT
conditions, respectively. In the DBT condition, participants
showed an improvement on the BDI-II, Resilience, and Trait
Anger scores at the post-treatment assessment (see Table 2),
although the improvement in Resilience was only margin-
ally significant (p = 0.057); whereas participants in the TAU
CBT condition did not exhibit pre-post improvements in any
variable (see Table 3).
Follow‑up Comparisons for Each Treatment
Follow-up analyses were performed based on the imputed
database. For the DBT condition, as Table 2 shows, contrasts
between T0 and T2, and between T0 and T3, revealed that
13
Cognitive Therapy and Research
there were statistically significant improvements in most of
the study variables from the pre-treatment assessment to the
follow-up assessments, except for State Anger and Cognitive
Reappraisal. In addition, contrasts between T1 and T2, and
between T2 and T3, showed that there was a trend toward
continued improvement on the Resilience and Emotional
Eating scores from the post-treatment assessment to the fol-
low-up assessments. Moreover, comparisons of T1 and T2
revealed that there was an improvement on the BDI-II and
impulsivity scores from the post-treatment assessment to the
first follow-up assessment. Lastly, comparisons of T2 and T3
revealed that there was an improvement on the Expressive
suppression and Trait Anger scores from the first follow-up
assessment to the second follow-up assessment.
In the TAU CBT condition (see Table 3), comparisons of
T0 and T2, and T0 and T3, revealed that there were statis-
tically significant improvements in the BDI-II, Resilience,
and Trait Anger scores from the pre-treatment assessment
to the follow-up assessments. Moreover, there were sta-
tistically significant improvements in the Expressive sup-
pression scores from the pre-treatment assessment to the
second follow-up assessment (T0–T3). Comparisons of
T1 and T2, and T2 and T3, showed that the Resilience and
Trait Anger scores improved during the follow-up periods,
although the improvement in the Trait Anger scores between
T1 and T2 was only marginally significant (p = 0.065). In
addition, comparisons of T1 and T2 revealed that there was
an improvement in the scores on the BDI-II and Cognitive
Reappraisal from the post-treatment assessment to the first
follow-up assessment.
Between‑subjects Comparisons
Mixed factor repeated ANOVA tests were performed based
on the imputed database to examine if changes in outcome
measures across the four time points (pre-treatment, post-
treatment, and 4- and 6-years follow-up assessments) dif-
fered significantly between DBT and TAU CBT groups. The
interaction of group × time was not statistically significant
on BDI-II (Pillai’s trace = 0.06, F[3, 105] = 2.24, p = 0.088,
η2 = 0.06), Cognitive Reappraisal (Pillai’s trace = 0.06,
F[3, 105] = 2.30, p = 0.082, η2 = 0.06), Expressive Sup-
pression (Pillai’s trace = 0.04, F[3, 105] = 0.14, p = 0.937,
η2 = 0.01), Resilience (Pillai’s trace = 0.02, F[3, 105] = 0.72,
p = 0.543, η2 = 0.02), Impulsivity (Pillai’s trace = 0.05, F[3,
105] = 1.82, p = 0.147, η2 = 0.05), State Anger (Pillai’s
trace = 0.01, F[3, 105] = 0.04, p = 0.988, η2 = 0.00), Trait
Anger (Pillai’s trace = 0.03, F[3, 105] = 0.93, p = 0.429,
 Author's personal copy
Cognitive Therapy and Research

η2 = 0.03), and Emotional Eating scores (Pillai’s trace = 0.07,

DBT Dialectical Behavior Therapy, T0 pre-treatment, T1 post-treatment, T2 follow up 1, T3 follow up 2, F intrasubject ANOVA test, η2 partial eta squared, p value statistical significance, BDI-II
p value
T2–T3

<.001
F[3, 105] = 2.48, p = 0.065, η 2 = 0.07), indicating that

.047

.366

.001

.010
.001
–
1
changes over time did not differ between the DBT and TAU
p value CBT groups on any variable at any time.
T1–T2

<.001
.007

.309

.002
Reliable Change Index

.02
Table 2  Comparison of means scores (standard deviations) in pre-treatment, post-treatment and follow ups with post hoc Bonferroni correction for the DBT condition (n = 64)

–
1

1
Reliable Change scores in the outcome measures for each
p value
T0–T3

<.001

<.001
<.001

<.001
treatment condition across all the time assessments were
.143

.043

.001
calculated based on the imputed database. Table 4 displays

–
Reliable Change Index-Improvement scores for each treat-
ment condition across the time assessments. In general, the
p value
T0–T2

<.001

<.001

<.001
.009
.334

.048

.005
DBT group showed the highest proportion of participants
–

indicating reliable change for depression (32.8–57.8%),

resilience (21.9–64.1%) and cognitive reappraisal (around
p value
T0–T1

30%) from pre-treatment to the follow-ups. Over one fifth of

.026

.105
.057

.002

the participants (around 25–60%) showed reliable change for

–
1

state and trait anger in both conditions from pre-treatment

to the follow-ups.
.01
.19

.98
.11
.33
.08

.19
.20
η2

Beck Depression Inventory, ERQ Emotion Regulation Questionnaire, STAXI State-Trait Anger Expression Inventory 2

Discussion
15.14***

7.63***
30.33***
5.40***

14.47***
15.46***
4.52**

0.31
F

The main purpose of this study was to compare long-term

treatment outcomes of two interventions, standard DBT vs.
20.70 (10.10)

73.33 (13.01)

TAU CBT, to treat BPD and ED comorbidity in a naturalis-

21.50 (4.24)
22.55 (3.59)

39.94 (2.49)

24.70 (7.06)
9.92 (2.76)

tic setting. Our main hypothesis was that, in the long term,
38 (8.03)
M (SD)

DBT would be superior to CBT TAU in improving variables

T3

related to emotion dysregulation (depression, anger, impul-

sivity, emotional eating, and emotion regulation strategies).
In the DBT condition, there was a statistically significant
67.61 (10.29)

22.81 (3.31)
17.89 (7.36)

23.59 (4.16)
11.82 (2.93)

39.64 (3.68)

24.39 (6.13)

40.41 (7.85)

improvement in most of the study variables (depression,

M (SD)

emotional eating, trait anger, impulsivity, resilience, and

expressive suppression) from pre-treatment to the follow-
T2

up periods (T0–T2 and T0–T3), except for state anger and

cognitive reappraisal. In addition, there was a trend toward
25.35 (16.28)

57.88 (18.76)

51.26 (19.80)
24.07 (7.82)
21.65 (7.08)
11.45 (5.57)

41.88 (6.74)

24.15 (8.93)

continued improvement on resilience, and the emotional

eating scores. In the TAU CBT condition, there was a sta-
M (SD)

tistically significant improvement in depression, resilience,

Levels of significance: *p < .05, **p < .01, ***p < .001
T1

and trait anger scores from the pre-treatment assessment to

the follow-up assessments (T0–T2 and T0–T3). There was
30.36 (15.49)

51.18 (20.57)

25.41 (12.52)

51.80 (25.47)

a trend toward continued improvement on the resilience and

27.02 (7.46)
19.97 (7.52)
13.25 (5.79)

43.07 (9.14)

trait anger scores.

M (SD)

To our knowledge, this is the first study to test emotional

T0

eating in individuals with BPD and EDs. Emotional eating

has been defined as the tendency to eat in order to regu-
late negative emotions, without attending to physiological
Expressive suppression
Cognitive reappraisal

hunger needs (López-Montoyo and Cebolla 2016). From a

DBT perspective, maladaptive eating behaviors are forms
Emotional eating

of emotion regulation used by individuals in response to

Impulsivity

emotions that are difficult to tolerate (Bankoff et al. 2012).

Resilience

STAXI

These results indicate that an ED factor related to emotion

BDI-II

State
Trait
ERQ

dysregulation decreased after a DBT intervention, and the

13
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Cognitive Therapy and Research

Table 3  Comparison of means scores (standard deviations) in pre-treatment, post-treatment and follow ups with post hoc Bonferroni correction
for the TAU CBT condition (n = 45)
T0 T1 T2 T3 F η2 T0–T1 T0–T2 T0–T3 T1–T2 T2–T3
M (SD) M (SD) M (SD) M (SD) p value p value p value p value p value

BDI-II 26.90 (13.87) 27.67 (16.78) 18.05 (3.38) 18.95 (3.41) 12.84*** .23 1 .001 .001 .003 1
ERQ
Cognitive reappraisal 21.65 (7.54) 19.85 (7.04) 23.40 (1.33) 23.62 (2.22) 5.87** .12 .631 .791 .588 .009 1
Expressive suppression 12.72 (6.05) 11.54 (4.95) 11.59 (1.85) 9.87 (0.96) 5.07** .10 .762 1 .015 1 <.001
Resilience 54 (19.12) 56.90 (17.79) 67.89 (4.75) 75.54 (5.55) 35.25*** .45 1 <.001 <.001 .001 <.001
Impulsivity 39.68 (8.79) 41.75 (7.21) 40.13 (3.06) 40.48 (2.56) 1.50 .03 – – – – –
STAXI
State 24.76 (11.31) 23.73 (8.45) 23.67 (2.02) 23.72 (2.69) 0.28 .01 – – – – –
Trait 27.07 (7.46) 25.57 (8.62) 22.24 (2.07) 20.80 (2.18) 15.73*** .26 .348 .001 <.001 .065 <.001
Emotional eating 46.69 (21.99) 44.93 (18.30) 42.91 (7.76) 39.48 (7.71) 2.43 .05 – – – – –

TAU CBT Treatment As Usual Cognitive Behavior Therapy, T0 pre-treatment, T1 post-treatment, T2 follow up 1, T3 follow up 2, F intrasubject
ANOVA test, η2 partial eta squared, p value statistical significance, BDI-II Beck Depression Inventory, ERQ Emotion Regulation Questionnaire,
STAXI State-Trait Anger Expression Inventory 2
Levels of significance: *p < .05, **p < .01, ***p < .001

Table 4  Reliable Change Index-Improvement: number of individuals (percentage) surpassing 1.96 on RCI
T0–T1 T0–T2 T0–T3 T1–T2 T2–T3
DBT TAU-CBT DBT TAU-CBT DBT TAU-CBT DBT TAU-CBT DBT TAU-CBT
n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

BDI-II 21 (32.8) 10 (22.2) 37 (57.8) 20 (44.4) 34 (53.1) 16 (35.6) 26 (40.6) 18 (40) 1 (1.6) 1 (2.2)
ERQ
Cognitive reappraisal 18 (28.1) 4 (8.9) 21 (32.8) 10 (22.2) 18 (28.1) 11 (24.4) 17 (26.6) 12 (26.7) 2 (3.1) 2 (4.49)
Expressive suppression 14 (21.9) 8 (17.8) 13 (20.3) 10 (22.2) 18 (28.1) 12 (26.7) 6 (9.4) 5 (11.1) 4 (6.3) 1 (2.2)
Resilience 14 (21.9) 8 (17.8) 35 (54.7) 20 (44.4) 41 (64.1) 24 (53.3) 22 (34.4) 18 (40) 3 (4.7) 1 (2.2)
Impulsivity 6 (9.4) 2 (4.4) 9 (14.1) 1(2.2) 8 (12.5) 1(2.2) 2 (3.1) 3 (6.7) 1(1.6) 0 (0.0)
STAXI
State 19 (29.7) 10 (22.2) 22 (34.4) 13 (28.9) 22(34.4) 14 (31.1) 18 (28.1) 8 (17.8) 3 (4.7) 2 (4.4)
Trait 22 (34.4) 12 (26.7) 28 (43.8) 20 (44.4) 33 (51.6) 26(57.8) 22 (34.4) 15 (33.3) 2 (3.1) 2 (4.4)
Emotional eating 6 (9.4) 4 (8.9) 25 (39.1) 13 (28.9) 27 (42.2) 15 (33.3) 18 (28.1) 8 (17.8) 1 (1.6) 0 (0.0)

T0 pre-treatment, T1 post-treatment, T2 follow up 1, T3 follow up 2. DBT Dialectical Behavior Therapy, TAU​Treatment As Usual, BDI-II Beck
Depression Inventory, ERQ Emotion Regulation Questionnaire, STAXI State-Trait Anger Expression Inventory 2

improvement was maintained in the long term. Regarding
depression, the improvement found with both interventions
is consistent with previous studies using shorter follow-ups
to evaluate treatments for BPD (e.g. McMain et al. 2012).
In a recent literature review on the effectiveness of DBT
for EDs, medium to large effect sizes were noted in treat-
ing depression symptoms (Lenz et al. 2014). Furthermore,
both treatments improved trait anger over time (although the
improvement between T1 and T2 in the TAU CBT condi-
tion was only marginally significant), which is a promising
outcome because previous studies show that personality
traits, such as chronic anger, are more resistant over time
(Álvarez-Tomás et al. 2017; Gunderson et al. 2011; Zanar-
ini et al. 2016). However, state anger did not improve in
any condition. Due to the emotional instability of the BPD
population, it is difficult to analyze state measures.
According to the biosocial theory (Linehan 1993a, b;
Crowell et al. 2009), poor impulse control and emotional
sensitivity are early biological vulnerabilities for BPD. A
child born with heightened biological sensitivity to emo-
tional cues encounters emotionally aversive experiences
(e.g., emotional neglect, invalidation) and consequently
develops biological and psychological alterations of the
emotion regulation system (e.g. Distel et al. 2011). The
psychological alterations manifest in adulthood involve
maladaptive or insufficient knowledge in how to understand,
label, regulate, or tolerate emotional responses effectively
(Neacsiu et al. 2014).

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Cognitive Therapy and Research
The results of this study are promising because they sug-
gest a good outcome on two fundamental etiological factors
of emotional vulnerability in BPD according to the bioso-
cial theory, impulsivity and emotion dysregulation (Crowel
et al. 2009). Specifically, the results show an improvement in
emotional suppression, a strategy aimed to escape or avoid
undesired internal experiences. One way of dealing with
aversive and intense emotions for BPD patients is to sup-
press them. This can be achieved by the use of impulsive
behaviors like non-suicidal self-injuries (Navarro-Haro et al.
2015). Emotional suppression also appears to be a signifi-
cant mediator between undesired affect reactivity and inten-
sity and BPD symptomatology, even after controlling for a
history of childhood sexual abuse (Rosenthal et al. 2008).
Another emotion regulation strategy is cognitive reap-
praisal, a form of cognitive change that involves reinterpret-
ing the meaning of a potentially emotion-eliciting situation
and thereby changing the trajectory of an emotional response
(Lazarus and Alfert 1964). However, cognitive reappraisal
did not significantly increase after treatment. Fruzzetti and
Shenk (2020) suggested that when we are highly emotionally
aroused, we demonstrate less cognitive capacity, self-aware-
ness and the ability to solve problems. Furthermore, some
of the characteristics of pervasive emotion dysregulation in
BPD are related with impairment in cognitive reappraisal
(difficulties drawing attention away from emotional stimuli,
failures in information processing, and problems organizing
activities addressed to non-mood-dependent goals) (Crowell
et al. 2009). A recent laboratory study has suggested that
individuals with BPD may have more difficulties with learn-
ing cognitive reappraisal (Schulze et al. 2011). Thus, further
practice on strategies proposed to address cognitive change
(e.g. checking the facts, reality acceptance; Neacsiu et al.
2014) might have helped to improve cognitive reappraisal
after the treatment.
Furthermore, DBT showed an increase in resilience
scores across all of the time periods. This result is interest-
ing from our point of view. Resilience is a broad concept that
refers to the ability to maintain wellbeing despite adversity
(Masten 2001) and has been associated with positive adjust-
ment in difficult and stressful situations, such as the ability
to problem solve or accept the results of change (Reivich
and Shatte 2002) instead of resisting or denying the change.
Furthermore, emotion-oriented coping has been associated
with low resilience (Campbell-Sills et al. 2006). Along
these lines, a qualitative study (Paris et al. 2014) compared
pairs of sisters, one with BPD and the other without BPD,
who had experienced severe abuse and neglect. The sisters
with BPD reported that they were unable to use strategies
related to resilience (e.g. seeking social support, manag-
ing negative emotional experiences, accepting the past).
These abilities are similar to the essential strategies taught
in DBT (e.g. problem-solving strategies, emotion regulation,
interpersonal effectiveness, mindfulness practice, and real-
ity acceptance skills; Linehan et al., 2015). The change in
resilience found in this study may indicate that DBT could
help to develop a protective factor against psychiatric dis-
orders in the long term in individuals with severe emotion
dysregulation.
Contrary to our hypotheses, there were no statistically
significant differences between DBT and TAU CBT in the
analyzed variables over time. Moreover, the RCI improve-
ment scores also provided useful supplemental data for
evaluating the treatment programs. In general, the percent-
ages of participants showing a clinically significant change
(improvement) over time were high in the DBT condition for
depression, resilience, and cognitive reappraisal. These find-
ings indicate that a great number of participants with BPD
and ED improved over time in the DBT condition, which is a
good indicator of clinical significance. We also would like to
mention that the TAU CBT condition retained fewer partici-
pants at post-treatment and in the follow-up periods than the
DBT condition, but these differences were not statistically
significant. This result is consistent with previous studies
showing that DBT has high retention rates after treatment
and at follow-up in BPD and ED populations (e.g. Linehan
et al. 2006; Navarro-Haro et al. 2018; Safer et al. 2010),
which may improve long-term cost-effectiveness.
We expected that DBT would show significantly higher
improvements in the outcomes more related to emotion
regulation over time. However, our results indicate that the
TAU CBT program showed a comparable maintenance of
several treatment outcomes over a 6-year period. The TAU
CBT program is a well-established treatment in the clinical
center, based in evidence-based programs and tailored to
the characteristics of the population they assist (severe ED
patients with personality disorder comorbidity). What our
study indicates is that a new program delivered in the center
(standard DBT) is also effective compared to a well-estab-
lished CBT program over time. Therefore, it was feasible to
establish standard DBT in a clinical center for the BPD and
ED sample with good results over time. In fact, the program
has been running since we conducted the first study (Navarro
et al. 2018) and it has become routine practice in the clini-
cal center, serving as an example of the implementation of
DBT in Spain.
Despite these findings, the study has several limitations.
First, randomization of participants was not carried out.
Therefore, this study has limitations related to internal
validity, and so we cannot interpret the results in terms
of treatment efficacy. Given that many RCTs have been
conducted to test the efficacy of DBT, our main goal was
to evaluate how effective these treatments were in the field
of routine psychotherapeutic practice. Another possible
limitation is the difference in the number of participants
assigned to the different conditions (64 participated in
13
 Author's personal copy
DBT and only 45 in TAU CBT) at pre-treatment, due to
the workload of the therapists. Nonetheless, results showed
that there were no differences between groups at baseline
on clinical and demographic variables. Furthermore, the
fact that some patients were taking psychotropic medica-
tions and receiving auxiliary therapy activities is also a
limitation because we did not study the effects of these
additional treatments on the study outcomes in the long
term. Finally, although long-term outcomes were statisti-
cally valid, the sample sizes at the follow-up points were
small. Randomized controlled trials with bigger sample
sizes at follow-up are needed to confirm the long-term
efficacy of these treatments.
In conclusion, results of this study support the prelimi-
nary long-term effectiveness of standard DBT for comor-
bid BPD and ED in naturalistic settings, and they contrib-
ute to the research on the efficacy of these treatments in the
field of routine psychotherapeutic practice. DBT may be a
good treatment to improve long-term impulsivity and emo-
tion regulation in people suffering from a severe mental
condition. Longitudinal studies with larger sample sizes
are needed to confirm these findings.
Acknowledgements This research was supported by the Gobierno de
Aragón (Group reference: S31_20D) and by Feder 2014–2020 “Con-
struyendo Europa desde Aragón”.
Author contributions All authors contributed to the study conception
and design. Material preparation, data collection and analysis were per-
formed by VGB, LBR, LB. The first draft of the manuscript was written
by MVNH and AG and all authors commented on previous versions
of the manuscript. All authors read and approved the final manuscript.
Funding The research presented in this paper was funded by Ministerio
de Economía y Competitividad, Spain, “Proyectos de investigación fun-
damental no orientada” (PSI2010-21423/PSIC), “Plan de Formación
de la investigación en la Universitat Jaume I” (P11B2005-32) and by
Generalitat Valenciana, Redes de Excelencia ISIC (ISIC/2012/012).
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Ethical approval The study was approved by the appropriate institu-
tional and/or national research ethics committee (University Jaume I of
Castellón, Spain) and certify that the study was performed in accord-
ance with the ethical standards as laid down in the 1964 Declaration
of Helsinki.
Informed consent Informed consent was obtained from all individual
participants included in the study.
Animal Rights This article does not contain any studies with animals
performed by any of the authors.
13
Cognitive Therapy and Research
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