Dialectical Behavioral Therapy (DBT) in Borderline Personality Disorder

This document was published more than 2 years ago. The nature of the evidence may have changed.

Summary and Conclusions

Technology and target group

Borderline personality disorder is characterized by a consistent pattern of instability in controlling feelings, deficiency in controlling impulses, problems with relationships, and poor self-esteem. In a clinical context, the disorder is expressed as difficulties in managing ones feelings, impulsive actions and aggressiveness, repeated episodes of self-inflicted injury, and suicide attempts. Patients with borderline personality disorder often have other personality disorders or diseases, eg, depression, eating disorders, drug abuse, or anxiety problems. Dialectical behavioral therapy (DBT) is an extensive and advanced form of cognitive behavioral therapy (CBT) that was developed specifically for chronically suicide-prone patients with borderline personality disorder. The DBT method includes several components, eg, behavior-changing techniques and methods for learning to accept feelings. Treatment is carried out in several steps, but self-injury and therapy-disrupting behaviors are prioritized when treatment commences. A distinctive characteristic of DBT is the extensive contact between the therapy team and the patient, eg, through individual therapy, group therapy, and telephone support. Furthermore, staff members working with this group of patients also receive guidance and support. One estimate showed that between 70 000 and 140 000 people in Sweden could possibly meet the diagnostic criteria for borderline personality disorder. The number in this group who would be likely candidates for DBT has not been determined.

Primary question

Can DBT reduce self-injurious behavior and drug abuse among people with borderline personality disorder?

Patient benefit

Six randomized controlled trials compared DBT to other psychiatric treatment. A large percentage of women were included in these trials. The duration of treatment was usually 1 year, and the outcomes varied by study, partly because different subgroups were studied. The results show that DBT leads to a reduction in self-injurious behavior and fewer dropouts from treatment. The effects were found to remain in followup for up to 2 years. Treatment also appeared to reduce the need for hospitalization and reduce drug use among substance abusers. There is no evidence to show that treatment outcomes would be influenced in patients who are also diagnosed with substance abuse. Likewise, there are no confirmed results concerning the impact of different treatment components on the outcome.

Economic aspects

A Swedish study investigated the cost of dialectical behavioral therapy. The total annual cost, per patient, for care decreased from 320 000 Swedish kronor (SEK) in the year before treatment commenced to 210 000 SEK when treatment was given. Health economic studies are needed to investigate the cost effectiveness of the method.

SBU´s appraisal of the evidence

There is limited scientific evidence showing that DBT reduces self-injurious behavior and that the effect remains at 2-year followup (Evidence grade 3)*. Treatment also appears to reduce the need for hospitalization and reduce drug use among people with addictions. Hence, DBT appears to be a promising form of treatment for patients with borderline personality disorder. However, it needs to be tested under Swedish conditions, and it is essential to conduct studies addressing the cost effectiveness of the method.

*Grading of the level of scientific evidence for conclusions. The grading scale includes three levels;
Evidence grade 1 = strong scientific evidence,
Evidence grade 2 = moderately strong scientific evidence,
Evidence grade 3 = limited scientific evidence.

This summary is based on a report prepared at SBU in collaboration with Prof. Gerhard Andersson (expert), Linköping University, Assoc. Prof. Margda Wærn (reviewer), Göteborg University, and Prof. Lars-Göran Öst (reviewer), Stockholm University.

The complete report is available only in Swedish.

SBU Alert is a service provided by SBU in collaboration with the Medical Products Agency, the National Board of Health and Welfare, and the Swedish Association of Local Authorities and Regions.


  1. Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M. Borderline personality disorder. Lancet 2004;364(9432):453-61. Review.
  2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed, text revision ed. American Psychiatric Association, Washington, DC, USA; 2000.
  3. Ekselius L, Tillfors M, Furmark T, Fredrikson M. Personality disorders in the general population: DSM-IV and ICD-10 defined prevalence as related to sociodemographic profile. Personality and Individual Differences 2001;30:311-20.
  4. Torgersen S, Kringlen E, Cramer V. The prevalence of personality disorders in a community sample. Arch Gen Psychiatry 2001;58(6):590-6.
  5. Zanarini MC, Frankenburg FR, Hennen J, Silk KR. The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. Am J Psychiatry 2003;160(2):274-83.
  6. Scheel KR. The empirical basis of dialectical behavior therapy: Summary, critique, and implications. Clin Psychol Sci Prac 2000;7:68-86.
  7. Bateman AW, Fonagy P. Effectiveness of psychotherapeutic treatment of personality disorder. Br J Psychiatry 2000;177:138-43. Review.
  8. Hawton K, Arensman E, Townsend E, Bremner S, Feldman E, Goldney R et al. Deliberate self harm: systematic review of efficacy of psychosocial and pharmacological treatments in preventing repetition. BMJ 1998;317(7156):441-7. Review.
  9. Linehan MM. Cognitive-behavioral treatment of borderline personality disorder. Guilford Press, New York, USA; 1993.
  10. Linehan MM, Armstrong HE, Suarez A, Allmon D, Heard HL. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 1991;48(12):1060-4.
  11. Lynch TR, Morse JQ, Mendelson T, Robins CJ. Dialectical behavior therapy for depressed older adults: a randomized pilot study. Am J Geriatr Psychiatry 2003;11(1):33-45.
  12. Safer DL, Telch CF, Agras WS. Dialectical behavior therapy for bulimia nervosa. Am J Psychiatry 2001;158(4):632-4.
  13. Telch CF, Agras WS, Linehan MM. Dialectical behavior therapy for binge eating disorder. J Consult Clin Psychol 2001;69(6):1061-5.
  14. Näslund GK. Borderline personlighetsstörning. Uppkomst, symptom, behandling, prognos. Natur och Kultur, Stockholm, Sverige; 1998.
  15. Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry 1999;156(10):1563-9.
  16. Bateman A, Fonagy P. Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. Am J Psychiatry 2001;158(1):36-42.
  17. Blennerhassett RC, ORaghallaigh JW. Dialectical behaviour therapy in the treatment of borderline personality disorder. Br J Psychiatry 2005;186:278-80.
  18. Beck AT, Freeman JB. Cognitive therapy of personality disorders. Guilford Press, New York, USA; 1990.
  19. Ryle A. Cognitive analytical therapy and borderline personality disorder. Wiley, Chichester; 1997.
  20. Evans K, Tyrer P, Catalan J, Schmidt U, Davidson K, Dent J et al. Manual-assisted cognitive-behaviour therapy (MACT): a randomized controlled trial of a brief intervention with bibliotherapy in the treatment of recurrent deliberate self-harm. Psychol Med 1999;29(1):19-25.
  21. Tyrer P, Thompson S, Schmidt U, Jones V, Knapp M, Davidson K et al. Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study. Psychol Med 2003;33(6):969-76.
  22. Linehan MM, Heard HL, Armstrong HE. Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Arch Gen Psychiatry 1993;50(12):971-4.
  23. Linehan MM, Tutek DA, Heard HL, Armstrong HE. Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. Am J Psychiatry 1994;151(12):1771-6.
  24. Linehan MM, Schmidt H 3rd, Dimeff LA, Craft JC, Kanter J, Comtois KA. Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. Am J Addict 1999;8(4):279-92.
  25. Linehan MM, Dimeff LA, Reynolds SK, Comtois KA, Welch SS, Heagerty P et al. Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug Alcohol Depend 2002;67(1):13-26.
  26. Koons CR, Robins CJ, Tweed JL, Lynch TR, Gonzalez AM, Morse JQ et al. Efficacy of dialectical behavior therapy in women with borderline personality disorder. Behav Ther 2001;32:371-90.
  27. Turner RM. Naturalistic evaluation of dialectical behavior therapy-oriented treatment for borderline personality disorder. Cognitive & Behavioral Practice 2000;7:413-9.
  28. Verheul R, van den Bosch LM, Koeter MW, de Ridder MA, Stijnen T, van den Brink W. Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in The Netherlands. Br J Psychiatry 2003;182:135-40.
  29. van den Bosch LM, Verheul R, Schippers GM, van den Brink W. Dialectical Behavior Therapy of borderline patients with and without substance use problems. Implementation and long-term effects. Addict Behav 2002;27(6):911-23.
  30. van den Bosch LM, Koeter MW, Stijnen T, Verheul R, van den Brink W. Sustained efficacy of dialectical behaviour therapy for borderline personality disorder. Behav Res Ther 2005;43(9):1231-41.
  31. Bohus M, Haaf B, Stiglmayr C, Pohl U, Bohme R, Linehan M. Evaluation of inpatient dialectical-behavioral therapy for borderline personality disorder--a prospective study. Behav Res Ther 2000;38(9):875-87.
  32. Simpson EB, Yen S, Costello E, Rosen K, Begin A, Pistorello J et al. Combined dialectical behavior therapy and fluoxetine in the treatment of borderline personality disorder. J Clin Psychiatry 2004;65(3):379-85.
  33. Soler J, Pascual JC, Campins J, Barrachina J, Puigdemont D, Alvarez E et al. Double-blind, placebo-controlled study of dialectical behavior therapy plus olanzapine for borderline personality disorder. Am J Psychiatry 2005;162(6):1221-4.
  34. Bohus M, Haaf B, Simms T, Limberger MF, Schmahl C, Unckel C et al. Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial. Behav Res Ther 2004;42(5):487-99.
  35. Shearin EN, Linehan MM. Dialectical behavior therapy for borderline personality disorder: theoretical and empirical foundations. Acta Psychiatr Scand Suppl 1994;379:61-8.
  36. Shearin EN, Linehan MM. Patient-therapist ratings and the relationship to progress in dialectical behavior therapy for borderline personality disorder. Behav Ther 1992;23:730-41.
  37. Kåver A, Nilsonne Å. Dialektisk beteendeterapi vid emotionell instabil personlighetsstörning. Teori, strategi och teknik. Natur och Kultur, Stockholm, Sverige; 2002.
  38. Heard H. Cost-effectiveness of dialectical behavior therapy in the treatment of borderline personality disorder. University of Washington, Washington, USA; 2000.
  39. Perseius K-I, Samuelsson M, Andersson E, Berndtsson T, Götmark H, Henriksson F et al. Does dialectical behavioural therapy reduce treatment costs for patients with borderline personality disorder. A pilot study. Vård i Norden 2004;24:27-30.
  40. Swenson CR, Torrey WC, Koerner K. Implementing dialectical behavior therapy. Psychiatr Serv 2002;53(2):171-8.
  41. Hawkins KA, Sinha R. Can line clinicians master the conceptual complexities of dialectical behavior therapy? An evaluation of a State Department of Mental Health training program. J Psychiatr Res 1998;32(6):379-84.
  42. Holender H. Dialektisk beteendeterapi (DBT) i Sverige. Lunds universitet, Lund, Sverige; 2003.
  43. Linehan MM. Dialektisk beteendeterapi. Färdighetsmanual. Natur och Kultur, Stockholm, Sverige; 2000.
  44. Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. The Personality Disorders Institute/Borderline Personality Disorder Research Foundation randomized control trial for borderline personality disorder: rationale, methods, and patient characteristics. J Personal Disord 2004;18(1):52-72.
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SBU Assessment presents a comprehensive, systematic assessment of available scientific evidence. The certainty of the evidence for each finding is systematically reviewed and graded. Full assessments include economic, social, and ethical impact analyses.

SBU assessments are performed by a team of leading professional practitioners and academics, patient/user representatives and SBU staff. Prior to approval and publication, assessments are reviewed by independent experts, SBU’s Scientific Advisory Committees and Board of Directors.

Published: 10/26/2005
Contact SBU: registrator@sbu.se
Report no: 2005-07