Supervised & authored by: Dr. Azhar Qureshi
Abstract
DBT (Dialectical Behavior Therapy) has shown effectiveness in the treatment of borderline personality disorder, but less is known about its effects on other disorders, presenting multiple treatment targets. This case study examines the effectiveness of DBT in a 26-year-old male diagnosed with bipolar II disorder, borderline personality traits, cannabis use disorder, and alcohol use disorder. The patient had a significant history of mood instability, impulsivity, suicidal ideation, and substance misuse. Treatment focused on applying skills in DBT related to managing emotions, handling distress, and practicing mindfulness to reduce self-harm, suicidality, and substance use while improving mood stability. Results indicated significant reductions in depression, mania, emotion dysregulation, suicidal ideation, alcohol use, and cannabis use from pre- to post-treatment, with skills utilization mediating these improvements. The patient achieved abstinence from alcohol and cannabis. This case highlights DBT’s potential efficacy as a transdiagnostic treatment that targets diverse, co-occurring clinical problems by providing clients with adaptive coping skills. Further research is warranted on DBT with comorbid bipolar disorder and substance use.
BACKGROUND
Dialectical Behavior Therapy (DBT), a proven and research-supported method developed by Dr. Marsha Linehan [5], was initially designed to address Borderline Personality Disorder (BPD) cases [3, 4]. Over time, DBT has evolved to treat a broad spectrum of mental health disorders effectively. This holistic therapeutic approach encompasses various vital components, including promoting mindfulness, instructing emotion regulation skills, enhancing interpersonal capabilities, providing tools for distress tolerance, crisis intervention techniques, and cultivating a validating therapeutic environment [5, 6]. Additionally, DBT focuses on structuring the environment, improving patient motivation to change, and generalizing new behaviors. Integrating these elements within DBT empowers individuals to manage their emotions, relationships, and crises effectively, ultimately contributing to improved mental well-being [6, 7].
DBT sets itself apart from other behavior therapies by incorporating mindfulness, a strong focus on emotion regulation, a dialectical approach, distress tolerance, and interpersonal skills [8]. It employs a structured format and provides ongoing support for long-term progress, making it a unique and comprehensive approach for individuals facing various mental health challenges [9]. In a study, DBT with prolonged exposure yielded the highest improvement in PTSD symptoms (71%), followed by those who started DBT PE but did not finish (54%). In contrast, standard DBT had a lower improvement rate (31%) [10]. Evidence has shown that DBT has successfully decreased anxiety and depression by over 68% [11]. Among various psychotherapies for treating people with BPD, DBT statistically significantly reduced suicidal behavior by about 50% [12]. Compared to Cognitive Behavioral Therapy (CBT), it appeared effective in reducing self-harm rates [13]. Inquiries persist concerning the capacity of DBT to effectively address a broader range of psychiatric conditions characterized by multiple treatment targets [2].
This case study explores the therapeutic potential of a six-month comprehensive DBT intervention for a 26-year-old male diagnosed with bipolar II disorder, borderline personality disorder traits, cannabis use disorder, and alcohol use disorder. The treatment aimed to improve emotion regulation, distress tolerance, mindfulness, and interpersonal effectiveness while targeting self-harm reduction, suicidality mitigation, substance use control, and mood stability enhancement. The study’s novelty lies in its multifaceted approach to addressing these diverse treatment objectives.
CASE PRESENTATION
Patient Information
The individual under consideration was a 26-year-old male of Caucasian ethnicity, who brought forth a multifaceted clinical scenario encompassing a significant medical history of fluctuations in mood, impulsive behaviors, recurrent episodes of contemplating self-harm, and substance misuse. A comprehensive evaluation was conducted, including a clinical interview and administering various questionnaires to arrive at a pertinent diagnosis.
Clinical Findings and Diagnostic Assessment
The initial phase of the study involved a comprehensive diagnostic assessment employing various assessment tools. Using the Beck Depression Inventory-II (BDI-II), the severity of depression was measured, Young Mania Rating Scale (YMRS) evaluated manic symptoms. Difficulties in Emotion Regulation Scale (DERS) assessed emotional dysregulation, and the Alcohol Use Disorders Identification Test (AUDIT) evaluated the use of alcohol. The assessment of cannabis use was conducted using the Cannabis Use Disorder Identification Test-Revised (CUDIT-R), and suicidal ideation and behaviors were examined through the Suicidal Behaviors Questionnaire-Revised (SBQ-R).
The analysis of these data revealed a diagnosis encompassing bipolar II disorder, borderline personality disorder traits, cannabis use disorder, and alcohol use disorder.
Therapeutic Intervention and Outcome
In response to the diagnosis, a well-structured six-month treatment plan was crafted to address the patient’s complex clinical needs. The patient participated in weekly individual therapy sessions customized to address their specific clinical concerns, focusing on borderline personality disorder traits, bipolar II disorder, cannabis use disorder, and alcohol use disorder. To offer continuous, personalized support, the plan included as-needed phone coaching. This feature allowed the patient to seek guidance and assistance during moments of distress or challenging situations outside of scheduled therapy sessions, helping them apply DBT skills effectively in real time. The patient actively engaged in DBT sessions following Marsha Linehan’s DBT manual structure. These sessions covered various DBT techniques and skills associated with mindfulness, managing distress, regulating emotions, enhancing interpersonal effectiveness, and providing a structured approach to improving emotion regulation and overall well-being.
Throughout the treatment, comprehensive data collection occurred using assessment tools like DERS, AUDIT, CUDIT-R, and SBQ-R. Standardized measures like BDI-II and YMRS were conducted every eight weeks to monitor mood and manic symptoms. The patient’s therapist also contributed by providing weekly ratings on mood, emotion regulation, and treatment engagement. Random urinalysis tests were performed twice monthly to validate self-reported substance use.
Following an intensive six-month treatment journey, a comprehensive post-treatment assessment was administered, involving reevaluating the pre-treatment questionnaires. Quantitative data were analyzed through repeated measures t-tests, comparing standardized measure scores before and after treatment. Clinician ratings were summarized descriptively. The patient exhibited noteworthy enhancements from the beginning to the end of treatment., including reduced depression severity, relief from manic symptoms, improved emotion regulation, reduced suicidal ideation, decreased alcohol use, and lessened cannabis use. These changes were compelling and indicative of substantial clinical progress. Of particular significance is the patient’s remarkable achievement of abstinence from both alcohol and cannabis during the six-month treatment.
DISCUSSION
DBT is a versatile approach addressing various domains by equipping individuals with skills associated with mindfulness, the ability to manage distress, regulate emotions, and enhance interpersonal effectiveness [13]. DBT is well-suited for complex cases as it provides a broader range of skills. DBT’s strength lies in simultaneously addressing multiple functional domains, offering a holistic approach for individuals with coexisting disorders, especially in managing suicidal ideation, self-harm, and chronic mental health challenges. However, it can be resource-intensive and require skilled therapists [14, 15]. In contrast, Cognitive-Behavioral Therapy, Acceptance and Commitment Therapy, Interpersonal Psychotherapy, and Mindfulness-Based Cognitive Therapy have more specific focal points.
DBT has shown efficacy in treating various disorders and behavior disorders, often as a solo treatment or combined with other approaches. The results of random effects meta-analyses indicated that DBT has proven to be successful in reducing self-inflicted harm and lowering the frequency of utilizing psychiatric crisis services [17, 18]. Besides, the therapy has also been used as an adjunct therapy to treat depression in individuals with substance use disorders. The study showed significant improvements in depression over a 16-week period [15, 16]. While DBT is not primarily designed to target manic symptoms, it has been used as an integral part of the treatment strategy for individuals with bipolar disorder [14]. Additionally, it has been demonstrated that individuals with BPD exhibit improved emotion regulation skills following a 16-week course of DBT treatment. [16]. For better outcomes, a consistently high level of commitment to the treatment is required, including attending therapy sessions, skills training, and active participation in the treatment process [17, 18]. In our specific case, this may explain the emergence of positive therapeutic outcomes in a complex clinical scenario.
Our findings suggest that DBT places a stronger emphasis on modifying multiple behaviors rather than altering thoughts, which has implications for clinical practice. Among this study’s limitations, several factors warrant consideration. The patient’s age, gender, and cultural background may have unique implications for treatment outcomes, highlighting the need for more diverse samples in future research. Furthermore, the study primarily relies on quantitative data and clinical observations, potentially overlooking qualitative insights that could provide a deeper understanding of the patient’s experience with DBT. Another aspect is the absence of long-term follow-up data, which could shed light on the sustainability of treatment effects and potential relapse rates beyond the six-month intervention. Such data would contribute significantly to understanding the enduring impact of DBT in cases like this. Lastly, resource-limited settings present distinct challenges, and adapting DBT to these environments requires further investigation. Developing more accessible and cost-effective versions of DBT could extend its benefits to a more extensive and diverse range of individuals facing similar complex clinical issues.
CONCLUSION
The case study serves as a compelling illustration of Dialectical Behavior Therapy’s (DBT) potential to effectively address the intricate challenges faced by individuals with complex clinical profiles. While the results are promising, it is imperative to underscore the need for further investigations in developing more accessible and cost-effective versions of DBT that can benefit a diverse range of individuals facing similar complex clinical issues.
INFORMED CONSENT/ETHICS APPROVAL
Informed consent was obtained from the patient for the case report.
CONFLICT OF INTEREST STATEMENT
The authors declare that there are no conflicts of interest.
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About the author:
Dr. Azhar Qureshi
As a physician and cardiologist, my training encompassed a comprehensive range of invasive and noninvasive procedures, providing extensive hands-on experience in echocardiography, cardiac stress testing, diagnostic catheterization, and coronary interventions. In addition, I developed skills in psychological assessments and formulating detailed case reports. This multifaceted training has equipped me with a strong foundation across cardiology and psychological studies and documentation to support my medical practice and research. I am passionate about medical writing and exchanging knowledge to help the global community.
