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Sex and gender in treatment response to dialectical behaviour therapy: current knowledge, gaps, and future directions

Published online by Cambridge University Press:  22 June 2022

S. Penta ,
S. Correia ,
M.A. Schneider ,
K. Holshausen ,
A.A. Nicholson ,
S.A. Haefner ,
C. Mutschler ,
A. Ferdossifard ,
K. Boylan  and
J. Hewitt
...Show all authors
S. Penta
Affiliation:
Youth Wellness Centre, St Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
S. Correia
Affiliation:
Youth Wellness Centre, St Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
M.A. Schneider
Affiliation:
Youth Wellness Centre, St Joseph’s Healthcare Hamilton, Hamilton, ON, Canada Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
K. Holshausen
Affiliation:
Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
A.A. Nicholson
Affiliation:
Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
S.A. Haefner
Affiliation:
Youth Wellness Centre, St Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
C. Mutschler
Affiliation:
Youth Wellness Centre, St Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
A. Ferdossifard
Affiliation:
Youth Wellness Centre, St Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
K. Boylan
Affiliation:
Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
J. Hewitt
Affiliation:
Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
S.L. Roth
Affiliation:
Youth Wellness Centre, St Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
R. Wilson
Affiliation:
Youth Wellness Centre, St Joseph’s Healthcare Hamilton, Hamilton, ON, Canada Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
T. Hatchard*
Affiliation:
Youth Wellness Centre, St Joseph’s Healthcare Hamilton, Hamilton, ON, Canada Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada Peter Boris Centre for Addictions Research, McMaster University and St Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
*
*Corresponding author. Email: thachar@stjosham.on.ca
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Abstract

Borderline personality disorder (BPD) is a mental health condition characterized by emotion dysregulation, interpersonal impairment, and high suicidality. Dialectical behaviour therapy (DBT) is the most widely studied psychotherapeutic treatment for BPD. To date, the vast majority of DBT research has focused on cisgender women, with a notable lack of systematic investigation of sex and/or gender differences in treatment response. In order to encourage effective, equitable treatment of BPD, further investigation into treatment targets in this population is critical. Here, we employed a systematic strategy to delineate gaps in the DBT literature pertaining to sex and gender differences and propose directions for future research. Findings demonstrate a significant discrepancy in measurement of sex and gender, particularly among gender-diverse individuals. Exploring DBT treatment response across the full spectrum of genders will facilitate the provision of more tailored, impactful care to all individuals who suffer from BPD.

Key learning aims

  1. (1) To date, DBT treatment literature has focused almost exclusively on cisgender women, with only two of 253 DBT studies in current literature accounting for transgender and gender diverse (TGD) individuals.

  2. (2) Recognize how gender minority stress may impact the prevalence of BPD among TGD individuals.

  3. (3) Learn how future research initiatives can be employed to rectify this gap in the DBT literature.

Keywords

borderline personality disorderdialectical behaviour therapygender minority stresstransgender and gender diverse
Type
Empirically Grounded Clinical Guidance Paper
Information
the Cognitive Behaviour Therapist , Volume 15 , 2022 , e30
Copyright
© The Author(s), 2022. Published by Cambridge University Press on behalf of the British Association for Behavioural and Cognitive Psychotherapies

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References

Further reading

Goldhammer, H., Crall, C., & Keuroghlian, A. S. (2019). Distinguishing and addressing gender minority stress and borderline personality symptoms. Harvard Review of Psychiatry, 27, 317–325. https://doi.org/10.1097/HRP.0000000000000234 CrossRefGoogle ScholarPubMed
Sloan, C. A., Berke, D. S., & Shipherd, J. C. (2017). Utilizing a dialectical framework to inform conceptualization and treatment of clinical distress in transgender individuals, Psychology: Research, Theory, and Practice, 48, 301–309. https://doi.org/10.1037/pro0000146 Google Scholar
Testa, R. J., Habarth, J., Peta, J., Balsam, K. & Bockting, W. (2015). Development of the gender minority stress and resilience measure. Psychology of Sexual Orientation and Gender Diversity, 2, 65–77. https://doi.org/10.1037/sgd0000081 CrossRefGoogle Scholar
Wupperman, P., & Edwards, E. (2017). Dialectical behavior therapy and gender. In Nadal, K. (ed), The SAGE Encyclopedia of Psychology and Gender (pp. 447–451). Thousand Oaks, CA, USA: SAGE Publications, Inc. https://doi.org/10.4135/9781483384269.n146 Google Scholar

References

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th edn). Washington, DC, USA.Google Scholar
Anzani, A., Panfilis, C. D., Scandurra, C., & Prunas, A. (2020). Personality disorders and personality profiles in a sample of transgender individuals requesting gender-affirming treatments. International Journal of Environmental Research and Public Health, 17, 1521. https://doi.org/10.3390/ijerph17051521 CrossRefGoogle Scholar
Aparicio-García, M. E., Díaz-Ramiro, E. M., Rubio-Valdehita, S., López-Núñez, M. I., & García-Nieto, I. (2018). Health and well-being of cisgender, transgender and non-binary young people. International Journal of Environmental Research and Public Health, 15, 2133. https://doi.org/10.3390/ijerph15102133 CrossRefGoogle ScholarPubMed
Barnow, S., Herpertz, S. C., Spitzer, C., Stopsack, M., Preuss, U. W., Grabe, H. J., … & Freyberger, H. J. (2007). Temperament and character in patients with borderline personality disorder taking gender and comorbidity into account. Psychopathology, 40, 369–378. https://doi.org/10.1159/000106467 CrossRefGoogle ScholarPubMed
Becker, D. (2019). Through the Looking Glass: Women and Borderline Personality Disorder. New York, USA: Routledge.10.4324/9780429495656CrossRefGoogle Scholar
Bjorklund, P. (2006). No man’s land: gender bias and social constructivism in the diagnosis of borderline personality disorder. Issues in Mental Health Nursing, 27, 3–23. https://doi.org/10.1080/01612840500312753 CrossRefGoogle Scholar
Busa, S., Janssen, A., & Lakshman, M. (2018). A review of evidence-based treatments for transgender youth diagnosed with social anxiety disorder. Transgender Health, 3, 27–33. https://doi.org/10.1089/trgh.2017.0037 CrossRefGoogle ScholarPubMed
Canadian Institutes of Health Research (2020). What is Sex? What is Gender? Retrieved from: https://cihr-irsc.gc.ca/e/48642.html Google Scholar
Chanen, A. M., Jovev, M., McCutcheon, L. K., Jackson, H. J., & McGorry, P. D. (2008). Borderline personality disorder in young people and the prospects for prevention and early intervention. Current Psychiatry Reviews, 4, 48–57. https://doi.org/10.2174/157340008783743820 CrossRefGoogle Scholar
Chapman, A. L. (2006). Dialectical behavior therapy: current indications and unique elements. Psychiatry, 3, 62.Google ScholarPubMed
Chaput, Y. J., & Lebel, M. J. (2007). Demographic and clinical profiles of patients who make multiple visits to psychiatric emergency services. Psychiatric Services, 58, 335–341. https://doi.org/10.1176/appi.ps.58.3.335 CrossRefGoogle ScholarPubMed
Chodzen, G., Hidalgo, M. A., Chen, D., & Garofalo, R. (2019). Minority stress factors associated with depression and anxiety among transgender and gender-nonconforming youth. Journal of Adolescent Health, 64, 467–471. https://doi.org/10.1016/j.jadohealth.2018.07.006 CrossRefGoogle ScholarPubMed
Choi-Kain, L. W., Finch, E. F., Masland, S. R., Jenkins, J. A., & Unruh, B. T. (2017). What works in the treatment of borderline personality disorder. Current Behavioral Neuroscience Reports, 4, 21–30. https://doi.org/10.1007/s40473-017-0103-z CrossRefGoogle ScholarPubMed
Cole, C. M., O’Boyle, M., Emory, L. E., & Meyer, III, W. J. (1997). Comorbidity of gender dysphoria and other major psychiatric diagnoses. Archives of Sexual Behavior, 26, 13–26.10.1023/A:1024517302481CrossRefGoogle ScholarPubMed
Cook, N. E., & Gorraiz, M. (2016). Dialectical behavior therapy for nonsuicidal self-injury and depression among adolescents: preliminary meta-analytic evidence. Child and Adolescent Mental Health, 21, 81–89. https://doi.org/10.1111/camh.12112 CrossRefGoogle ScholarPubMed
Craig, S. L., & Austin, A. (2016). The AFFIRM open pilot feasibility study: a brief affirmative cognitive behavioral coping skills group intervention for sexual and gender minority youth. Children and Youth Services Review, 64, 136–144. https://doi.org/10.1016/j.childyouth.2016.02.022 CrossRefGoogle Scholar
Dimeff, L., & Linehan, M. M. (2001). Dialectical behavior therapy in a nutshell. The California Psychologist, 34, 10–13.Google Scholar
Duišin, D., Batinić, B., Barišić, J., Djordjevic, M. L., Vujović, S., & Bizic, M. (2014). Personality disorders in persons with gender identity disorder. The Scientific World Journal. https://doi.org/10.1155/2014/809058 CrossRefGoogle ScholarPubMed
Ellison, W. D., Rosenstein, L. K., Morgan, T. A., & Zimmerman, M. (2018). Community and clinical epidemiology of borderline personality disorder. Psychiatric Clinics, 41, 561–573. https://doi.org/10.1016/j.psc.2018.07.008 Google ScholarPubMed
Flentje, A. (2019). AWARENESS: development of a cognitive-behavioral intervention to address intersectional minority stress for sexual minority men living with HIV who use substances. Psychotherapy, 57, 35. https://doi.org/10.1037/pst0000243 CrossRefGoogle ScholarPubMed
Ford, J. D., & Courtois, C. A. (2021). Complex PTSD and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation, 8, 1–21. https://doi.org/10.1186/s40479-021-00155-9 CrossRefGoogle ScholarPubMed
Fowler, J. C., Carlson, M., Orme, W. H., Allen, J. G., Oldham, J. M., Madan, A., & Frueh, B. C. (2020). Diagnostic accuracy of DSM-5 borderline personality disorder criteria: toward an optimized criteria set. Journal of Affective Disorders, 279, 203–207. https://doi.org/10.1016/j.jad.2020.09.138 CrossRefGoogle ScholarPubMed
Garland, J., & Miller, S. (2020). Borderline personality disorder: Part 1 – assessment and diagnosis. BJPsych Advances, 26, 159–172. doi: 10.1192/bja.2019.76 CrossRefGoogle Scholar
Gill, D., & Warburton, W. (2014). An investigation of the biosocial model of borderline personality disorder. Journal of Clinical Psychology, 70, 866–873. https://doi.org/10.1002/jclp.22074 CrossRefGoogle ScholarPubMed
Goldhammer, H., Crall, C., & Keuroghlian, A. S. (2019). Distinguishing and addressing gender minority stress and borderline personality symptoms. Harvard Review of Psychiatry, 27, 317–325. https://doi.org/10.1097/HRP.0000000000000234 CrossRefGoogle ScholarPubMed
Goodman, M., Patil, U., Steffel, L., Avedon, J., Sasso, S., Triebwasser, J., & Stanley, B. (2010). Treatment utilization by gender in patients with borderline personality disorder. Journal of Psychiatric Practice, 16, 155–163. https://doi.org/10.1097/01.pra.0000375711.47337.27 CrossRefGoogle ScholarPubMed
Griffin, J. A., Casanova, T. N., Eldridge-Smith, E. D., & Stepleman, L. M. (2019). Gender minority stress and health perceptions among transgender individuals in a small metropolitan southeastern region of the United States. Transgender Health, 4, 247–253. https://doi.org/10.1089/trgh.2019.0028 CrossRefGoogle Scholar
Hendricks, M. L., & Testa, R. J. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: an adaptation of the minority stress model. Professional Psychology, Research, and Practice, 43, 460–467. https://doi.org/10.1037/a0029597 CrossRefGoogle Scholar
Heylens, G., Elaut, E., Kreukels, B. P., Paap, M. C., Cerwenka, S., Richter-Appelt, H., … & De Cuypere, G. (2014). Psychiatric characteristics in transsexual individuals: multicentre study in four European countries. British Journal of Psychiatry, 204, 151–156. https://doi.org/10.1192/bjp.bp.112.121954 CrossRefGoogle ScholarPubMed
Huang, Y., Kotov, R., De Girolamo, G., Preti, A., Angermeyer, M., Benjet, C., … & Kessler, R. C. (2009). DSM-IV personality disorders in the WHO World Mental Health Surveys. British Journal of Psychiatry, 195, 46–53. https://doi.org/10.1192/bjp.bp.108.058552 CrossRefGoogle ScholarPubMed
Jablensky, A. (2016). Psychiatric classifications: validity and utility. World Psychiatry, 15, 26–31.10.1002/wps.20284CrossRefGoogle ScholarPubMed
Jäggi, T., Jellestad, L., Corbisiero, S., Schaefer, D. J., Jenewein, J., Schneeberger, A., … & Garcia Nuñez, D. (2018). Gender minority stress and depressive symptoms in transitioned Swiss transpersons. BioMed Research International, 2018, 1–10. https://doi.org/10.1155/2018/8639263 CrossRefGoogle ScholarPubMed
Johns, M. M., Lowry, R., Andrzejewski, J., Barrios, L. C., Demissie, Z., McManus, T., … & Underwood, J. M. (2019). Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students – 19 states and large urban school districts, 2017. Morbidity and Mortality Weekly Report, 68, 67–71. https://doi.org/10.15585/mmwr.mm6803a3 CrossRefGoogle Scholar
Koerner, K., & Linehan, M. M. (1997). Case formulation in dialectical behavior therapy for borderline personality disorder. Handbook of Psychotherapy Case Formulation, pp. 340–367. New York, USA: Guilford Press.Google Scholar
Korpaisarn, S., & Safer, J. D. (2018). Gaps in transgender medical education among healthcare providers: a major barrier to care for transgender persons. Reviews in Endocrine and Metabolic Disorders, 19, 271–275. https://doi.org/10.1007/s11154-018-9452-5 CrossRefGoogle Scholar
Korzekwa, M. I., Dell, P. F., Links, P. S., Thabane, L., & Webb, S. P. (2008). Estimating the prevalence of borderline personality disorder in psychiatric outpatients using a two-phase procedure. Comprehensive Psychiatry, 49, 380–386. https://doi.org/10.1016/j.comppsych.2008.01.007 CrossRefGoogle ScholarPubMed
Lenzenweger, M. F., Lane, M. C., Loranger, A. W., & Kessler, R. C. (2007). DSM-IV personality disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 62, 553–564. https://doi.org/10.1016/j.biopsych.2006.09.019 CrossRefGoogle ScholarPubMed
Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, USA: Guilford Press.Google Scholar
Linehan, M. M., Korslund, K. E., Harned, M. S., Gallop, R. J., Lungu, A., Neacsiu, A. D., … & Murray-Gregory, A. M. (2015). Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis. JAMA Psychiatry, 72, 475–482. https://doi.org/10.1001/jamapsychiatry.2014.3039.CrossRefGoogle ScholarPubMed
Lykens, J. E., LeBlanc, A. J., & Bockting, W. O. (2018). Healthcare experiences among young adults who identify as genderqueer or nonbinary. LGBT Health, 5, 191–196. https://doi.org/10.1089/lgbt.2017.0215 CrossRefGoogle ScholarPubMed
Madeddu, F., Prunas, A., & Hartmann, D. (2009). Prevalence of Axis II disorders in a sample of clients undertaking psychiatric evaluation for sex reassignment surgery. Psychiatric Quarterly, 80, 261–267. https://doi.org/10.1007/s11126-009-9114-6 CrossRefGoogle Scholar
Meaney, R., Hasking, P., & Reupert, A. (2016). Prevalence of borderline personality disorder in university samples: systematic review, meta-analysis and meta-regression. PloS One, 11, e0155439. https://doi.org/10.1371/journal.pone.0155439 CrossRefGoogle ScholarPubMed
Meybodi, A. M., Hajebi, A., & Jolfaei, A. G. (2014). The frequency of personality disorders in patients with gender identity disorder. Medical Journal of the Islamic Republic of Iran, 28, 90.Google ScholarPubMed
Nolen-Hoeksema, S. (2012). Emotion regulation and psychopathology: the role of gender. Annual Review of Clinical Psychology, 8, 161–187. https://doi.org/10.1146/annurev-clinpsy-032511-143109 CrossRefGoogle ScholarPubMed
Pachankis, J. E., Hatzenbuehler, M. L., Rendina, H. J., Safren, S. A., & Parsons, J. T. (2015). LGB-affirmative cognitive-behavioral therapy for young adult gay and bisexual men: a randomized controlled trial of a transdiagnostic minority stress approach. Journal of Consulting and Clinical Psychology, 83, 875. https://doi.org/10.1037/ccp0000037 CrossRefGoogle ScholarPubMed
Panos, P. T., Jackson, J. W., Hasan, O., & Panos, A. (2014). Meta-analysis and systematic review assessing the efficacy of dialectical behavior therapy (DBT). Research on Social Work Practice, 24, 213–223. https://doi.org/10.1177/1049731513503047 CrossRefGoogle Scholar
Reisner, S. L., White Hughto, J. M., Gamarel, K. E., Keuroghlian, A. S., Mizock, L., & Pachankis, J. E. (2016). Discriminatory experiences associated with posttraumatic stress disorder symptoms among transgender adults. Journal of Counseling Psychology, 63, 509. https://doi.org/10.1037/cou0000143 CrossRefGoogle ScholarPubMed
Rider, G. N., McMorris, B. J., Gower, A. L., Coleman, E., Brown, C., & Eisenberg, M. E. (2019). Perspectives from nurses and physicians on training needs and comfort working with transgender and gender-diverse youth. Journal of Pediatric Health Care, 33, 379–385. https://doi.org/10.1016/j.pedhc.2018.11.003 CrossRefGoogle ScholarPubMed
Safer, J. D. (2016). The large gaps in transgender medical knowledge among providers must be measured and addressed. Endocrine Practice, 22, 902. https://doi.org/10.4158/EP161388.CO CrossRefGoogle ScholarPubMed
Safer, J. D., Coleman, E., Feldman, J., Garofalo, R., Hembree, W., Radix, A., & Sevelius, J. (2016). Barriers to healthcare for transgender individuals. Current Opinion in Endocrinology, Diabetes, and Obesity, 23, 168–171. https://doi.org/10.1097/MED.0000000000000227 CrossRefGoogle ScholarPubMed
Sansone, R. A., & Sansone, L. A. (2011). Gender patterns in borderline personality disorder. Innovations in Clinical Neuroscience, 8, 16–20.Google ScholarPubMed
Shipherd, J. C., Maguen, S., Skidmore, W. C., & Abramovitz, S. M. (2011). Potentially traumatic events in a transgender sample: Frequency and associated symptoms. Traumatology, 17, 56–67. https://doi.org/10.1177/1534765610395614.CrossRefGoogle Scholar
Sloan, C. A., Berke, D. S., & Shipherd, J. C. (2017). Utilizing a dialectical framework to inform conceptualization and treatment of clinical distress in transgender individuals, Psychology: Research, Theory, and Practice, 48, 301–309. https://doi.org/10.1037/pro0000146 Google Scholar
Stoffers-Winterling, J. M., Voellm, B. A., Rücker, G., Timmer, A., Huband, N., & Lieb, K. (2012). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews, 2012. https://doi.org/10.1002/14651858.CD005652.pub2 Google Scholar
Tadić, A., Wagner, S., Hoch, J., Başkaya, Ö., Von Cube, R., Skaletz, C., … & Dahmen, N. (2009). Gender differences in axis I and axis II comorbidity in patients with borderline personality disorder. Psychopathology, 42, 257–263. https://doi.org/10.1159/000224149 Google ScholarPubMed
Tan, K. K., Treharne, G. J., Ellis, S. J., Schmidt, J. M., & Veale, J. F. (2019). Gender minority stress: a critical review. Journal of Homosexuality, 67, 1471–1489. https://doi.org/10.1080/00918369.2019.1591789 CrossRefGoogle ScholarPubMed
Testa, R. J., Habarth, J., Peta, J., Balsam, K. & Bockting, W. (2015) Development of the gender minority stress and resilience measure. Psychology of Sexual Orientation and Gender Diversity, 2, 65–77. https://doi.org/10.1037/sgd0000081 CrossRefGoogle Scholar
Tomko, R. L., Trull, T. J., Wood, P. K., & Sher, K. J. (2014). Characteristics of borderline personality disorder in a community sample: comorbidity, treatment utilization, and general functioning. Journal of Personality Disorders, 28, 734–750. https://doi.org/10.1521/pedi_2012_26_093 CrossRefGoogle Scholar
Wetterborg, D., Dehlbom, P., Långström, N., Andersson, G., Fruzzetti, A. E., & Enebrink, P. (2020). Dialectical behavior therapy for men with borderline personality disorder and antisocial behavior: a clinical trial. Journal of Personality Disorders, 34, 22–39. https://doi.org/10.1521/pedi_2018_32_379 CrossRefGoogle ScholarPubMed
Wupperman, P. & Edwards, E. (2017). Dialectical behavior therapy and gender. In Nadal, K. (ed.), The SAGE Encyclopedia of Psychology and Gender (pp. 447–451). Thousand Oaks, CA, USA: SAGE Publications, Inc. https://doi.org/10.4135/9781483384269.n146 Google Scholar
Zimmerman, M., Chelminski, I., & Young, D. (2008). The frequency of personality disorders in psychiatric patients. Psychiatric Clinics of North America, 31, 405–420. https://doi.org/10.1016/j.psc.2008.03.015 CrossRefGoogle ScholarPubMed
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