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Dialectical Behavioral Therapy Programs - CAM 395

Description
PURPOSE 
To provide parameters to assist staff with review of benefit requests for Dialectical Behavioral Therapy (DBT) programs and to ensure benefit coverage is applied in a consistent manner. This document is not a standard of care, but is developed utilizing industry standard guidelines, peer reviewed literature and current evidence-based recommendations. 

This document addresses DBT programs and not DBT therapy that is a component of another program such as intensive outpatient treatment or individual outpatient counseling.

DESCRIPTION
Dialectical Behavioral Therapy is a program for patients who suffer from severe symptoms that include dysregulation in emotion, behaviors, relationships, cognition and sense of self. These symptoms may be favorably modified by learning the DBT core skills of mindfulness, interpersonal effectiveness, emotional regulation and distress tolerance. DBT was originally developed for the treatment of individuals with Borderline Personality Disorder (BPD). It has also been proposed as a treatment for other disorders including mood disorders, post-traumatic stress disorder, substance use disorders and eating disorders. However, additional research support is needed for these diagnoses. 

Criteria for borderline personality disorder (DSM-5 code 301.83, F60.3) is defined in Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, (DSM-5) as: 

“A pervasive pattern of instability of interpersonal relationships, self-image, and affects and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by 5 (or more) of the following: 

  1. Frantic efforts to avoid real or imagined abandonment (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) 
  2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 
  3. Identity disturbance: markedly and persistently unstable self-image or sense of self 
  4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.) 
  5. Recurrent suicidal behavior, gestures and/or threats or self-mutilating behavior. 
  6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).2 
  7. Chronic feelings of emptiness. 
  8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms excluding suicidal or self-mutilating behavior. 

Dialectal Behavioral Therapy Program
According to American Psychiatric Association guidelines, DBT consists of approximately 1 year of manual-guided therapy, which includes 1 hour weekly individual therapy for 1 year and 2.5 hours of group skills training per week for 6-12 months. 

There is also a requirement for all therapists to meet weekly for team consultation. 

Skills training is taught in a series of 4 modules: Emotional Regulation, Interpersonal Effectiveness, Distress Tolerance and Mindfulness.

CLINICAL GUIDELINES   
The effectiveness of DBT has been established. It is a useful therapeutic option for the treatment of individuals with Borderline Personality Disorder. 

Admission Criteria: (Must meet all)

  1. Patients who are at least 15 years old with a primary diagnosis of BPD (or BPD traits if an adolescent) documented by mental health providers in the preceding one year.
  2. An evaluation by a mental health provider provided to CBA that includes all of the following: 
    1. Symptoms of NSSI, chronic suicidal ideation, frequent/chronic urges to self-injure.
    2. Quality of the individual’s relationships, frustration tolerance, and emotional reactivity.
    3. Response to current and previous outpatient treatment, to include the patient’s ability to respond to therapeutic strategies and the ability to remain in treatment.
    4. History of psychiatric hospitalizations, treatment in partial hospitalizations and/or intensive outpatient treatment programs.  
  3. Severe behaviors and symptoms occurring over the previous 12 months (such as NSSI, chronic suicidal ideations, suicide attempts, or parasuicidal behavior).
  4. The psychiatric symptoms have directly resulted in significant impairment in at least one of the following areas:
    1. Family
    2. Work/school
    3. Social/interpersonal
    4. Health/medical compliance 
  5. Measurable progress is expected as compared to the patient's baseline level of functioning prior to the DBT intervention. Examples of measureable progress may include but not limited to: 
    1. Decrease in number of treatment episodes in a more restrictive treatment setting. 
    2. Decreased self-destructive behaviors. 
    3. Decrease in psychiatric symptoms with increased functioning in activities of daily living. 

REFERENCES

  1. Adrian M, McCauley E, Berk MS, Asarnow JR, Korslund K, Avina C, Gallop R, Linehan MM. (2019). Predictors and moderators of recurring self-harm in adolescents participating in a comparative treatment trial of psychological interventions. J Child Psychol Psychiatry. 60(10):1123-1132. 
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders-5 . Washington, DC.
  3. American Psychiatric Association, “Guideline watch practice guideline for the treatment of patients with borderline personality disorder,” March 2005; http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bpd/watch.pdf.  Accessed August 29, 2023. 
  4. American Psychiatric Association, “Practice guideline for the treatment of patients with borderline personality disorder,” October 2001; http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bpd.pdf. accessed August 29, 2023.
  5. Chapman AL. (2006). Dialectical behavior therapy: current indications and unique elements. Psychiatry. 3(9):62-68.
  6. Cunningham K, Wolbert R, & Lillie, B. (2004). It’s about me solving my problems: Client’s assessments of dialectical behavior therapy. Cognitive and Behavioral Practice. 11(2):248-256.
  7. Dimeff L A, & Linehan MM. (2008). Dialectical behavior therapy for substance abusers. Addiction science & clinical practice. 4(2):39–47. 
  8. Fassbinder E, Assmann N, Schaich A, et al. (2018). PRO*BPD: effectiveness of outpatient treatment programs for borderline personality disorder: a comparison of Schema therapy and dialectical behavior therapy: study protocol for a randomized trial. BMC Psychiatry. 18(1):341. Published 2018 Oct 19. doi:10.1186/s12888-018-1905-6
  9. Katz LY & Cox BJ. (2002). Dialectical behavior therapy for suicidal adolescent inpatients. Clinical Case Studies. 1(1):81-92. 
  10. Koons C, Robins CJ, Tweed JL, Lynch TR, Gonzelez AM, Morese JQ, et al. (2001). Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy. 32:371-390. 
  11. Laurence Y, Gunasekara S, & Miller AL. (2002). Dialectical behavior therapy for inpatient and outpatient parasuicidal adolescents. Adolescent Psychiatry. 26:161-178. 
  12. Levenduski PG. (2000). Dialectical behavior therapy: So far so soon. Clinical Psychology. 7(1):99-100. 
  13. Linehan MM. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: The Guilford Press.
  14. Linehan MM. (2015). DBT skills training manual 2015. New York, NY: The Guilford Press.
  15. Linehan MM. (2000). The empirical basis of dialectical behavior therapy: Development of new treatments versus evaluation of existing treatment. Clinical Psychology. 7(1):113-119. 
  16. Lineham MM, Armstrong HE, Suarez A, Allmon D, & Heard HL. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry. 48(12):1060-1064.
  17. Linehan MM, et al. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy versus therapy by experts for suicidal behaviors and borderline personality disorder. Arch General Psychiatry. 63:757-66.
  18. Linehan MM, Cochran BN, & Kehrer CA. (2001). Dialectical behavior therapy for borderline personality disorder. In David H. Barlow (Ed.). Clinical handbook of psychological disorders: A step-by-step treatment manual 3:470-522. 
  19. McCauley E, Berk MS, Asarnow JR, Adrian M, Cohen J, Korslund K, Avina C, Hughes J, Harned M, Gallop R, Linehan MM. (2018). Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk for Suicide: A Randomized Clinical Trial. JAMA Psychiatry. 2018 Aug 1;75(8):777-785. doi: 10.1001/jamapsychiatry.2018.1109. Erratum in: JAMA Psychiatry. 2018 Aug 1;75(8):867.
  20. McMain SF, et al. (2018). The effectiveness of 6 versus 12-months of dialectical behaviour therapy for borderline personality disorder: the feasibility of a shorter treatment and evaluating responses (FASTER) trial protocol. BMC Psychiatry. 2018 Jul;18(1):230.
  21. National Institute for Health and Clinical Excellence (NICE). Borderline personality disorder: recognition and management. CG78. 2009 Jan, updated 2018 Aug [https://www.nice.org.uk/guidance/cg78] accessed 8/22/18.
  22. Perseius KI, Ojehagen A, Ekdahl S, Asberg M, & Samuelsson M. (2003). Treatment of suicidal and deliberate self-harming patients with borderline personality disorder using dialectical behavior therapy: The patients’ and the therapists’ perceptions. Archives of Psychiatric Nursing. 17(5):218-227. 
  23. Rathus J and Miller A. DBT skills manual for adolescents. 2015. New York, NY: The Guilford Press.
  24. Robins CJ, & Chapman AL. (2004). Dialectical behavior therapy: Current status, recent developments, and future directions. Journal of Personality Disorders. 18(1):73-89. 
  25. Robins CJ, Ivanoff AM, & Linehan MM. (2001). Dialectical behavior therapy. In W. John Livesley (Ed.). Handbook of personality disorders: Theory, research, and treatment (pp. 437-459). New York: The Guilford Press. 
  26. Safer DL, et al. Dialectical behavior therapy for bulimia nervosa. Amer J Psychiatry. 2001;158:632-4.
  27. Sinnaeve R, et al. Effectiveness of step-down versus outpatient dialectical behavior therapy for patients with severe levels of borderline personality disorder: a pragmatic randomized controlled trial. Borderline Personal Disord Emot Dysregul 2018 Jul;10(5):12.
  28. Turner RM. (2000). Understanding dialectical behavior therapy. Clinical Psychology. 7(1):95-98. 
  29. U.S. Preventive Services Task Force. Clinical summary: suicide risk in adolescents, adults, and older adults: screening. 2014 May. [https://www.uspreventiveservicestaskforce.org/Page/Document/ClinicalSummaryFinal/suicide-risk-in-adolescents-adults-and-older-adults-screening] accessed 08/22/18.
  30. Verheul R, et al. Dialectical behavior therapy for women with borderline personality disorder. Brit J Psychiatry. 2003;182:135-40. 
  31. Wilks CR, et al. A randomized controlled trial of an Internet delivered dialectical behavior therapy skills training for suicidal and heavy episodic drinkers. J Affect Disord. 2018 May;232:219-228.
  32. Warner N, Murphy M. Dialectical behavior therapy skills training for individuals with substance use disorder: A systematic review. Drug Alcohol Rev. 2022 Feb;41(2):501-516. doi: 10.1111/dar.13362. Epub 2021 Aug 1. PMID: 34337811.

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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08/14/2025 New Policy

 

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