Standard Research Article

Psychotherapy and
Psychosomatics Received: July 27, 2023
Psychother Psychosom
Accepted: March 9, 2024
DOI: 10.1159/000538404 Published online: June ▪▪▪, 2024

The Effectiveness of Dialectical Behavior Therapy

Compared to Schema Therapy for Borderline
Personality Disorder: A Randomized Clinical Trial
Nele Assmann a, b Anja Schaich a, b Arnoud Arntz c Till Wagner a

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Philipp Herzog a, d, e Daniel Alvarez-Fischer a, f Valerija Sipos a
Kamila Jauch-Chara a, b Jan Philipp Klein a Michael Hüppe g
Ulrich Schweiger a Eva Fassbinder a, b
a
Department of Psychiatry, Psychosomatics and Psychotherapy, University of Lübeck, Lübeck, Germany;
bDepartment of Psychiatry and Psychotherapy, Christian-Albrechts-Universität zu Kiel, Kiel, Germany;
c
Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands; dDepartment of
Psychology, Harvard University, Cambridge, MA, USA; eDepartment of Psychology, University of
Kaiserslautern–Landau, Landau, Germany; fInstitute of Neurogenetics, University of Lübeck, Lübeck, Germany;
g
Department of Anaesthesiology, University of Lübeck, Lübeck, Germany

Keywords Personality Disorder Severity Index at 1-year naturalistic

Borderline personality disorder · Randomized clinical trials · follow-up. Results: Between November 26, 2014, and De-
Effectiveness · Psychotherapy research · Treatment cember 14, 2018, we enrolled 164 patients (mean age = 33.7
outcome [SD = 10.61] years). Of these, 81 (49.4%) were treated with ST
and 83 (50.6%) with DBT, overall, 130 (79.3%) were female.
Intention-to-treat analysis with generalized linear mixed
Abstract models did not show a significant difference at 1-year
Introduction: In the treatment of borderline personality naturalistic follow-up between DBT and ST for the BPDSI
disorder (BPD), there is empirical support for both dialectical total score (mean difference 3.32 [95% CI: –0.58–7.22], p =
behavior therapy (DBT) and schema therapy (ST); these 0.094, d = −24 [–0.69; 0.20]) with lower scores for DBT. Pre-to-
treatments have never been compared directly. This study follow-up effect sizes were large in both groups (DBT: d =
examines whether either of them is more effective than the 2.45 [1.88–3.02], ST: d = 1.78 [1.26–2.29]). Conclusion: Pa-
other in treating patients with BPD. Methods: In this ran- tients in both treatment groups showed substantial im-
domized, parallel-group, rater-blind clinical trial, outpatients provements indicating that even severely affected patients
aged between 18 and 65 years with a primary diagnosis of with BPD and various comorbid disorders can be treated
BPD were recruited in a tertiary outpatient treatment center successfully with DBT and ST. An additional non-inferiority
(Lübeck, Germany). Participants were randomized to DBT or trial is needed to show if both treatments are equally
ST with one individual and one group session per week over
1.5 years. The primary outcome was the BPD symptom
severity assessed with the mean score of the Borderline Nele Assmann and Anja Schaich share first authorship.

[email protected] © 2024 The Author(s). Correspondence to:

www.karger.com/pps Published by S. Karger AG, Basel Nele Assmann, nele.assmann @ uksh.de

This article is licensed under the Creative Commons Attribution-

NonCommercial 4.0 International License (CC BY-NC) (http://www.
karger.com/Services/OpenAccessLicense). Usage and distribution for
commercial purposes requires written permission.
effective. The trial was retrospectively registered on the self-harm, and dissociation better and faster than ST. At
German Clinical Trials Register, DRKS00011534 without the same time, ST would be better in improving the
protocol changes. © 2024 The Author(s). quality of life and reducing general symptom severity and
Published by S. Karger AG, Basel depressive symptomatology (see study protocol for a
detailed explanation [18]).

Introduction
Materials and Methods
Several psychotherapy methods are available for
treating borderline personality disorder (BPD) with Study Design
good empirical evidence [1–3], and international The PRO*BPD study design is a single-center randomized
clinical trial. The recruitment of participants took place in a
guidelines highly recommend disorder-specific psy- tertiary outpatient treatment center of a university clinic affiliated
chotherapy for patients suffering from BPD [4–6]. Two with inpatient treatment in Lübeck, Germany, mainly treating
of the most established treatments include dialectical severely affected patients who cannot receive treatment elsewhere

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behavior therapy (DBT) [7, 8] and schema therapy (ST) or cannot sufficiently be treated by practitioners in private
[9, 10]. DBT is the most frequently studied treatment for practices. The PRO*BPD study was designed in adherence to the
Consolidated Standards of Reporting Trials (CONSORT) guide-
BPD, and its effectiveness has been demonstrated in lines and methodology [23] and follows methodological recom-
several randomized controlled trials (RCTs) [2, 3]. Even mendations for trials of psychological interventions [24] (sum-
though ST is less often studied so far, there are prom- marized in online suppl. Table S1; for all online suppl. material, see
ising results from two large [11, 12] and one small https://doi.org/10.1159/000538404). The planned sample size was
randomized trial [13] as well as studies in routine care N = 160 based on a power analysis (power 80%; medium effect size,
α = 0.05, n = 128) and taking attrition (20%, n = 32) into account
[14–16]. [25]. Details about the study design are published in the study
DBT and ST have never been compared in a ran- protocol [18].
domized trial so far. Overall, there is a need for com-
parative clinical trials. Comparing the effectiveness of Participants
BPD treatments may improve patients’ informed choices Patients were eligible when they (1) were between 18 and
and guide decision-making about which treatments to 65 years of age, (2) had a primary diagnosis of BPD (diagnosed
with the Structural Clinical Interview for DSM-IV for Axis II;
prioritize in health care systems [17]. SCID-II-Interview) [26], (3) had a BPD severity score >20 points
The programs for BPD (PRO*BPD) study is the first on the Borderline Personality Disorder Severity Index (BPDSI),
randomized trial to compare the effectiveness of ST and Version 4 [27], (4) gave informed consent, and (5) were able and
DBT in patients with BPD [18]. It was implemented into a willing to participate reliably in therapy and assessment pro-
routine tertiary care setting of an outpatient clinic affil- cedures. Exclusion criteria were (1) a lifetime diagnosis of a
psychotic disorder, (2) intellectual deficits (IQ <85), (3) poor
iated with inpatient services. This outpatient service was German language skills, and (4) acute substance use disorder
explicitly set up to treat severely affected patients with that required detoxification treatment. Participation was pos-
BPD who are repeatedly seen in emergency rooms or sible after completing detoxification treatment and 4 weeks of
would otherwise be treated in inpatient settings. Research abstinence. Participants with cannabis dependence could par-
in this population is fundamental considering that BPD is ticipate if they committed to working on abstinence during
treatment.
associated with high societal costs [19–22], primarily
caused by inpatient treatment. Randomization and Masking
The primary hypothesis was that BPD associated Randomization was conducted by Prof. Michael Hüppe, who
symptoms differ between DBT and ST at the 1-year was not involved in the data collection and therapy using the
naturalistic follow-up. Since information from litera- program BiaS (11.02) [28]. After completing the baseline assess-
ture does not allow predictions on the directionality of the ment, participants were randomized to the two conditions (ST or
DBT). Randomization was stratified by sex to avoid biases due to
difference, a two-sided hypothesis was chosen. Secondary unbalanced sex distribution. The allocation sequence was con-
outcomes included treatment retention, general symptom cealed from both participants and researchers. Raters were blind to
severity, depression, dissociation, quality of life, psy- the assignment; participants were informed about their condition
chosocial functioning, and participation. In addition, during the first therapy session.
based on former research and theoretical considerations
Procedure
regarding DBT and ST, secondary hypotheses were Participants completed assessments at baseline, 0.5 years after
formulated regarding differential effects in the secondary the start of treatment, one year after the start of treatment,
outcomes: We hypothesized that DBT reduces suicidality, posttreatment (1.5 years), and two naturalistic follow-up

2 Psychother Psychosom Assmann et al.

DOI: 10.1159/000538404
assessments (0.5 years and one year). In the following, the 1-year mission. Patients could also be “pushed out” of the treatment
follow-up assessment will be referred to as follow-up (primary program based on a decision of the therapist team and the local
outcome). Assessments included self-report measures and inter- supervisor [18]. We decided not to define explicit rules for a
views (conducted by blind and independent raters trained in the patient to be “pushed out” of both conditions. It should be
interviews). Due to a wide range of measures, the baseline as- noted that this is a difference from the standard DBT protocol
sessment consisted of three to four appointments with the patients [22]. In the PRO*BPD trial, a “push out” was always decided
and was scheduled within 3 months before the start of treatment. by the therapist team and the local supervisors and was
In case, there were more than 3 months between assessment of the consistent with the respective treatment manual except for the
primary outcome and start of treatment (due to availability of deviation mentioned above. After the end of study treatment,
treatment slots and missed appointments), the interview of the no further treatment was recommended. As it was a natu-
primary outcome was repeated. ralistic follow-up, further treatment was not prohibited but
registered at follow-up assessments. If needed, patients had
Outcomes the opportunity to see their former therapist monthly or less
The primary outcome was the severity of BPD assessed by the frequently. We had some deviations from our original protocol
total score of the BPDSI-IV at 1-year naturalistic follow-up. The due to the COVID-19 pandemic and therefore conducted a
BPDSI is a semi-structured interview including 70 items rating the sensitivity analysis excluding all participants affected by the

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frequency and severity of the nine BPD traits described in the pandemic (online suppl. material).
DSM-IV over the prior 3 months. The BPDSI is a reliable in-
strument with good psychometric qualities [29, 30]. In the present Therapists
study, the assessed interrater reliability was excellent (all intra-class Therapists were advanced DBT and ST therapists and thera-
correlation coefficients >0.997 [ICC], online suppl. material). In pists who were new to ST or DBT but were experienced in CBT,
addition, suicidality and the number of suicide attempts were with training before administering the treatment and learning the
identified using BPDSI data. An increase of 11.70 or more in the method under close supervision. Local and external certified
BPDSI total score compared to the baseline assessment was defined specialists trained therapists for the specific method in several
as deterioration [11]. workshops. They participated in weekly supervision sessions under
Secondary outcome measures included a self-rating the direction of the locally approved supervisors (DBT: VS, US, ST:
questionnaire of the burden experienced by BPD manifes- EF) and team meetings.
tations (BPD checklist) [31], the severity of depression (Quick
Inventory of Depressive Symptoms, QIDS-SR) [32], global Treatment Integrity
symptom severity (Brief Symptom Inventory, BSI) [33], All individual and group sessions were videotaped, and ad-
dissociation (Dissociation Tension Scale, DSS) [34], psy- herence and competence were rated in a random selection of
chosocial functioning and participation (World Health Or- session tapes from different treatment stages (each treatment stage
ganization Disability Assessment Schedule 2.0, WHODAS 2.0 6 months) by trained raters. The videos of the sessions were rated
[35] and Work and Social Adjustment Scale, WSAS [36]) and altogether after the end of the study treatment. Individual sessions
quality of life (World Health Organization Quality of Life were rated using an adapted version (May 2014) of the Therapy
questionnaire, WHOQOL) [37]. Comorbid mental disorders Adherence and Competence Scale for therapy of BPD by Young
were assessed using the German version of the SCID-I and II- et al. [41] which was also used in Giesen-Bloo et al. [11] and the
Interview [38, 39]. For further information on secondary Dialectical Behavior Therapy Adherence Checklist – Individual
outcomes, see online supplementary material. Psychophar- Therapy (DBT AC-I) observer-rated version [42]. The latter was
macological treatment and demographic parameters were also chosen because ratings with the originally planned DBT adherence
assessed. Treatment retention was also analyzed as a sec- manual [43] were only possible by DBT-specialists certified for this
ondary outcome. To register also unwanted iatrogenic effects and were not covered by the funding of our study. Adherence to ST
of psychotherapy, we recorded adverse events (inpatient group sessions was rated using a scale combining the Schema
treatment, suicide attempts, cases of death) and analyzed Therapist Competency Scale for individual therapy sessions
deterioration in the BPDSI. (STCS-I-1) [44] and the Group Schema Therapy Rating Scale
(GSTRS) and its revised version (GSTRS-R) [45]. Each item of the
Treatment scales was code 0/1 for adherence and 1–6 for competence. For the
Patients were randomized to DBT or ST; both included one DBT group sessions, there was no freely available rating scale.
individual session (60 min) and one group session (120 min) Ratings of DBT group sessions would have been available from
per week and followed a written protocol [7, 8, 10, 40]. Groups certified raters who did not participate in this study. Unfortu-
consisted of up to 10 BPD patients and two therapists and were nately, funding was not available for these ratings. Ten videos of
offered in a semi-open format. The start of the individual DBT group sessions were rated using the ST scale to ensure
therapy was planned four to 10 weeks before the beginning of discrimination. Details on the rater training can be found in the
group therapy. Eligible patients who could not attend group online supplementary material.
sessions due to family, professional, or educational duties were
provided weekly individual therapy only. The treatment du- Statistical Analysis
ration was 1.5 years. Patients could stop the treatment pro- Originally, the hypothesis that there is a difference between
gram prematurely and were considered as an “early success” if patients treated with DBT and ST regarding the reduction of
their BPDSI score was less than 15 and the therapist team BPD symptoms was operationalized as a difference between the
agreed that the patient should stop the program due to re- slopes over time (baseline to 1-year naturalistic follow-up) [18].

DBT versus Schema Therapy in Borderline Psychother Psychosom 3

Personality Disorder DOI: 10.1159/000538404
Due to unexpected baseline differences between DBT and ST The number of suicide attempts during the last 3 months
(especially self-rated BPD symptoms and depression, see online was analyzed using generalized estimating equations with a
suppl. Table S2), we had to adapt our analysis plan and had to Tweedie distribution (because of many zero counts) with a log
control for the baseline scores (see below and online suppl. link and first-order autoregression for the repeated part.
material). Moreover, controlling for baseline scores is recom- Treatment retention was analyzed using GLMM survival
mended independently from baseline differences [46]. As a analysis.
consequence, we had to change the operationalization of the Effect sizes were expressed as r for the fixed effects in the
primary hypothesis and tested the difference at 1-year natu- GLMM analyses and Cohen’s d as conventional within- and
ralistic follow-up. between-groups effect size. For a description of effect sizes, see
The statistical analyses were performed with SPSS, version 28. online supplementary material.
Data analyses followed the intention-to-treat (ITT) principle and Additionally, we conducted a completer analysis of the primary
used all available data. Patients were included in the ITT sample if outcome, including all patients that completed treatment after
they were randomized and attended at least one individual session 1.5 years or left the program earlier after remission. Further, we
where they were informed about treatment condition. Missing conducted a sensitivity analysis including only those patients who
values were not imputed as generalized linear mixed models received the combination of group and individual therapy. We also
(GLMMs) can validly estimate effects under the same assumptions conducted a sensitivity analysis following the original analytic plan

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as multiple imputation. including all assessment points and not controlling for baseline
A step-by-step report of the statistical analyses can be found in differences. Lastly, we conducted a sensitivity analysis excluding
the online supplementary material. Given skewed distributions, the medication covariate.
continuous outcome variables were analyzed with GLMM gamma
regression. As gamma regression cannot handle zeros, a small
value (0.01) was added to all scores, if zeros existed. Where es-
timation allowed, we included a random effect of the treatment
cohort to account for the fact that cohorts of patients participated Results
in group therapy together. Time was modeled according to the best
model fit, e.g., linear, logarithmic, or segmented development of Patient Flow and Sample Characteristics
scores over time. We used a piece-wise regression model if the Between November 26, 2014, and December 14, 2018,
primary inspection of the data indicated that change during 255 patients were screened for eligibility, and 164 were
treatment had a different slope than change during the naturalistic included in the PRO*BPD trial’s ITT sample of the
follow-up period, and a comparison of model fit confirmed this
impression. For piece-wise coded regression, we defined all as-
PRO*BPD trial. The last follow-up assessment was
sessments of the treatment phase as one section and the follow-up conducted on January 20, 2022. The CONSORT flow
assessments separately. As predefined in the study protocol, we diagram of participant recruitment is presented in
included the use of psychotropic medication as a running covariate Figure 1. Table 1 displays the demographic and clinical
coding the use for every assessment point. Since this can be characteristics of the ITT sample. The mean number of
discussed controversially, we conducted a sensitivity analyses sessions before the start of group therapy was M = 4.3
without the medication covariate. The covariance structure for the (DBT and ST), and the average number of individual
repeated part and time was modeled according to the best
model fit. sessions was M = 44.48 (DBT) and M = 46.7 (ST) for the
Additional covariates were included as we observed systematic intent-to-treat sample and M = 52.4 (DBT) and M = 52.1
baseline differences between ST and DBT in almost all outcome (ST) for the completer sample.
variables with higher scores for DBT patients (online suppl. Table
S2). We included a centered baseline global severity score based on Treatment Integrity
principal component analysis, including all outcome variables at
baseline and the number of comorbidities on axis I and II as well as
Overall, 500 videos out of 7,475 individual sessions
the centered baseline variable as a covariate and excluded the and 43 videos out of 436 group sessions were rated by
baseline assessment in the dependent time variable for all out- trained raters. The interrater reliability was assessed for
comes [46]. Therefore, the main effect of treatment after 1-year 20 ratings of individual sessions (ten ST and ten DBT)
naturalistic follow-up was the primary test of treatment differ- and 19 ratings of group sessions (ten ST and nine DBT).
ences. Thus, the fixed effects in the GLMM included time,
Interrater reliability showed to be very good both for
medication, treatment, and their interaction, as well as global
severity, and the particular baseline score was also included in the the ratings of the individual sessions (ICC between 0.88
fixed part. A further fixed effect of time piece-wise and its in- and 0.961) and for the ST ratings of the group sessions
teraction with treatment and medication were included if a piece- (ICCs between 0.991 and 0.992). There was significant
wise regression model was used. The exact configuration of the discrimination between ST and DBT at the ST, re-
GLMM for each outcome variable is specified in online supple- spectively, DBT adherence and competence scales (all
mentary Table S3 and a definition of all variables included in the
model can be found in online suppl. Table S4. For a detailed step- p < 0.009). ST group adherence and competence ratings
by-step description of the statistical analyses, refer to online also indicated a good differentiation between the
supplementary material. conditions (all p < 0.001).

4 Psychother Psychosom Assmann et al.

DOI: 10.1159/000538404
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Fig. 1. CONSORT diagram of participant flow.

Mean adherence to the respective manuals was 4.99 for DBT. Mean adherence in ST group therapy
93.33% in ST and 99.18% in DBT individual therapy. was 98.10%, and mean therapeutic competence
Mean therapeutic competence was 5.27 for ST and was 5.41.

DBT versus Schema Therapy in Borderline Psychother Psychosom 5

Personality Disorder DOI: 10.1159/000538404
Table 1. Descriptive statistics at baseline

Treatment condition

all (N = 164) DBT (n = 83) ST (n = 81)

Characteristic
Age, years, M (SD) 33.71 (10.61) 34.54 (11.15) 32.85 (10.01)
Gender, n (%)
Male 33 (20.1) 17 (20.5) 16 (19.8)
Female 130 (79.3) 66 (79.5) 64 (79.0)
Non-binary 1 (0.6) – 1 (1.2)
Relationship status, n (%)
Partner 82 (50.0) 41 (49.4) 41 (50.6)
No partner 82 (50.0) 42 (50.6) 40 (49.4)

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Education level, n (%)
No/primary education 9 (5.5) 5 (6.0) 4 (4.9)
Lower secondary education 92 (56.1) 46 (55.4) 46 (56.8)
Upper secondary education 49 (29.9) 26 (31.3) 23 (28.4)
Tertiary education 14 (8.5) 6 (7.2) 8 (9.9)
Ethnic background, n (%)
German 151 (92.1) 78 (94.0) 74 (91.4)
Different 12 (7.3) 5 (6.0) 7 (8.6)
Work status, n (%)
Working 20 (12.2) 7 (8.4) 13 (16.0)
Studying 17 (10.4) 7 (8.4) 10 (12.3)
Homemaker 12 (7.3) 6 (7.2) 6 (7.4)
Disability pension 41 (25.0) 22 (26.5) 19 (23.5)
Unable to work due to sick leave 44 (26.8) 25 (30.1) 19 (23.5)
Unemployed 15 (9.1) 8 (9.6) 7 (8.6)
Retirement pension 3 (1.8) 3 (3.6) –
Other 12 (7.3) 5 (6.0) 7 (8.6)
BPD severity
BPDSI at baseline, M (SD) 32.80 (8.71) 33.19 (9.38) 32.39 (8.01)
Number of BPD criteria (SKID-II) 7.26 (1.26) 7.23 (1.32) 7.30 (1.21)
Comorbid Disorders
Number of comorbid SCID-I diagnoses, M (SD) 3.99 (1.95) 4.12 (1.88) 3.85 (2.03)
Number of comorbid SCID-II diagnoses (excl. BPD), M (SD) 1.35 (1.12) 1.37 (1.06) 1.32 (1.18)
Comorbid personality disorders, n (%)
Paranoid personality disorder 37 (22.6) 17 (20.5) 20 (24.7)
Schizoid personality disorder 1 (0.6) – 1 (1.2)
Schizotypal personality disorder 6 (3.7) 3 (3.6) 3 (3.7)
Antisocial personality disorder 3 (1.8) 1 (1.2) 2 (2.5)
Histrionic personality disorder 12 (7.3) 9 (10.8) 3 (3.7)
Narcissistic personality disorder 13 (7.9) 4 (4.8) 9 (11.1)
Avoidant personality disorder 69 (42.1) 39 (47.0) 30 (37.0)
Dependent personality disorder 21 (12.8) 14 (16.9) 7 (8.6)
Obsessive-compulsive personality disorder 59 (36.0) 27 (32.5) 32 (39.5)
Comorbid disorders axis I, n (%)
Any comorbid axis I diagnosis 161 (98.2) 82 (98.8) 79 (97.5)
Affective disorders 108 (65.9) 59 (71.1) 49 (60.5)
Anxiety disorders 144 (87.8) 74 (89.2) 70 (86.4)
Somatic symptom disorder 21 (12.8) 11 (13.3) 10 (12.3)
Substance use disorder 51 (31.1) 24 (28.9) 27 (33.3)
Eating disorders 76 (46.3) 41 (49.4) 35 (43.2)

6 Psychother Psychosom Assmann et al.

DOI: 10.1159/000538404
Table 1 (continued)

Treatment condition

all (N = 164) DBT (n = 83) ST (n = 81)

Psychiatric medication1, n (%) 126 (76.8) 64 (77.1) 62 (76.5)

Previous treatment, n (%) 154 (93.9) 82 (98.8) 72 (88.9)
Previous psychotherapeutic treatment, n (%) 151 (92.1) 80 (96.4) 71 (87.7)
1
Including medication irregularly taken as needed.

Main Outcome 1-year naturalistic follow-up (Table 2). The within-group

The GLMM showed a significant reduction of BPD pre-follow-up effect sizes were large for the BPD

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severity measured by the BPDSI-IV total score over time Checklist, BSI, QIDS-SR, WSAS, and WHODAS and
(0.5 years to 1-year naturalistic follow-up) with large effect small to large for the DSS (Table 2) and the WHOQOL
sizes (pre-post and pre-follow-up) for both conditions subscales (online suppl. Table S7).
(Table 2; Fig. 2a). However, treatment had no significant
effect at 1-year naturalistic follow-up (t131 = 1.69, p = 0.94, Treatment Retention
d = −0.24 [−0.69; 0.20]). See online supplementary Table Figure 2b shows treatment retention during the
S5 for the effects of GLMM covariates on all outcomes. The 1.5 years treatment period. Deviation contrasts of the
completer and sensitivity analyses did not show different GLMM survival analysis showed that in the second
results (see online suppl. material). quarter, significantly more patients dropped out from
DBT, t 870 = −2.79, p = 0.005 (ST: 0% vs. DBT: 7.2%),
Secondary Outcomes whereas in the fifth quarter, significantly more pa-
BPDSI-Based Secondary Outcomes tients dropped out from ST t 870 = −2.21, p = 0.028
All BPDSI subscales except for (para)suicide showed (ST: 4.9% vs. DBT 0%). The overall dropout rate was
a significant reduction over time (0.5 years to 1-year 22.9% for DBT and 23.5% for ST also including few
naturalistic follow-up) (online suppl. Table S6). For “push-outs” (3.6% DBT; 1.2% ST). Details on reasons
this subscale, the within-group pre-follow-up effect for drop out can be found in online supplementary
sizes were also large in both conditions indicating a Table S8.
substantial improvement between baseline and
0.5 years which was not included in the GLMM. The Deterioration and Adverse Events
within-group pre-follow-up effect sizes for all other Deterioration was found in <1% of all assessments
subscales were large; only in the subscale anger the (0.74% DBT, 0.76% ST). For an overview of adverse
effect size in the ST condition was medium. This events during the study period, see online supplementary
subscale was the only one with a significant treatment material.
effect at 1-year naturalistic follow-up: patients in the
DBT condition had significantly lower scores at this Effects of Psychotropic Medication
time point. The proportion of patients taking psychotropic
The suicidality score showed no significant effects, and medication is descripted in online supplementary Table
the within-group pre-post effect sizes were medium in S9 separately for each assessment point and different
both conditions (online suppl. Table S6). For the number medication categories. The main effects and interactions
of suicide attempts in the last 3 months, there were also involving psychotropic medication in the GLMMs are
no significant effects. The within-group pre-follow-up reported in online supplementary Table S5 and in-
effect sizes were small to medium. terpreted in the online supplementary results.

Other Secondary Outcomes Treatment during the Naturalistic Follow-Up Phase

All GLMM of secondary outcomes showed a signifi- An overview of the treatments received during the
cant time effect (0.5 years to 1-year naturalistic follow- naturalistic follow-up period can be found in online
up), indicating improvement, but no effect of treatment at supplementary Table S8. Briefly, 3.0% (0.5 years) and

DBT versus Schema Therapy in Borderline Psychother Psychosom 7

Personality Disorder DOI: 10.1159/000538404
 8
Table 2. Estimated means, 95% CIs, and effect sizes for the primary and secondary outcomes and effects (time, time piece-wise, and treatment) of the GLMM

Estimated means (95% CI), effect size Cohen’s d Effects of the GLMMa

DBT ST between-group effect size db

[95% CI]

Outcome and M [95% CI] within-group effect M [95% CI] within-group effect observed estimated t df p r
time point size dc [95% CI] size dc [95% CI]

BPDSI total
Baseline M = 32.80e – Time −10.12 244 <0.001 0.54
0.5 years 25.20 [23.53; 1.00 [0.54; 1.45] 27.76 [25.98; 0.64 [0.19; 1.08] −0.24 −0.27 Time piece-wise 4.98 260 <0.001 0.29
26.99] 29.66] [−0.58; 0.10] [−0.61; 0.07]
1 year 21.21 [19.64; 1.70 [1.17; 2.17] 23.43 [21.71; 1.29 [0.81; 1.77] −0.04 −0.21 Treatment at 1.69 131 0.094 0.15
22.91] 25.28] [−0.39; 0.31] [−0.56; 0.14] 1-year FU

Psychother Psychosom
1.5 years 17.85 [16.02; 2.33 [1.77; 2.89] 19.77 [17.76; 1.94 [1.41; 2.47] −0.01 −0.17 Time × Treatment 0.08 245 0.936 <0.01

DOI: 10.1159/000538404
(post) 19.89] 22.01] [−0.40; 0.37] [−0.56; 0.22]
0.5 years FU 17.58 [15.78; 2.39 [1.83; 2.95] 20.20 [18.11; 1.86 [1.34; 2.38] −0.17 −0.19 Time piece-wise × 0.49 260 0.628 0.03
19.59] 22.53] [−0.59; 0.26] [−0.61; 0.24] Treatment
1 year FU 17.31 [15.03; 2.45 [1.88; 3.02] 20.63 [17.79; 1.78 [1.26; 2.29] −0.15 −0.24
19.94] 23.93] [−0.60; 0.30] [−0.69; 0.20]
BPD checklistd
Baseline M = 84.67e – Time −7.06 291 <0.001 0.38
0.5 years 61.92 [55.31; 0.94 [0.49; 1.39] 72.08 [64.39; 0.48 [0.04; 0.93] −0.03 −0.32 Treatment at 1.65 86 0.102 0.18
69.33] 80.70] [−0.39; 0.33] [−0.68; 0.04] 1-year FU
1 year 54.61 [49.14; 1.32 [0.84; 1.79] 64.51 [57.90; 0.82 [0.36; 1.27] −0.09 −0.26 Time × treatment 0.436 291 0.663 0.03
60.70] 71.87] [−0.47; 0.28] [−0.63; 0.12]
1.5 years 48.17 [42.89; 1.69 [1.19; 2.19] 57.73 [51.22; 1.15 [0.68; 1.62] −0.02 −0.20
(post) 54.10] 65.08] [−0.46; 0.42] [−0.64; 0.24]
0.5 years FU 42.48 [36.87; 2.07 [1.54; 2.60] 51.67 [44.66; 1.48 [0.99; 1.98] −0.19 −0.25
48.95] 59.78] [−0.66; 0.27] [−0.72; 0.22]
1 year FU 37.47 [31.40; 2.45 [1.88; 3.02] 46.24 [38.60; 1.82 [1.30; 2.33] −0.12 −0.25
44.70] 55.40] [−0.63; 0.38] [−0.76; 0.25]
DSS
Baseline M = 2.90e − Time −2.76 179 0.006 0.20
0.5 years 2.12 0.45 [0.01; 0.89] 2.40 0.27 [−0.17; 0.71] −0.07 −0.15 Treatment at 1.31 246 0.193 0.08
[1.73; 2.58] [1.99; 2.90] [−0.43; 0.28] [−0.50; 0.21] 1-year FU
1 year 1.82 0.67 [0.22; 1.11] 2.06 0.49 [0.05; 0.93] 0.13 −0.15 Time × treatment 0.48 178 0.633 0.04
[1.54; 2.16] [1.74; 2.43] [−0.24; 0.50] [−0.52; 0.23]

Assmann et al.
1.5 years 1.57 0.88 [0.43; 1.33] 1.76 0.71 [0.26; 1.16] −0.03 −0.11
(post) [1.27; 1.93] [1.42; 2.18] [−0.47; 0.42] [−0.56; 0.33]
0.5 years FU 1.57 0.88 [0.43; 1.33] 1.90 0.60 [0.16; 1.05] −0.09 −0.20
[1.30; 1.89] [1.57; 2.30] [−0.57; 0.40] [−0.68; 0.29]
1 year FU 1.57 0.88 [0.43; 1.33] 2.05 0.49 [0.05; 0.94] 0.12 −0.26
[1.23; 1.99] [1.57; 2.69] [−0.40; 0.63] [−0.78; 0.26]

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 Table 2 (continued)

Estimated means (95% CI), effect size Cohen’s d Effects of the GLMMa

DBT ST between-group effect size db

[95% CI]

Outcome and M [95% CI] within-group effect M [95% CI] within-group effect observed estimated t df p r

Personality Disorder
time point size dc [95% CI] size dc [95% CI]

BSI
Baseline M = 1.94e – Time −5.20 246 <0.001 0.31
0.5 years 1.64 0.44 [0.01; 0.88] 1.77 0.24 [−0.19; 0.68] 0.10 −0.16 Treatment at 1.45 147 0.150 0.12
[1.50; 1.79] [1.63; 1.92] [−0.25; 0.46] [−0.52; 0.19] 1-year FU
1 year 1.49 0.69 [0.25; 1.14] 1.64 0.44 [−0.00; 0.88] 0.08 −0.19 Time × treatment 0.71 245 0.481 0.05
[1.38; 1.61] [1.52; 1.77] [−0.29; 0.45] [−0.56; 0.19]

DBT versus Schema Therapy in Borderline

1.5 years 1.35 0.95 [0.49; 1.40] 1.53 0.63 [0.18; 1.07] 0.10 −0.15
(post) [1.23; 1.48] [1.39; 1.67] [−0.34; 0.55] [−0.60; 0.30]
0.5 years FU 1.23 1.20 [0.73; 1.66] 1.42 0.82 [0.37; 1.27] −0.07 −0.20
[1.09; 1.39] [1.25; 1.61] [−0.56; 0.41] [−0.68; 0.29]
1 year FU 1.11 1.45 [0.97; 1.93] 1.32 1.01 [0.55; 1.47] 0.05 −0.21
[0.95; 1.31] [1.12; 1.55] [−0.47; 0.57] [−0.73; 0.31]
QIDS−SR
Baseline M = 16.26e – Time −5.03 202 <0.001 0.33
0.5 years 14.27 [13.26; 0.42 [0.08; 0.76] 14.30 [13.33; 0.42 [0.08; 0.75] 0.20 −0.01 Treatment at 1.35 147 0.179 0.11
15.35] 15.33] [−0.16; 0.55] [−0.36; 0.35] 1-year FU
1 year 13.23. [12.33; 0.67 [0.31; 1.02] 13.67 [12.77; 0.56 [0.21; 0.90] 0.16 −0.08 Time × treatment 1.31 203 0.193 0.09
14.64] 14.64] [−0.22; 0.53] [−0.46; 0.29]
1.5 years 12.26 [11.30; 0.91 [0.52; 1.30] 13.08 [12.04; 0.70 [0.30; 1.10] 0.11 −0.08
(post) 13.30] 14.20] [−0.34; 0.55] [−0.53; 0.36]
0.5 years FU 11.36 [10.26; 1.16 [0.73; 1.57] 12.51 [11.25; 0.85 [0.41; 1.27] −0.07 −0.12
12.59] 13.90] [−0.55; 0.41] [−0.61; 0.36]
1 year FU 10.53 [9.27; 1.40 [0.96; 1.83] 11.96 [10.46; 0.99 [0.51; 1.46] 0.08 −0.18
11.97] 13.68] [−0.44; 0.60] [−0.7; 0.34]

Psychother Psychosom
DOI: 10.1159/000538404
WSAS
Baseline M = 23.59e – Time −2.39 411 0.018 0.12
0.5 years 18.93 [16.69; 0.67 [0.23; 1.11] 21.23 [18.75; 0.32 [−0.12; 0.76] 0.02 −0.19 Treatment at −0.10 273 0.924 0.01
21.48] 24.03] [−0.33; 0.38] [−0.55; 0.16] 1-year FU
1 year 18.45 [16.65; 0.75 [0.30; 1.19] 20.04 [18.08; 0.50 [0.05; 0.94] 0.10 −0.12 Time × treatment −0.89 412 0.374 0.04
20.11] 22.22] [−0.27; 0.48] [−0.50; 0.26]
1.5 years 17.97 [16.28; 0.83 [0.38; 1.28] 18.93 [17.07; 0.67 [0.22; 1.12] 0.19 −0.05
(post) 19.83] 20.99] [−0.26; 0.64] [−0.50; 0.40
0.5 years FU 17.51 [15.59; 0.91 [0.46; 1.36] 17.88 [15.76; 0.85 [0.22; 1.12] 0.12 −0.02
19.66] 20.25] [−0.36; 0.60] [−0.50; 0.45]
1 year FU 17.06 [14.72; 0.99 [0.53; 1.44] 16.88 [14.39; 1.02 [0.56; 1.48] 0.24 0.01
19.77] 19.80] [−0.28; 0.75] [−0.50; 0.53]

9
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 Table 2 (continued)

10
Estimated means (95% CI), effect size Cohen’s d Effects of the GLMMa

DBT ST between-group effect size db

[95% CI]

Outcome and M [95% CI] within-group effect M [95% CI] within-group effect observed estimated t df p r
time point size dc [95% CI] size dc [95% CI]

WHODAS
Baseline M = 41.89e – Time −3.39 314 <0.001 0.19
0.5 years 32.13 [29.16; 0.68 [0.24; 1.13] 34.38 [31.31; 0.51 [0.07; 0.95] 0.06 −0.13 Treatment at −0.41 182 0.682 0.03
35.41] 37.75] [−0.28; 0.40] [−0.47; 0.21] 1-year FU
1 year 30.66 [28.07; 0.81 [0.36; 1.25] 31.81 [29.17; 0.71 [0.26; 1.16] 0.16 −0.06 Time × treatment −0.83 314 0.405 0.05
33.49] 34.69] [−0.19; 0.52] [−0.42; 0.29]

Psychother Psychosom
1.5 years 29.25 [26.27; 0.93 [0.47; 1.38] 29.43 [26.43; 0.91 [0.45; 1.37] 0.21 −0.01

DOI: 10.1159/000538404
(post) 32.57] 32.77] [−0.22; 0.64] [−0.44; 0.42]
0.5 years FU 27.91 [24.18; 1.05 [0.59; 1.51] 27.23 [23.58; 1.11 [0.65; 1.58] 0.02 0.03
32.21] 31.46] [−0.41; 0.44] [−0.40; 0.46]
1 year FU 26.63 [22.09; 1.17 [0.70; 1.64] 25.20 [20.89; 1.31 [0.83; 1.79] 0.05 0.05
32.09] 30.40] [−0.42; 0.52] [−0.42; 0.52]

Estimated means are in original scale. Effect sizes r are defined as r  √(t2/ (t2 + df )), these represent the effect size associated with the effect tests in the fixed part of the
GLMM. Time was coded in steps of 0.5 years and centered at the last follow-up (2.5 years). Hence, the treatment effect represents the difference between treatments at 2.5 years.
BPDSI, Borderline Personality Disorder Severity Index; BPD Checklist, Borderline Personality Disorder Checklist; DSS, Dissociation Tension Scale; BSI, Brief Symptom Inventory;
QIDS-SR, Quick Inventory of Depressive Symptoms – Self-rating; WSAS, Work and Social Adjustment Scale; WHODAS, World Health Organisation Disability Assessment Schedule.
FU, follow-up. aEffects of global severity, medication and baseline scores are presented in the supplement. bStandardized mean differences: difference between means divided
by the pooled SD; calculated on observed means (transformed scale) and the pooled SD of the observed means calculated at each time point based on a GLMM gamma
regression with only a fixed intercept; respectively, on the estimated means (corrected for baseline) and pooled SD of the observed means; positive values indicate higher scores
for DBT and negative values higher scores for ST. cCalculated as difference between transformed means divided by the square-root of the baseline variance of a model with no
random parts and only a fixed intercept. dEstimated means are −46.99 points lower than on the original scale. Scores were transformed by subtracting 46.99 to bring the
minimum to just greater than 0 to enable gamma regression. eBaseline means are overall descriptive means because the baseline score was included as covariate in the GLMM
to control for baseline differences.

Assmann et al.
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a

Fig. 2. Treatment outcome. a Change in

BPDSI scores. The graph shows BPD se-
verity measured by the BPDSI-IV total
score over time (0.5 years–2.5 years) for
DBT (blue) and ST (orange). Data are ex-
pressed as mean ± SE. b Treatment re-
tention per quarter: The graphs shows
treatment retention during the 1.5 years
treatment period. In the second quarter,
significantly more patients dropped out
from DBT (blue), whereas in the fifth
quarter, significantly more patients drop-
b
ped out from ST (orange). The overall
dropout rate was similar in both treatment
groups (22.9% for DBT and 23.5% for ST).

0.6% (1 year) of all patients received inpatient treatment Discussion

during the follow-up period, but the information was
missing for 49.4% (0.5 years) and 54.9 (1 year) of all This study aimed to compare the effectiveness of
patients. About one-third of all patients received out- DBT and ST for patients with BPD who received
patient treatment during the follow-up period, mainly treatment in a tertiary outpatient center affiliated with
between one and eight sessions in 0.5 years, but again inpatient treatment. Significant reductions in BPD and
there was no information for about one half of the sample. general symptom severity, as well as improvements in

DBT versus Schema Therapy in Borderline Psychother Psychosom 11

Personality Disorder DOI: 10.1159/000538404
psychosocial functioning and quality of life, were ob- Further limitations include the absence of a waiting
served in both treatment conditions. Within-group list control condition. We felt that such a control
effect sizes from pre-follow-up were large for most of condition would have been unethical in our setting due
the outcome variables, pointing out the effectiveness of to the high illness severity and the long treatment pe-
ST and DBT in this specific outpatient setting. See riod, and a no-treatment or treatment-as-usual control
online supplementary discussion in the online sup- group might have enhanced patients’ resistance to
plementary material for comparing pre-post within- participate in a randomized trial and thus endangered
group effect sizes in our studies with previous studies the representativeness of the study group and the
on psychotherapy in BPD. practicability of patient recruitment. Moreover, previ-
In contrast to our hypotheses, there were no significant ous studies have shown that DBT and ST are superior to
differences between DBT and ST at 1-year naturalistic treatment as usual [3, 12, 13]. Even though missing data
follow-up in the primary and almost all secondary out- due to study dropout are to be expected in BPD patients,
comes. There was a significant effect of treatment at 1- the missing assessments might extenuate the validity of
year naturalistic follow-up in favor of DBT in the BPDSI our results. The deviations from the standard DBT

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subscale anger. This finding seems to be plausible in that protocol (a small group of patients without group
DBT focuses on emotion regulation. However, it has to be treatment and individual decisions on “push-out”) must
stressed that this effect was only found in one subscale. also be seen as limitations. Even though the sensitivity
Although retention rates at 1.5 years did not differ be- analysis excluding patients without group therapy did
tween the conditions, DBT patients tended to drop out not show any different results in our trial, a component
earlier than ST patients. Overall, dropout rates were low analysis on DBT points out the importance of skills
compared to a recent meta-analysis [47] (online suppl. training groups [50]. For the adherence checks, an al-
material for detailed discussion). ternative to the “gold-standard” has to be chosen be-
One possible explanation for the absence of a dif- cause extern ratings were not covered by the funding of
ference between ST and DBT might be shared factors of the study. The single-site character of our study and the
ST and DBT (e.g., an explicit treatment framework and specific focus of our tertiary outpatient treatment center
coherent explanatory model, an active, supporting, and on severely affected patients also limits the external
validating therapist, focus on emotions, the balance of validity. Strengths of the study include the interview-
acceptance and change strategies) which are especially based primary outcome with an excellent ICC and the
relevant for BPD patients and therefore might cause wide range of secondary outcomes covering a broad
similar symptom reduction in both treatments. How- array of BPD manifestations and other symptoms. We
ever, ST and DBT use very different explanatory models also recorded adverse events, performed treatment in-
and treatment techniques [48] (e.g., skill training in tegrity checks, included a 1-year naturalistic follow-up
DBT and experiential techniques in ST) in practice. period, and followed CONSORT guidelines and
These different techniques might result in similar methodology. Most importantly, minimal exclusion
outcomes by using different pathways of change. criteria were applied so that BPD patients with almost
Possibly, there are differential effects for specific sub- all comorbidities could participate and a broad array of
groups of BPD patients even though there is no sig- BPD patients is represented.
nificant difference between the two methods for the
whole group of patients on average. As a meta-analysis
recently supported the heterogeneity of treatment ef- Conclusion
fects for both outcomes (i.e., BPD symptoms and
functioning) in BPD [49], maybe one treatment is more The Pro*BPD trial was the first to compare the ef-
suitable than the other for patients with specific fectiveness of DBT and ST for BPD patients in a large
characteristics (e.g., different patterns of childhood randomized trial. Patients in both treatment groups
abuse, comorbid disorders) facilitating a personalized showed substantial improvements indicating that even
treatment selection. Of course, with two bona fide severely affected patients with BPD and various comorbid
psychotherapies, differences between the two groups disorders can be treated successfully with DBT and ST.
might have been too small to detect with our sample Overall the treatments did not show significant differ-
size, being a limitation of the study. The present study is ences, except for anger and treatment retention. An
not designed as a non-inferiority trial and, thus, cannot additional equivalence trial is warranted to test whether
prove that ST is as effective as DBT. both treatments are equivalent in effectiveness.

12 Psychother Psychosom Assmann et al.

DOI: 10.1159/000538404
 Acknowledgments SCEM, Scuole APC-SPC-SICC-IGB-AIPC, Tunisian Association
of CBT, Turkish Association for Cognitive & Behavioural Psy-
We dedicate this study and manuscript to Ulrich Schweiger. In chotherapies, Ukraine Association for CBT, Ukraine Institute for
the Department of Psychiatry and Psychotherapy in Lübeck, CBT, University of Bordeaux, VGCT, VST, WCBCT; supervising
Ulrich Schweiger did not only introduce dialectical behavioral research at the mental health institute PsyQ (remuneration to the
therapy and schema therapy but numerous other modern methods University of Amsterdam); and being chair of the board of the
of psychotherapy. He thus laid the foundation for this trial and PDO foundation, North Holland postgraduate training institute
supported it in all stages. He was involved in the conceptualization (unpaid). Dr. Assmann provided workshops on ST (Institut für
of the study, supervision as well as analysis and interpretation of Schematherapie Hamburg, Ausbildungsinstitut für Verhaltens-
the data. Without him, this study would not have been possible. therapie und Verhaltensmedizin Hannover), received personal
His untimely death in November 2022 left an irreplaceable fees from supervision in ST and received grants from Lübeck
gap. However, his passion for modern psychotherapy and his University for an observational study and for open access pub-
commitment to improving treatment for patients with severe lication fees (both outside the submitted work). PD Dr. Fassbinder
mental disorders will continue to serve as an inspiration and guide. reported receiving grants for the PROBPD study from the Else
Further, we wish to thank all patients and therapists participating Kröner-Fresenius-Stiftung and the University of Lübeck, and
in this trial as well as our research assistants and students for their grants outside the submitted work from Addisca GmbH; receiving

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engagement. royalties from Beltz Verlag and Elsevier Books; receiving personal
fees from supervision in ST and group ST and from workshops and
presentations on CBT, imagery rescripting, personality disorders,
ST, and behavioral activation for Ausbildungsinstitut für Ver-
Statement of Ethics
haltenstherapie und Verhaltensmedizin Hannover, Arbeitsge-
The study was reviewed and approved by the Ethics Committee meinschaft Wissenschaftliche Psychotherapie Berlin, the DGPPN,
of Lübeck University, reference number 13–005. Furthermore, the IPAM Marburg, IFT-Nord Institut für Therapie- und Ge-
patients provided written informed consent to participate in this sundheitsforschung gemeinnützige GmbH Kiel, IPP Halle, Institut
study. für Schematherapie Hamburg, Institut für Schematherapie Köln,
Institut für Schematherapie Berlin, Oberberg Kliniken, and the
WCBCT; and being co-chair of the Deutscher Fachverband für
Verhaltenstherapie eV (unpaid) and member of the board of the
Conflict of Interest Statement Gesellschaft zur Erforschung und Therapie von Persön-
lichkeitsstörungen (GePs) e.V. Prof. Klein received funding for
Dr. Alvarez-Fischer reported receiving consultancy fees and clinical trials (German Federal Ministry of Health, Servier),
fees for lectures, workshops, and brochures from Takeda Pharma payments for presentations on internet interventions (Oberberg,
GmbH and Medice Arzneimittel Pütter GmbH & Co KG in the last Servier, Stillachhaus), consulting fees from developers and dis-
12 months. Neither activity represents a conflict of interest. Prof. tributors of internet interventions (all about me, Ethypharm),
Arntz reported receiving grants from the Netherlands Organi- payments for workshops and books (Beltz, Elsevier, Hogrefe, and
zation for Health Research and Development and Netherlands Springer) on psychotherapy for chronic depression and psychiatric
Foundation for Mental Health, and receiving other grants outside emergencies. Dr. Schaich received intramural from University of
the submitted work from Netherlands’ Organization for Scientific Lübeck (Habiliationsförderung für Wissenschaftlerinnen), per-
Research (NWO), Netherlands Organization for Health Research sonal fees from supervision in ST and imagery rescripting, pay-
and Development (ZONMW), Stichting Achmea Ge- ments for manuscripts (Thieme) and workshops (ISST Hamburg)
zondheidszorg, CZ Fonds, Stichting Volksbond Rotterdam, and on ST, support for attending meetings and/or travel from GePs
Stichting tot Steun VCVGZ; receiving royalties (paid to the e.V. Hamburger Fellowship and Verbund Norddeutscher Uni-
university) from Academic Press, American Psychological Asso- versitäten (Impulse Forschung) as well as funding of open access
ciation Press, Beltz, Bohn Stafleu van Loghum, Boom Uitgevers, publication from Lübeck University. Dr. Schweiger received
Cambridge University Press, Context Press, Guilford, De Tijdst- royalty fees from Beltz, Herder, Hogrefe, Kohlhammer, and
room, Oxford University Press, SAGE Publications, Uitgeverij Springer; fees for workshops for institutes associated with the
Nieuwezijds, Wiley; providing workshops and lectures on cog- Deutsche Fachverband für Verhaltenstherapie on psychotherapy
nitive behavioral therapy, imagery rescripting, personality disor- topics; and was Vice President of the Deutsche Fachverband für
ders, schema therapy, and small-scale research in clinical practice Verhaltenstherapie (no honorarium). Dr. Sipos reported receiving
(remuneration to the university) for the BABCP, Bulgarian As- royalty fees from Beltz, Herder, Hogrefe, Kohlhammer, and
sociation for CBT, Clinical Academic Group for Psychotherapy Springer; receiving personal fees from supervision in DBT and
Denmark, Danish Competence Centre for Psychotherapy, psychotherapy and fees for workshops on psychotherapy topics for
EABCT, ECNP, ESSPD, Estonian CBT Association, German IFT-Nord Institut für Therapie- und Gesundheitsforschung ge-
Psychosomatic Congress, GGZ InGeest, Greek CBT Association, meinnützige GmbH Kiel, IPAM Marburg, Leipziger Ausbil-
ICCP, Institut für Schematherapie Frankfurt, ISC International, dungsinstitut für Psychologische Psychotherapie (LAP), Zentrum
ISSPD, ISST, Jellinek, Kenniscentrum Persoonlijkheids- für Psychologische Psychotherapie der Universität Heidelberg
stoornissen, Leiden University Medical Center, Lemion, Moroccan (ZPP Heidelberg), and was a board member of the Dachverband
Association of CBT, Norwegian Psychological Association, Dialektische Behaviourale Therapie (DBT) e.V. (no honorarium).
Parnassia/PsyQ, Polish Association for Cognitive and Behavioural Dr. Herzog, Prof. Jauch-Chara, Prof. Hüppe, and Dr. Wagner
Therapies, Portuguese Association of Behaviour Therapy, Psyflix, reported that he has no conflict of interest to declare.

DBT versus Schema Therapy in Borderline Psychother Psychosom 13

Personality Disorder DOI: 10.1159/000538404
 Funding Sources Assmann, Schaich, and Arntz. Obtained funding: Fassbinder and
Schaich. Administrative, technical, or material support: Schaich,
The Pro*BPD study was supported by the Else Kröner- Assmann, Fassbinder, Jauch-Chara, Hüppe, Herzog, Wagner,
Fresenius-Stiftung (2018_A152). Dr. Fassbinder obtained inter- Alvarez-Fischer, Sipos, and Schweiger. Supervision: Fassbinder,
nal funding from the University of Lübeck (Einzelprojektförder- Sipos, and Schweiger. Since Ulrich Schweiger deceased in No-
ung und Habiliationsförderung für Wissenschaftlerinnen, Sektion vember 2022, he could not review the final version of the
Medizin). Dr. Schaich obtained funding from the University of manuscript but contributed to the preparation, execution,
Lübeck (Habilitationsförderung für Wissenschaftlerinnen, Sektion analysis and publication of the study in an essential way.
Medizin). Funding bodies played no role in the design of the study,
in the collection, analysis, and interpretation of data, in the writing
of the manuscript, and in the decision to submit the manuscript for
Data Availability Statement
publication.
In this study, data of outpatients of a mental health clinic
were analyzed. In order to protect the privacy of these patients
Author Contributions and ensure the secure storage of their data, we refrain from
making the data freely available in a repository. However, the

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Dr. Assmann and Dr. Schaich had full access to all the data in data can be shared with researchers who provide a methodo-
the study. They take responsibility for the data’s integrity and the logically sound proposal to Nele Assmann (Nele.Assmann@
data analysis’s accuracy. Concept and design: Fassbinder, Arntz, uksh.de). Proposals may be submitted up to 36 months following
and Schweiger. Acquisition, analysis, or interpretation of data: the publication of the principal analysis, and the decision will be
Schaich, Assmann, Arntz, Fassbinder, Klein, and Schweiger. made by the steering committee. In case of an approval of the
Drafting of the manuscript: Assmann, Schaich, Fassbinder, proposal data and additional, related documents will be available
Arntz, and Klein. Critical revision of the manuscript for im- (study protocol, statistical analysis plan) with a signed data
portant intellectual content: all authors. Statistical analysis: access agreement.

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DBT versus Schema Therapy in Borderline Psychother Psychosom 15

Personality Disorder DOI: 10.1159/000538404