IMPORTANCE: Current therapeutic approaches are inaccessible to many people with chronic pain and frequently fail to address emotion dysregulation as a key factor in psychological comorbidity and pain intensity. An effective and accessible emotion regulation-focused intervention is needed.
OBJECTIVES: To compare the efficacy of online dialectical behavioral therapy for chronic pain plus treatment as usual (iDBT-Pain) with only treatment as usual on emotion dysregulation in people with chronic pain.
DESIGN, SETTING, AND PARTICIPANTS: This 2-arm randomized clinical trial was conducted from March 2023 to September 2024 in Australia. Participants were adults with chronic pain (lasting =3 months) and weekly pain intensity of 3 or higher out of 10 (10 indicating worst pain), without psychotic or personality disorders, and without dementia. Eligible participants were randomly assigned (1:1 ratio) to receive either iDBT-Pain for 9 weeks or treatment as usual only. Intention-to-treat data analyses were performed between August and September 2024.
INTERVENTIONS: The iDBT-Pain group received 8 group-based 90-minute therapist-guided online sessions as well as an app and a handbook for self-learning. Content focused on DBT skills training, including pain science education. Participants in the treatment-as-usual group continued usual care, which consisted of treatment options that can be accessed in the community.
MAIN OUTCOMES AND MEASURES: The primary outcome was emotion dysregulation at 9 weeks after randomization. The Difficulties in Emotion Regulation Scale (score range: 18-90, with higher scores indicating higher emotion dysregulation) was used in assessment.
RESULTS: Among 89 participants (mean [SD] age, 51.5 [14.2] years; 74 females [83%]), 44 (49%) were randomly assigned to the treatment-as-usual group and 45 (51%) were randomly assigned to the iDBT-Pain group. Overall, 79 participants (89%) completed the 9-week assessment. Between-group difference in emotion dysregulation over time favored iDBT-Pain over treatment as usual at 9 weeks (-4.88; 95% CI, -9.20 to -0.55; P = .03; Cohen d = -0.46 [95% CI, -0.87 to -0.08]).
CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, the iDBT-Pain intervention, delivered through a self-learning and therapist-guided hybrid approach, resulted in sustained improvements in emotion dysregulation in people with chronic pain.
TRIAL REGISTRATION: Anzctr.org.au Identifier: ACTRN12622000113752.
| Discipline Area | Score |
|---|---|
| Psychologist |  |
| Physician |  |
Physician rater
When a psychological therapy is compared in a trial to "treatment as usual," there is no way to know if any benefits are attributable to the specific intervention vs nonspecific aspects of therapy, placebo, and/or Hawthorne effects. Furthermore, it is disappointing to find a study of an intervention in patients with chronic pain that does not report pain as an outcome variable. It makes one wonder whether this is post-hoc salami science.
Physician rater
This study highlights the importance of emotional regulation in managing chronic pain. This addresses the limitations of CBT interventions in this area of care.
Psychologist rater
It would be helpful to look at additional outcomes (e.g., improvement in function).
Psychologist rater
This study found statistically significant but a relatively small between-group difference in improved emotional dysregulation in the group treated with online DBT designed for chronic pain patients. The intervention would likely be more powerful with an in-person group treatment.
Psychologist rater
Promising results for emotion dysregulation while quite discouraging for pain intensity or interference.
Psychologist rater
This is an interesting preliminary study. I am particularly interested in the improvements in depression and pain intensity (and puzzled by the increase in depression in the control group). No apparent improvement in pain interference in either group was disappointing. It would have been helpful to know whether any improvement in vocational status occurred in the context of this intervention.
, McMaster University