Learning objective

After reading this article, you should be able to:

1. Describe the components and potential benefits of dialectical behavior and social rhythm therapy (DBSRT) as a treatment approach for individuals with comorbid bipolar disorder (BD) and borderline personality disorder (BPD).

Review of: Bailey BC et al, Am J Psychother 2023; epub ahead of print.

Study type: Proposal

Bipolar disorder (BD) and borderline personality disorder (BPD) are hard enough to treat on their own. But it’s especially challenging for patients with both.

What BD and BPD have in common–emotional dysregulation, suicidality, and disrupted circadian rhythm–are what led researchers to combine dialectical behavior therapy (DBT) and interpersonal and social rhythm therapy (IPSRT) into a new type of psychotherapy they call dialectical behavior and social rhythm therapy (DBSRT). 

DBT is a first-line psychotherapy for BPD that combines group skills training, individual therapy, telephone consults between therapy sessions, and team therapist consultation. It is a 12-month treatment program that targets emotional dysregulation and reduces suicidality–two of the three features common to BD and BPD. 

IPSRT is a first-line psychotherapy for BD and consists of both interpersonal therapy (IPT) and social rhythm therapy (SRT). IPSRT helps establish daily routines, build positive relationships, and reduce interpersonal distress. It consists of about 20 sessions and is an effective adjunctive treatment for bipolar depression. A primary goal of SRT is improvement of disrupted circadian rhythm, the third feature common to BD and BPD.

This proposed new psychotherapy, DBSRT, consists of a pretreatment phase to assess the appropriateness of therapy, identify goals, enhance motivation and commitment, and gain the patient’s commitment to staying alive. It is followed by four additional stages: safety and behavior stabilization; mood stabilization and trauma work; living life, reaching goals, and prevention; and deeper meaning, prevention, and termination.

Researchers treated comorbid BD and BPD in a 20-year-old White female using DBSRT. The patient had just been hospitalized after attempting suicide. She had a family history of BD and a history of childhood sexual abuse. She had tried aripiprazole and lamotrigine but had poor adherence.

During DBSRT, the patient was able to move from life-threatening behaviors to a focus on mood stabilization. She experienced one depressive episode during week 7 of therapy, but she did not require hospitalization, and researchers reported being able to stabilize her mood more quickly than with previous episodes. (For an overview of the concepts discussed in this article, see the table, “Psychotherapy Approaches for BPD and BD,” below).

Carlat Take

Combining dialectical behavior therapy with social rhythm therapy may be better than either one alone for comorbid BD and BPD. But it’s still too early to know if this new approach, dialectical behavior and social therapy (DBSRT), is effective.

Table. Psychotherapy Approaches for BPD and BD

APA citation

Bailey, B. C., Novick, D., Boyce, K., & Swartz, H. A. (2023). Dialectical Behavior and Social Rhythm Therapy for Comorbid Bipolar Disorder and Borderline Personality Disorder. American journal of psychotherapy, appipsychotherapy20230006. Advance online publication. https://doi.org/10.1176/appi.psychotherapy.20230006