Does DBT affect emotional regulation and impulsivity from the beginning of implementation? A 3-year naturalistic study on transdiagnostic groups in addictology

Does DBT affect emotional regulation and impulsivity from the beginning of implementation? 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A 3-year naturalistic study on transdiagnostic groups in addictology Amaury DURPOIX, Luisa WEINER, Christelle PORCHE, Marie WALTER, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5389668/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Jan, 2026 Read the published version in Substance Abuse Treatment, Prevention, and Policy → Version 1 posted 4 You are reading this latest preprint version Abstract Introduction . Addictions and eating disorders are the 2 deadliest psychiatric disorders. Central processes in both disorders are emotional dysregulation and impulsivity, maladaptive emotion regulation strategies have an important role in the development and maintenance of eating disorders and addictions. The standard treatment for emotion regulation is Dialectical Behavioral Therapy (DBT), its implementation is often a challenge but can be facilitated by transdiagnostic groups. As few data are available on these groups in addictology, the aim of our study was to check that emotional dysregulation and impulsivity are improved as soon as transdiagnostic DBT groups are implemented. Method . Eight two-month cycles of transdiagnostic DBT groups were led between 2021 and 2023. The 35 participants had substance addiction (89%), behavioral addiction (14%), or eating disorder (20%). Other psychiatric comorbidities, especially borderline personality disorder (42.9%), were also present. The evolution of questionnaires completed by the participants and the attrition rate were analyzed. Results . The average dropout rate was 21%. During DBT, the improvement reached high effect sizes for emotional dysregulation (d=0.9), positive cognitive emotional regulation (d=0.978) and negative cognitive emotional regulation (d=1.04), and medium effect sizes for impulsivity (d=0.586) and mindfulness (d=0.766). Depending on the cycle, clinical outcomes ranged from 0% to 31% improvement in emotional dysregulation and from 12% to 100% retention. An association was found between attrition rate and therapists' level of experience (effect size = 0.320, p=.001). Discussion . While we know the effectiveness of DBT on emotional dysregulation and impulsivity, two particularly important functions in addictology, we found that their improvement can occur as soon as this therapy is implemented despite challenges present. These results suggest that transdiagnostic format, which is a solution to facilitate DBT implementation, preserves the effects of DBT. In addictology, few therapies address emotional regulation and impulsivity: CBT is less suitable for severe cases because change and acceptance skills are not dialectically balanced, and pharmacotherapy does not act on limbic system by top-down mechanisms because it does not teach skills. Therefore, to improve emotion regulation of patients with addictions, it is necessary to study solutions more often to facilitate implementation of DBT such as transdiagnostic groups. dialectical behavior therapy emotion regulation skills training transdiagnostic substance use disorder eating disorder behavioral addiction emotion dysregulation Figures Figure 1 Introduction Addictions and eating disorders are the two deadliest psychiatric disorders (Chesney et al., 2014; Harris & Barraclough, 1998), each disorder has a high organic impact and a high rate of violent deaths (suicide, car accidents, overdoses, settling scores, etc.). Their 10-year mortality rate reaches about 20% for addictions (Hjemsæter et al., 2019) and 1 to 5% for eating disorders (Arcelus et al., 2011; Smink et al., 2012). This rate increases in the case of comorbidity between them (Courbasson et al., 2012a), which is relatively common (30-70% for bulimia, 12-18% for anorexia nervosa, and 8-33% for binge eating episodes (Bahji et al., 2019; Holderness et al., 1994; Pearlstein, 2002; Vastag, 2001; Wilfley et al., 2000)). Eating disorders share so many common mediators with addictions that they are sometimes considered addictive behaviors (Davis & Claridge, 1998; Kanarek et al., 2009; Meule, 2015): anorexia nervosa can be described like starvation and exercise addiction, bulimia nervosa and binge-eating disorder like food addiction. With a lifetime prevalence of approximatively 2-8% for addictions (Merikangas & McClair, 2012) and 2-5% for eating disorders (Smink et al., 2012), they are involved in about 30% of deaths before the age of 65 (Battini & Perozziello, 2023). To improve the treatment of these disorders, current research emphasizes the importance of better considering mediators and focusing less exclusively on addictive or eating behaviors (Tiffany et al., 2012). Two central processes of addictions and eating disorders are emotional dysregulation (Brockmeyer et al., 2014; Cavicchioli et al., 2018; Lavender et al., 2015; Luijten et al., 2017; Stellern et al., 2023), classically defined as a pattern of emotional experience and /or expression that interferes with appropriate goal-directed behavior (Beauchaine, 2015), and impulsivity, classically defined as a predisposition toward rapid and unplanned reactions to internal or external stimuli with diminished regard to the negative consequences (Hamilton et al., 2015). Studies have shown that maladaptive emotion regulation strategies play an important role in the development and maintenance of eating disorders and addictions (Evers et al., 2010; Heatherton & Baumeister, 1991; Stewart et al., 2006; Wiser & Telch, 1999). Both appear to stem from the desire for emotional reward, emotional relief of negative aversive states (Stewart et al., 2006) and an inability to control impulsive behavior (Dawe & Loxton, 2004). Emotional regulation is critical to improve the duration of abstinence maintenance (Cavicchioli, Movalli, & Maffei, 2019; Haktanır & Callender, 2020; Maffei et al., 2018) and processes critical to recover from addiction, such as distress tolerance and reduced impulsivity (Cavicchioli et al., 2020, 2023). Given this, ED and impulsivity should be considered more often as primary outcomes to study the effects of treatments targeting addictions and eating disorders, especially if we want to include weaned patients as ED and impulsivity may be involved in relapse (Berking et al., 2011). Dialectical Behavior Therapy (DBT) is the gold standard treatment for emotional dysregulation, it reduces suicidality (DeCou et al., 2019), addiction (Flynn et al., 2019; Haktanır & Callender, 2020; Salsman, 2020), and eating disorders (Rozakou-Soumalia et al., 2021). DBT promotes the use of effective emotion regulation strategies (Neacsiu et al., 2010). DBT has accumulated the most data for its efficacy in Borderline Personality Disorder (BPD) (Linehan et al., 1991; Storebø et al., 2020), and its efficacy for addiction has been studied primarily in cases of comorbidity with BPD (Lee et al., 2015). Some studies have focused on the efficacy of DBT for addiction without BPD, including two randomized controlled trials: one evaluating opioid addiction (Azizi et al., 2010) and the other evaluating the comorbidity of substance use disorder (SUD) and eating disorder (Asarnow et al., 2021; Courbasson et al., 2012a). In BPD, addiction improves during DBT by improving emotional dysregulation (Axelrod et al., 2011), notably through the use of skills such as mindfulness (Cavicchioli, Movalli, & Maffei, 2019; Cavicchioli, Movalli, Vassena, et al., 2019). The decrease of impulsivity during DBT also induces several improvements for BPD, such as substance use or suicide attempts (Sparapani, 2015). While the effects of DBT are generally well studied, few data have been collected on its effects on emotional regulation and impulsivity during implementation (Comtois & Landes, 2018), namely during application of therapy by a new team, nor on solutions to facilitate it such as the transdiagnostic format (Durpoix, Lachaux, et al., 2023; Reinholt et al., 2021). Implementation is a particularly delicate moment because it requires transforming theoretical knowledge learned during training into practical skills. As this is a moment with high challenges, it's difficult to collect analyzable clinical data. The knowledge we have on DBT implementation is acquired mainly through retrospective and declarative studies with practitioners. So we don't really know the effects of DBT at that time. We can suppose that patients improve less because therapists lack automatisms, or conversely that they improve more related to a novelty effect. Answering these questions is important to help therapists implement DBT without abandoning it 2 to 5 years later, as happens in half of the teams (King et al., 2018). To complete the understanding of the DBT impact on addictive disorders, we conducted a naturalistic study evaluating the evolution of emotional dysregulation and impulsivity during transdiagnostic DBT groups recently implemented in addictology. Our hypothesis was that emotional dysregulation and impulsivity would improve as soon as DBT groups are implemented. Methods Recruitment & Design Besides research, to integrate DBT, patients had to meet several eligibility criteria: they had to regularly consult for an addiction or an eating disorder at the addiction medicine department in Strasbourg University Hospital, they had to have an associated emotional dysregulation and understand its link with the addictive/eating behaviors, and they had to be interested in participating in therapy. These criteria were assessed by a psychiatrist before the participation to therapy. Any addictive or eating disorder included in international classifications (DSM-5 or ICD-11) associated with emotional dysregulation was eligible. Screen addiction, although not included in the international classifications, was eligible for therapy if it caused clinical distress in the patient. Patients who met the eligibility criteria were assigned on a waiting list with treatment as usual while awaiting enrollment in the DBT group. Patients who did not meet the eligibility criteria continued with treatment as usual and did not participate in the study. There were no specific exclusion criteria for therapy. Clinical assessment for enrollment to therapy was deferred if patients were unable to participate due to hospitalization for somatic or psychiatric emergencies. However, all patients were assessed for the program as soon as possible after the emergency was over and discharge from the hospital was complete. Participants committed to one cycle of therapy and could then re-engage for the other cycle. They were invited to sign a therapeutic contract during the pre-therapy evaluation session. Participants were also informed that their data could be used for the research, that they could refuse and that this would not negatively affect the therapy. Approval was obtained from the Ethics Committee of the Faculty of Medicine of Strasbourg (CE 2023-121). Participants Between 2021 and 2023, therapy included 35 participants, composed of 23 women/ 12 men and aged 20 to 61 years (mean 41.0, SD 11.6). They consulted public addiction medicine department for substance addiction (86%), behavioral addiction (17%) and/or eating disorder (23%). The types of addiction or eating disorders were alcohol (71.4%), cannabis (17.1%), cocaine (5.7%), opiates (2.9%), chemsex by 3-MMC/GHB/poppers (2.9%), bulimia nervosa (14.3%), restrictive anorexia (5.7%), gambling addiction (5.7%), sex addiction (5.7%), and screen addiction (2.9%). Some (14%) had been abstinent for an average of 8.4 months at the beginning of the group. Most patients (91.4%) had received at least one diagnosis of a psychiatric comorbidity (Table 1): borderline (42.9%) or obsessive (17.1%) or avoidant personality disorder (2.9%), bipolar disorder (17.1%), characterized depressive episode (8.6%), ADHD (11.4%), posttraumatic stress disorder (2.9%), social phobia (5.7%), generalized anxiety disorder (2.9%). The diagnoses were made by a psychiatrist. Table 1 : Mental disorders and psychotropic medications of participants Addictions disorders Psychiatric comorbidities (91.4%) Psychotropic (71.4%) Substance use disorder (86%) Personality disorder Antidepressant (34.2%) Alcohol (71.4%) Borderline (42.9%) SRI (31.4%) Cannabis (17.1%) Obsessive (17.1%) SNRI (5.7%) Cocaine (5.7%) Avoidant (2.9%) Opiates (2.9%) Mood disorder Mood stabilizer (25.7%) 3-MMC/GHB (2.9%) Bipolar (17.1%) Lithium (2.9%) Eating disorder (23%) Depressive episode (8.6%) Lamotrigine (17.1%) Bulimia nervosa (14.3%) Antipsychotic 9 Restrictive anorexia (5.7%) Other Others (40%) Behavioral addiction (17%) ADHD (11.4%) Methylphenidate (2.9%) Gambling addiction (5.7%) PTSD (2.9%) Anxiolytic (31.4%) Sex addiction (5.7%) Social phobia (5.7%) Methadone (2.9%) Screen addiction (2.9%) Generalized anxiety (2.9%) Acamprosate (2.9%) Baclofen, Nalmefen (17.1%) Transdiagnostic Dialectical and Behavioral Therapy skills training Standalone DBT skills training groups were implemented in 2021 at the addictology department of Strasbourg. Participants received DBT as described in the two reference manuals (Linehan, 1993a, 1993b) with adaptations made for transdiagnostic groups (Durpoix, Lachaux, et al., 2023; Neacsiu et al., 2014). The 4 modules of skills were covered: i.e., mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness (Table 2). The skills training groups took place over 2 two-months and consisted of weekly sessions (2 h), and a weekly team consultation for therapists (1.5 h). There was only one group at a time. Thus, 2 x 4 cycles were conducted between 2021 and 2023. Participants were engaged for one cycle, and they could start with cycle 1 or cycle 2 depending on the progress in the program. Patients who missed approximately half of a cycle (≥ 4 sessions) were considered withdrawn from that cycle and could to re-engage if they wished to participate in a new cycle. Although individual DBT and telephone coaching were not offered, participants were motivated to use digital tools that have demonstrated interest (Durpoix et al., 2021; Prada et al., 2017). All participants were required to attend regular appointments with their addiction specialist or psychiatrist through their department for medication review and treatment monitoring. No structured therapy or structured counseling was provided during these appointments. Table 2 : List of DBT Skills taught Cycle Modules Sessions Skills Clinical assessment and engagement for cycle 1 Cycle 1 Mindfulness 1 Wise mind and “what” skills of mindfulness 2 “How” skills of mindfulness Distress Tolerance 3 STOP & TIP skills 4 ACCEPTS skills 5 IMPROVE and self-soothing skills 6 Radical acceptance and willingness Interpersonal Effectiveness 7 DEAR MAN skill 8 GIVE and FAST skills 9 Validation others and self-validation Debriefing session and engagement for cycle 2 Cycle 2 Mindfulness 10 Wise mind and “what” skills of mindfulness 11 “How” skills of mindfulness Emotional Regulation 12 Understand, identify and name emotions 13 Fact-checking 14 Opposite action 15 Problem solving 16 ABC skills 17 PLEASE skills Debriefing session of therapy Therapists Four therapists participated in the implementation of DBT groups in a French addictology department between 2021 and 2023. The four DBT therapists were a psychiatrist, a nurse, a clinical psychologist, and a CBT-trained psychiatric intern. Their participation depended on their availability. The level of DBT training ranged from low to medium and the level of DBT experience ranged from 0 to 10 cycles (Table 3, Supplementary Material). A DBT group was led by two to three therapists. An estimate of individual therapist adherence to DBT could not be made. Before to lead a group, therapists had observed at least one DBT group, read the reference manual, and watched YouTube videos summarizing the skills (Durpoix et al., 2021). Three therapists had also received one or more formal medium trainings (2 to 7 days), but none had be able to benefit from the intensive 2x5 days training. In addition to weekly team consultations, the therapists received an external team consultation as described by Gaglia (Gaglia, 2018) during the first 2 cycles. Table 3 : Characteristics of the 4 professionals who implemented DBT Therapists DBT training level DBT experience level Animated Cycles T1 Psychiatrist Low 0-7 cycles Cycles 1 to 8 T2 Nurse Low 0-1 cycles Cycles 3 to 4 Medium 2-5 cycles Cycles 5 to 8 T3 CBT Psychologist Medium 0-3 cycles Cycles 3 to 6 T4 Psychiatry Intern Medium 7-10 cycles Cycles 1-2 & 7-8 Measures and procedure Attrition rate was recorded for each cycle. Attrition was considered when a patient missed approximately half of a cycle (≥ 4 sessions). This attrition was considered complete (called "drop-out") if the patient did not return for another cycle, or partial (called "pause") if the patient returned for another cycle. During therapy, participants completed standardized questionnaires before therapy, after cycle 1, and after cycle 2. For the before-and-after analysis, we used the first and last completed questionnaires. As the targeted psychological process was a decrease in emotional dysregulation, we focused on the before-and-after development of the DERS. The other scales focused on the use of emotional regulation skills (cognitive emotional regulation with CERQ, mindfulness with KIMS), specific emotional difficulties (BPD symptoms with BSL-23, anxiety with BAI, and hopelessness with H), as well as the behavioral and social consequences of emotional dysregulation (impulsivity with UPPS, and social functioning with QFS). The characteristics of each questionnaire are listed below: DERS (Gratz & Roemer, 2004): The Difficulties in Emotion Regulation Scale is a 36-item self-questionnaire, that assesses different facets of emotional dysregulation: non-acceptance of negative emotions, difficulty engaging in goal-directed behavior, lack of impulse control in emotional situations, lack of regulatory strategies, lack of emotional awareness and lack of emotional clarity. The higher the DERS score, the greater the emotional regulation difficulties. Psychometric analyses in a non-clinical population indicate good internal consistency (Cronbach's α = 0.93), and good test-retest reliability over a 4-8 week period (r = 0.88, p < 0.01). The French translation (Dan-Glauser & Scherer, 2013) showed high congruence with the original (α = 0.92). CERQ (Garnefski et al., 2001): The Cognitive Emotion Regulation Questionnaire is a 36-item self-questionnaire measuring 9 cognitive strategies used to cope with negative events (acceptance, positive refocusing, refocus on planning, positive reappraisal, putting into perspective, self-blame, catastrophizing, rumination, blaming others). Using a 5-point Likert scale, each strategy is measured by a 4-item subscale. As evaluated in adults (Garnefski & Kraaij, 2007), the CERQ subscales have good internal consistency (α = 0.75-0.87) and test-retest reliability at 1-year intervals (r = 0.48-0.65). KIMS (Baer et al., 2004): The Kentucky Inventory of Mindfulness Skills is a 39-item self-questionnaire with a 5-point scale. This questionnaire measures the general tendency to be fully aware in daily life. It includes 4 subscales: Observing (e.g., "I pay attention to how my emotions affect my thoughts and behavior"), Describing (e.g., "I know how to find the words to describe my feelings"), Acting with awareness (e.g., "When I do something, I'm only focused on what I'm doing and nothing else") and Accepting without judgment (e.g., "I criticize myself for having irrational or inappropriate emotions" - reverse item). These subscales show good internal consistency (α = 0.83-0.91) and test-retest reliability over a period of 14-17 days (r = 0.65-0.86). The French version has similar psychometric properties (Nicastro et al., 2010). BSL-23 (Wolf et al., 2009): The Borderline-Symptom List is a 23-item self-questionnaire with a 4-point scale that assesses BPD symptoms one week prior to the assessment. The items address both diagnostic criteria, such as affective instability and self-harming behavior, as well as borderline-typical empirical findings regarding self-criticism, trust issues, emotional vulnerability, and feelings of shame, loneliness, and helplessness (Kleindienst et al., 2020). BSL-23 has high internal consistency validity and test-retest reliability, notably in the French version (α = 0.94, r=0.84 – (Nicastro et al., 2016)). BAI (Beck et al., 1988): The Beck Anxiety Inventory is a 21-item self-questionnaire with a 4-point scale that assesses anxiety using a 2-factor model (somatic symptoms, and cognitive-affective symptoms). It showed excellent internal consistency (α = 0.92), and good test-retest reliability over 1 week (r = 0.75). The BAI ranges from 0-20 (mild), through 21-30 (moderate), to 31+ (severe). BHS (Beck et al., 1974, p. 197): The Beck Hopelessness Scale is a 20-item true/false self-questionnaire that assesses three major aspects of hopelessness: feelings about the future, loss of motivation, and expectations. Validity and reliability have been well established (α = 0.93). UPPS (Whiteside & Lynam, 2001): The Urgency Perseverance Premeditation Sensation Seeking Impulsive Behavior scale is a 45-item self-questionnaire with a 4-point scale assessing impulsivity. It includes 4 subscales with good internal consistency: urgency (α = 0.86), lack of perseverance (α = 0.82), lack of premeditation (α = 0.91), sensation seeking (α = 0.90). A shorter 20-items version translated into French (Billieux et al., 2012) contains 5 subscales with correct internal consistency and test-retest reliability: negative urgency (α = 0,78, r = 0,87), positive urgency (α = 0.70, r = 0.84), lack of premeditation (α = 0.79, r = 0.85), lack of perseverance (α = 0.84, r = 0.85), sensation seeking (α = 0,83, r = 0,92). QFS (Zanello et al., 2004, 2006): The Social Functioning Questionnaire is a 16-item self-questionnaire with a 5-point scale that assesses two facets of social functioning (frequency of behaviors, and satisfaction with them). Psychometric analyses in a population combining healthy and sick subjects, such as anxiety and depressive disorders, personality disorders, psychotic disorders, indicate correct internal consistency and 15-day test-retest reliability (α = 0,65-0,83, r = 0,69-0,71). Statistical analysis Data were analyzed using SPSS (version 27). We performed a descriptive analysis of cycle participation and the evolution of emotional dysregulation and impulsivity. Then, we compared the evolution of questionnaires between before and after DBT using a Student’s T-test. Statistical significance was considered for p-values <.05. Effect sizes were calculated using Cohen's d and considered strong if greater than 0.8, medium if greater than 0.5, and small if greater than 0.3. The conditions for the application of the tests were respected for each questionnaire (normal distribution and homogeneity of variances). Finally, we studied the relationships between clinical outcomes and therapists’ level. We analyzed the influence of experience level on DERS progression with Pearson correlation and on attrition with T-test. We also analyzed the influence of training level on DERS progression with T-test and on attrition with χ2 test. Because the distribution of DERS progression was not normal, the T-test was replaced with the Mann-Whitney test, and Pearson correlation was replaced with the Spearman correlation. Results Descriptive statistics Among the 35 patients who have engaged in therapy to date, 80% completed one cycle (28/35) and 49% have completed both cycles (17/35). As the DBT groups continue, some patients will soon participate in the 2nd cycle. On 17 occasions, 29% of patients (10/35) started a cycle but did not complete it. This amounts to 62 participations in a cycle. The rate of complete attrition or "drop-out", i.e. stopping the cycle without subsequent participation, was 21% (13/62). The rate of partial attrition or "pause", i.e. stopping the cycle and rejoining in a subsequent cycle, was 6% (4/62). Questionnaires were completed by 57% of participants (20/35) after the 1st cycle, and by 43% (15/35) after the 2nd cycle. Twenty-four participants (69%) completed at least one of the 2 questionnaires in addition to the pretherapy questionnaire. Changes in before-and-after questionnaires The DERS and 5 other questionnaires showed a statistically significant improvement (Table 4). The effect sizes were large for DERS, CERQ+ and CERQ- and medium for KIMS and UPPS. Table 4 : Evolution of self-questionnaires 24/35 Before Therapy After Therapy Effect Size (Cohen’s d) M SD M SD DERS 118.29 23.99 95.04 30.10 0.900*** CERQ+ 49.96 11.04 60.63 13.01 0.978*** CERQ- 49.33 8.38 41.38 10.40 1.040*** KIMS 110.21 19.45 127.33 23.41 0.766*** BSL-23 1.46 1.08 1.34 1.11 0.196 BAI 24.17 12.89 21.29 17.38 0.283 BHS 10.00 4.85 8.25 5.19 0.332 UPPS 52.33 9.17 46.54 10.19 0.586 ** QFS 54.71 9.23 57.79 9.01 0.407* *p<.05, **p<.005, ***p<.001 Improvement in DERS score was 25.6% for participants with BPD and 16.5% for participants without BPD, but the difference was not statistically significant (d = 0.429, p=.102). The attrition rate per cycle averaged 26.6% for patient with BPD and 25% for patient without BPD, their difference was not statistically significant (χ=0.0225, p=.881). Influence of therapists’ level on clinical outcomes Retention and improvement rates in DERS varied over the 8 cycles performed between 2021 and 2023 (Figure 1, Supplementary Material). Retention reached its lowest level in cycle 4. The decrease in improvement was greatest in cycles 3 and 4 when the groups were led by therapists with experience <3 cycles. Between cycles 4 and 5, one of the therapists underwent formal medium training and the rate of improvement and retention increased again. Therapists had an average attrition rate of 32.2% (including 26.2% dropouts) when their level of training was low, and 19.9% (including 19% dropouts) when their level of training was medium, but there was no significant difference between both (χ = 1.71, p=.191). Patients who interrupted their participation had on average therapists with an experience of 2.74 cycles, and those who remained had an average of therapists with an experience of 4.40 cycles, their difference was significant between the two (effect size = 0.320, p=.001). Participants' improvement in DERS averaged 19.1% for therapists with low training, and 19.3% for therapists with medium training, the difference between the two was not significant (effect size = 0.0211, p=.859). There was also no statistically significant correlation between DERS improvement and therapist experience (rho=-0.068, p=.494). Discussion Our naturalistic study aimed to investigate the effects of transdiagnostic DBT groups at the beginning of implementation in addictology on emotional regulation and impulsivity. Our results showed that from the start of implementation, transdiagnostic DBT groups were effective in reducing emotional (dys)regulation with a high effect size and impulsivity with a medium effect size, two processes important in addictology. Transdiagnostic DBT is poorly studied, its effect on DERS has been analyzed once in the only available randomized controlled trial (Neacsiu et al., 2014)). Their effect size of 1.86 was higher than our effect size of 0.9, but their patients were included for anxiety or depressive disorders and only 13,6% had a comorbidity with addictive disorders. In contrast, the evolution of DERS has often been studied during unidiagnostic DBT groups, notably in substance addictions with effect sizes close to ours at 1.08 (Cavicchioli, Movalli, Vassena, et al., 2019) or at 0.54 (Cavicchioli et al., 2023), or in eating disorders with an effect size of 0.69 according to a recent meta-analysis (Rozakou-Soumalia et al., 2021). To our knowledge, our study is the first to investigate the effects of transdiagnostic DBT for addictive disorders on emotional dysregulation and impulsivity. Regarding the other questionnaires, fewer studies are available to compare their evolution during DBT. The evolution of CERQ and KIMS during DBT groups has already been studied, but not yet in patients with addictive disorders. We found an effect size of 0.978 for CERQ +, 1.040 for CERQ- and 0.766 for KIMS, which is consistent with the significant changes found during DBT in other clinical populations for both CERQ (Abdullahi & Nouri, 2024; Kalantarian et al., 2024; Sepehri et al., 2016) and KIMS (Klodnick et al., 2021; Perroud et al., 2012, p. 201). The evolution of UPPS had not yet been studied during transdiagnostic DBT groups, but was sometimes studied during unidiagnostic DBT groups for substance addiction: the effect size of 0.586 found in our study was quite close to the evolution present in the study by Cavicchioli et al (Cavicchioli et al., 2023). The evolution of QFS had never been studied during DBT to our knowledge, even though we know the effect of DBT on social functioning (Wilks et al., 2016). Our results are consistent with the literature on DBT, effect sizes were generally in line with other studies. When they were lower, this may be linked to differences in the population because our results are in line with those found in DBT groups implemented in addictology for longer. The attrition rate observed in our study was close to the 20% rate found in a study on DBT for SUD-eating disorder comorbidity (Courbasson et al., 2012b). Further studies are needed to know the influence of diagnosis on DERS progression. Our study didn’t find significant differences depending on BPD diagnostics, like van den Bosh et al (van den Bosch et al., 2002) didn’t find differences in BPD population depending on addiction comorbidity. At long-term, a study showed that regardless their diagnosis, participants improved their emotional instability and substance use one year after transdiagnostic DBT for BPD, bipolar disorder, and/or ADHD (Durpoix, Lachaux, et al., 2023). DBT has an important place in addictology to reduce the impact of emotional dysregulation and impulsivity. This therapy is particularly suitable to treat life-threatening behaviors (suicide behavior, overdose…) which are frequent in patients with addictive behaviors. Unlike CBT, DBT teaches acceptance-oriented emotional regulation skills in addition to change-oriented skills. These different skills make it suitable for improving the distress tolerance in suicidal patients (Durpoix, Rolling, et al., 2023). Their learning acts on the emotions generated by the limbic system by improving its connectivity with the prefrontal cortex through a top-down mechanism, thus complementing pharmacotherapy that acts on the limbic system through a bottom-up mechanism (Luo et al., 2023; Quidé et al., 2012). Their combination has sometimes been studied in addictology, DBT has been shown to be effective in opioid addiction in combination with methadone replacement treatment (Rezaie et al., 2021) or levomethadyl acetate hydrochloride (Linehan et al., 2002). Anti-craving drugs such as baclofen could also be interesting to combine with DBT, but no studies exist on the effectiveness of their combination to our knowledge. Like any treatment, DBT can be difficult to implement in a new healthcare team. On average, half of teams stop DBT, usually after 2 to 5 years (King et al., 2018). As a high level of distress in emotional dysregulation affects 135 million people worldwide (DuBose et al., 2018), it is important to assess potential solutions to the challenges encountered during the implementation of DBT. A paradox is that training requires funding, but funding often comes only once the effectiveness of DBT has been proven at the local level (Tan et al., 2023). Non-intensive DBT training makes the principles of therapy more affordable and the transdiagnostic format facilitates patient recruitment (Durpoix, Lachaux, et al., 2023; Reinholt et al., 2021). Our study suggests that these solutions preserve the effects of DBT on emotional dysregulation and impulsivity in addictology. This finding is consistent with the study by Pasciezny & Conor (Pasieczny & Connor, 2011) which showed that the effect of DBT on psychometric criteria did not vary according to the intensity of therapist training. DBT therefore acts on the emotional regulation and impulsivity of addictions despite the many challenges of implantation. These results can help other teams to dare to implement DBT, there is no need to wait several years before obtaining results. As our study shows, results can vary over time, especially at the beginning of implementation. These results reminder that the implementation of a therapy is not a passive process (Fairburn & Wilson, 2013). Responsibility of implementation doesn’t only depend on therapists, good institutional cohesion is necessary in order not to give up (Swales, 2010). Several authors warn about the lack of implementation studies that prevent us from correctly discerning whether a negative result comes from therapy failure or implementation failure (Comtois & Landes, 2018; Proctor et al., 2011). Our study provides arguments to avoid deeming a therapy implementation ineffective and abandoning it, as a lack of effectiveness can be corrected notably with an increase in therapists’ level of experience. The strength of our study lay in its naturalistic design with sufficient data to analyze in practice the effect of DBT groups on emotional dysregulation and impulsivity in a population of patients comorbid with addictive disorders. Naturalistic studies have the advantage to know better the effects of an intervention in practice reality. A problem is that the most of these studies on DBT are conducted with intensively trained therapists (Walton & Comtois, 2018), like for randomized controlled trials (Miga et al., 2019; Shafran et al., 2009), although the implementation is often done by inexperienced DBT therapists with non-intensive training. Our study fills this data gap by showing the reality of DBT therapists. The cycle-by-cycle evaluation of evolution of emotional dysregulation, impulsivity, attrition, and therapist levels provided a detailed picture of the successes and difficulties encountered during DBT implementation. We succeed to have enough data, even if naturalistic studies have often a lot of missing data (Shafran et al., 2009). Except Pasciezny & Connor (Pasieczny & Connor, 2011), we didn’t know none other studies which investigated the effects of the level of DBT therapists on patients’ evolution. The strength of our study was also its limitation . The naturalistic design of our study does not allow us to state that the improvement of emotion dysregulation and impulsivity would be the same or different with groups implemented since longer, as we do not have a comparison with a randomized control group. Furthermore, while we analyzed the theoretical and practical level in DBT, the low adherence to therapeutic principles and other obstacles referenced in the literature (therapist burnout, philosophical attitude hostile to evidence-based practices, etc.) were more difficult to study. It would have been interesting to know the influence of these factors on the evolution of emotional dysregulation and impulsivity, particularly during cycles with declining results. Similarly, we were unable to assess the influence of non-DBT professional experience on the evolution of emotional dysregulation and impulsivity. We don’t know whether this experience before starting DBT is an advantage or disadvantage. Precautions should be taken given the small samples. In conclusion , while we know the effectiveness of DBT on emotional dysregulation and impulsivity, two particularly important functions in addictology, we found that their improvement can occur as soon as the therapy is implemented despite challenges present. In addictology, few therapies act on emotional regulation and impulsivity: CBT is less suitable for severe cases and pharmacotherapy does not provide top-down learning. It is therefore important to improve the implementation of DBT by assessing barriers to implementation. Our study found that the results could be irregular depending on the period of implantation but improved with the experience of the therapists. This highlights the importance of good institutional cohesion to overcome these challenges of implementation. Comparative studies are necessary to verify if patient improvement would be different with groups implemented since longer or with highly trained and experienced therapists. Declarations Ethical Approval and Consent to participate The study was approved by the ethics committee of the Strasbourg’s Medicine Faculty (CE-2023-121). Participants were individually informed in written that their data could be used anonymously to evaluate the program and that they were allowed to refuse to participate. Consent for publication All of the material is owned by the authors and/or no permissions are required. Availability of data and materials The results/data/figures in this manuscript have not been published elsewhere, nor are they under consideration (from you or one of your Contributing Authors) by another publisher. Competing interests The authors declare that they have no competing interests. Funding Open access funding provided by University Hospitals of Strasbourg. The authors received no specific funding for this work. Authors’ contributions A. D., L. W., S. W., LM. D. and L. L. designed the research protocol. S. W., L. W. and A. D. developed the intervention program and therapy materials for patients. A. D., C. P., M. W., and LM. D. recruited participants and conducted therapy sessions together. L. L., L. W. and S. W provided support for therapy. A. D. and F. S. conducted the statistical analyses and wrote the first draft of the manuscript, which was then reviewed by L. L and L. W. Acknowledgements We want to thank the clinicians who helped us to implement these DBT groups in Strasbourg: Ms Saliha Derrouazi, Ms Valérie Poussardin and Ms Doha Bemmouna. We also want to thank the professionals who trained us to DBT: Pr Nader Perroud, Pr Shelley McMain and Pr Michaela Swales. References Abdullahi, R., & Nouri, T. (2024). Dialectical Behavior Therapy : Impact on Self-Harming Behaviors, Bullying, and Cognitive Emotion Regulation in Delinquent Teenagers. Journal of Adolescent and Youth Psychological Studies (JAYPS) , 5 (5), 14‑20. https://doi.org/10.61838/kman.jayps.5.5.3 Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality Rates in Patients With Anorexia Nervosa and Other Eating Disorders : A Meta-analysis of 36 Studies. Archives of General Psychiatry , 68 (7), 724‑731. https://doi.org/10.1001/archgenpsychiatry.2011.74 Asarnow, J. R., Berk, M. S., Bedics, J., Adrian, M., Gallop, R., Cohen, J., Korslund, K., Hughes, J., Avina, C., Linehan, M. M., & McCauley, E. (2021). Dialectical Behavior Therapy for Suicidal Self-Harming Youth : Emotion Regulation, Mechanisms, and Mediators. Journal of the American Academy of Child and Adolescent Psychiatry , 60 (9), 1105-1115.e4. https://doi.org/10.1016/j.jaac.2021.01.016 Axelrod, S. R., Perepletchikova, F., Holtzman, K., & Sinha, R. (2011). Emotion Regulation and Substance Use Frequency in Women with Substance Dependence and Borderline Personality Disorder Receiving Dialectical Behavior Therapy. The American journal of drug and alcohol abuse , 37 (1), 37‑42. https://doi.org/10.3109/00952990.2010.535582 Azizi, A., Borjali, A., & Golzari, M. (2010). The effectiveness of emotion regulation training and cognitive therapy on the emotional and addictional problems of substance abusers. Iranian Journal of Psychiatry , 5 (2), 60‑65. Baer, R. A., Smith, G. T., & Allen, K. B. (2004). Assessment of mindfulness by self-report : The Kentucky inventory of mindfulness skills. Assessment , 11 (3), 191‑206. https://doi.org/10.1177/1073191104268029 Bahji, A., Mazhar, M. N., Hudson, C. C., Nadkarni, P., MacNeil, B. A., & Hawken, E. (2019). Prevalence of substance use disorder comorbidity among individuals with eating disorders : A systematic review and meta-analysis. Psychiatry Research , 273 , 58‑66. https://doi.org/10.1016/j.psychres.2019.01.007 Battini, T., & Perozziello, A. (2023). Epidémiologie des addictions. In Les Addictions . Elsevier Health Sciences. Beauchaine, T. P. (2015). Future Directions in Emotion Dysregulation and Youth Psychopathology. Journal of Clinical Child & Adolescent Psychology , 44 (5), 875‑896. https://doi.org/10.1080/15374416.2015.1038827 Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety : Psychometric properties. Journal of Consulting and Clinical Psychology , 56 , 893‑897. https://doi.org/10.1037/0022-006X.56.6.893 Beck, A. T., Weissman, A., Lester, D., & Trexler, L. (1974). The measurement of pessimism : The Hopelessness Scale. Journal of Consulting and Clinical Psychology , 42 (6), 861‑865. https://doi.org/10.1037/h0037562 Berking, M., Margraf, M., Ebert, D., Wupperman, P., Hofmann, S. G., & Junghanns, K. (2011). Deficits in Emotion-Regulation Skills Predict Alcohol Use During and After Cognitive Behavioral Therapy for Alcohol Dependence. Journal of consulting and clinical psychology , 79 (3), 307‑318. https://doi.org/10.1037/a0023421 Billieux, J., Rochat, L., Ceschi, G., Carré, A., Offerlin-Meyer, I., Defeldre, A.-C., Khazaal, Y., Besche-Richard, C., & Van der Linden, M. (2012). Validation of a short French version of the UPPS-P Impulsive Behavior Scale. Comprehensive Psychiatry , 53 (5), 609‑615. https://doi.org/10.1016/j.comppsych.2011.09.001 Brockmeyer, T., Skunde, M., Wu, M., Bresslein, E., Rudofsky, G., Herzog, W., & Friederich, H.-C. (2014). Difficulties in emotion regulation across the spectrum of eating disorders. Comprehensive Psychiatry , 55 (3), 565‑571. https://doi.org/10.1016/j.comppsych.2013.12.001 Cavicchioli, M., Movalli, M., Bruni, A., Terragni, R., Maria Elena, G., Borgia, E., Begarani, M., & Ogliari, A. (2023). The Initial Efficacy of Stand-Alone DBT Skills Training for Treating Impulsivity Among Individuals With Alcohol and Other Substance Use Disorders. Behavior Therapy , 54 (5), 809‑822. https://doi.org/10.1016/j.beth.2023.02.006 Cavicchioli, M., Movalli, M., & Maffei, C. (2019). Difficulties with emotion regulation, mindfulness, and substance use disorder severity : The mediating role of self-regulation of attention and acceptance attitudes. The American Journal of Drug and Alcohol Abuse . https://www.tandfonline.com/doi/full/10.1080/00952990.2018.1511724 Cavicchioli, M., Movalli, M., Ramella, P., Vassena, G., Prudenziati, F., & Maffei, C. (2020). Feasibility of dialectical behavior therapy skills training as an outpatient program in treating alcohol use disorder : The role of difficulties with emotion regulation and experiential avoidance. Addiction Research & Theory , 28 (2), 103‑115. https://doi.org/10.1080/16066359.2019.1590558 Cavicchioli, M., Movalli, M., Vassena, G., Ramella, P., Prudenziati, F., & Maffei, C. (2019). The therapeutic role of emotion regulation and coping strategies during a stand-alone DBT Skills training program for alcohol use disorder and concurrent substance use disorders. Addictive Behaviors , 98 , 106035. https://doi.org/10.1016/j.addbeh.2019.106035 Cavicchioli, M., Vassena, G., Movalli, M., & Maffei, C. (2018). Addictive behaviors in alcohol use disorder : Dysregulation of reward processing systems and maladaptive coping strategies. Journal of Addictive Diseases , 37 (3‑4), 173‑184. https://doi.org/10.1080/10550887.2019.1643211 Chesney, E., Goodwin, G. M., & Fazel, S. (2014). Risks of all-cause and suicide mortality in mental disorders : A meta-review. World Psychiatry: Official Journal of the World Psychiatric Association (WPA) , 13 (2), 153‑160. https://doi.org/10.1002/wps.20128 Comtois, K. A., & Landes, S. J. (2018). Implementing DBT : An Implementation Science Perspective. In M. A. Swales (Éd.), The Oxford Handbook of Dialectical Behaviour Therapy (p. 0). Oxford University Press. https://doi.org/10.1093/oxfordhb/9780198758723.013.54 Courbasson, C., Nishikawa, Y., & Dixon, L. (2012a). Outcome of Dialectical Behaviour Therapy for Concurrent Eating and Substance Use Disorders. Clinical Psychology & Psychotherapy , 19 (5), 434‑449. https://doi.org/10.1002/cpp.748 Courbasson, C., Nishikawa, Y., & Dixon, L. (2012b). Outcome of dialectical behaviour therapy for concurrent eating and substance use disorders. Clinical Psychology & Psychotherapy , 19 (5), 434‑449. https://doi.org/10.1002/cpp.748 Dan-Glauser, E. S., & Scherer, K. R. (2013). The Difficulties in Emotion Regulation Scale (DERS) : Factor structure and consistency of a French translation. Swiss Journal of Psychology , 72 , 5‑11. https://doi.org/10.1024/1421-0185/a000093 Davis, C., & Claridge, G. (1998). The eating disorders as addiction : A psychobiological perspective. Addictive Behaviors , 23 (4), 463‑475. https://doi.org/10.1016/S0306-4603(98)00009-4 Dawe, S., & Loxton, N. J. (2004). The role of impulsivity in the development of substance use and eating disorders. Neuroscience & Biobehavioral Reviews , 28 (3), 343‑351. https://doi.org/10.1016/j.neubiorev.2004.03.007 DeCou, C. R., Comtois, K. A., & Landes, S. J. (2019). Dialectical Behavior Therapy Is Effective for the Treatment of Suicidal Behavior : A Meta-Analysis. Behavior Therapy , 50 (1), 60‑72. https://doi.org/10.1016/j.beth.2018.03.009 DuBose, A. P., Botanov, Y., & Ivanoff, A. (2018). International Implementation of Dialectical Behaviour Therapy : The Challenge of Training Therapists Across Cultures. In M. A. Swales (Éd.), The Oxford Handbook of Dialectical Behaviour Therapy (p. 0). Oxford University Press. https://doi.org/10.1093/oxfordhb/9780198758723.013.58 Durpoix, A., Lachaux, E., Weiner, L., & Weibel, S. (2023). Transdiagnostic Skills Training Group of Dialectical Behavior Therapy : A Long-Term Naturalistic Study. Borderline Personality Disorder and Emotion Dysregulation . https://doi.org/10.21203/rs.3.rs-2845259/v1 Durpoix, A., Rolling, J., Coutelle, R., & Lalanne, L. (2023). Psychotherapies in opioid use disorder : Toward a step-care model. Journal of Neural Transmission . https://doi.org/10.1007/s00702-023-02720-8 Durpoix, A., Weiner, L., Bemmouna, D., Lachaux, E., Krasny-Pacini, A., & Weibel, S. (2021). Psychoéducation et régulation émotionnelle en temps de confinement : Faisabilité et intérêt de vidéos YouTube de thérapie comportementale dialectique. Annales Médico-psychologiques, revue psychiatrique . https://doi.org/10.1016/j.amp.2021.10.016 Evers, C., Marijn Stok, F., & de Ridder, D. T. D. (2010). Feeding Your Feelings : Emotion Regulation Strategies and Emotional Eating. Personality and Social Psychology Bulletin , 36 (6), 792‑804. https://doi.org/10.1177/0146167210371383 Fairburn, C. G., & Wilson, G. T. (2013). The dissemination and implementation of psychological treatments : Problems and solutions. International Journal of Eating Disorders , 46 (5), 516‑521. https://doi.org/10.1002/eat.22110 Flynn, D., Joyce, M., Spillane, A., Wrigley, C., Corcoran, P., Hayes, A., Flynn, M., Wyse, D., Corkery, B., & Mooney, B. (2019). Does an adapted Dialectical Behaviour Therapy skills training programme result in positive outcomes for participants with a dual diagnosis? A mixed methods study. Addiction Science & Clinical Practice , 14 (1), 28. https://doi.org/10.1186/s13722-019-0156-2 Gaglia, A. (2018). Shaping Therapists Towards Adherence : A How-to Guide. In M. A. Swales (Éd.), The Oxford Handbook of Dialectical Behaviour Therapy (p. 0). Oxford University Press. https://doi.org/10.1093/oxfordhb/9780198758723.013.60 Garnefski, N., & Kraaij, V. (2007). The Cognitive Emotion Regulation Questionnaire. European Journal of Psychological Assessment , 23 (3), 141‑149. https://doi.org/10.1027/1015-5759.23.3.141 Garnefski, N., Kraaij, V., & Spinhoven, P. (2001). Negative life events, cognitive emotion regulation and emotional problems. Personality and Individual Differences , 30 (8), 1311‑1327. https://doi.org/10.1016/S0191-8869(00)00113-6 Gratz, K. L., & Roemer, L. (2004). Multidimensional Assessment of Emotion Regulation and Dysregulation : Development, Factor Structure, and Initial Validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment , 26 (1), 41‑54. https://doi.org/10.1023/B:JOBA.0000007455.08539.94 Haktanır, A., & Callender, K. A. (2020). Meta-Analysis of Dialectical Behavior Therapy (DBT) for Treating Substance Use. Research on Education and Psychology , 4 (Special Issue), Article Special Issue. Hamilton, K. R., Mitchell, M. R., Wing, V. C., Balodis, I. M., Bickel, W. K., Fillmore, M., Lane, S. D., Lejuez, C. W., Littlefield, A. K., Luijten, M., Mathias, C. W., Mitchell, S. H., Napier, T. C., Reynolds, B., Schütz, C. G., Setlow, B., Sher, K. J., Swann, A. C., Tedford, S. E., … Moeller, F. G. (2015). Choice impulsivity : Definitions, measurement issues, and clinical implications. Personality Disorders: Theory, Research, and Treatment , 6 (2), 182‑198. https://doi.org/10.1037/per0000099 Harris, C., & Barraclough, B. (1998). Excess mortality of mental disorder. The British Journal of Psychiatry , 173 (1), 11‑53. https://doi.org/10.1192/bjp.173.1.11 Heatherton, T. F., & Baumeister, R. F. (1991). Binge eating as escape from self-awareness. Psychological Bulletin , 110 (1), 86‑108. https://doi.org/10.1037/0033-2909.110.1.86 Hjemsæter, A. J., Bramness, J. G., Drake, R., Skeie, I., Monsbakken, B., Benth, J. Š., & Landheim, A. S. (2019). Mortality, cause of death and risk factors in patients with alcohol use disorder alone or poly-substance use disorders : A 19-year prospective cohort study. BMC Psychiatry , 19 (1), 101. https://doi.org/10.1186/s12888-019-2077-8 Holderness, C. C., Brooks-Gunn, J., & Warren, M. P. (1994). Co-morbidity of eating disorders and substance abuse review of the literature. International Journal of Eating Disorders , 16 (1), 1‑34. https://doi.org/10.1002/1098-108X(199407)16:13.0.CO;2-T Kalantarian, E., Homaei, R., & Bozorgi, Z. D. (2024). Effects of Emotional Schema Therapy and Dialectical Behavior Therapy on Cognitive Emotion Regulation in Patients with Bipolar II Disorder. Modern Care Journal , 21 (1), Article 1. https://doi.org/10.5812/mcj-138135 Kanarek, R. B., D’Anci, K. E., Jurdak, N., & Mathes, W. F. (2009). Running and addiction : Precipitated withdrawal in a rat model of activity-based anorexia. Behavioral neuroscience , 123 (4), 905‑912. https://doi.org/10.1037/a0015896 King, J. C., Hibbs, R., Saville, C. W. N., & Swales, M. A. (2018). The survivability of dialectical behaviour therapy programmes : A mixed methods analysis of barriers and facilitators to implementation within UK healthcare settings. BMC Psychiatry , 18 (1), Article 1. https://doi.org/10.1186/s12888-018-1876-7 Kleindienst, N., Jungkunz, M., & Bohus, M. (2020). A proposed severity classification of borderline symptoms using the borderline symptom list (BSL-23). Borderline Personality Disorder and Emotion Dysregulation , 7 (1), 11. https://doi.org/10.1186/s40479-020-00126-6 Klodnick, V. V., Kissane, B., Johnson, R. P., Malina, C., Ewing, A., & Fagan, M. A. (2021). Adapting Dialectical Behavior Therapy for Young Adults Diagnosed with Serious Mental Health Conditions in Residential Care : A Feasibility Study. Residential Treatment for Children & Youth . https://www.tandfonline.com/doi/full/10.1080/0886571X.2020.1751017 Lavender, J. M., Wonderlich, S. A., Engel, S. G., Gordon, K. H., Kaye, W. H., & Mitchell, J. E. (2015). Dimensions of emotion dysregulation in anorexia nervosa and bulimia nervosa : A conceptual review of the empirical literature. Clinical Psychology Review , 40 , 111‑122. https://doi.org/10.1016/j.cpr.2015.05.010 Lee, N. K., Cameron, J., & Jenner, L. (2015). A systematic review of interventions for co-occurring substance use and borderline personality disorders. Drug and Alcohol Review , 34 (6), 663‑672. https://doi.org/10.1111/dar.12267 Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline personality disorder (p. xvii, 558). Guilford Press. Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder (p. xii, 180). Guilford Press. Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-Behavioral Treatment of Chronically Parasuicidal Borderline Patients. Archives of General Psychiatry , 48 (12), 1060‑1064. https://doi.org/10.1001/archpsyc.1991.01810360024003 Linehan, M. M., Dimeff, L. A., Reynolds, S. K., Comtois, K. A., Welch, S. S., Heagerty, P., & Kivlahan, D. R. (2002). Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence , 67 (1), 13‑26. https://doi.org/10.1016/s0376-8716(02)00011-x Luijten, M., Schellekens, A. F., Kühn, S., Machielse, M. W. J., & Sescousse, G. (2017). Disruption of Reward Processing in Addiction : An Image-Based Meta-analysis of Functional Magnetic Resonance Imaging Studies. JAMA Psychiatry , 74 (4), 387‑398. https://doi.org/10.1001/jamapsychiatry.2016.3084 Luo, J., Liang, M., Yi, P., & Li, X. (2023). The Neuropsychological Mechanisms of Treatment of Bipolar Disorder and Borderline Personality Disorder : Activation Likelihood Estimation Meta-Analysis of Brain Imaging Research. The Journal of Clinical Psychiatry , 84 (3), 46362. https://doi.org/10.4088/JCP.22r14463 Maffei, C., Cavicchioli, M., Movalli, M., Cavallaro, R., & Fossati, A. (2018). Dialectical Behavior Therapy Skills Training in Alcohol Dependence Treatment : Findings Based on an Open Trial. Substance Use & Misuse , 53 (14), 2368‑2385. https://doi.org/10.1080/10826084.2018.1480035 Merikangas, K. R., & McClair, V. L. (2012). Epidemiology of substance use disorders. Human Genetics , 131 (6), 779‑789. https://doi.org/10.1007/s00439-012-1168-0 Meule, A. (2015). Back by Popular Demand : A Narrative Review on the History of Food Addiction Research. The Yale Journal of Biology and Medicine , 88 (3), 295‑302. Miga, E. M., Neacsiu, A. D., Lungu, A., Heard, H. L., & Dimeff, L. A. (2019). Dialectical behaviour therapy from 1991-2015 : What do we know about clinical efficacy and research quality? In The Oxford handbook of dialectical behaviour therapy (p. 415‑465). Oxford University Press. Neacsiu, A. D., Eberle, J. W., Kramer, R., Wiesmann, T., & Linehan, M. M. (2014). Dialectical behavior therapy skills for transdiagnostic emotion dysregulation : A pilot randomized controlled trial. Behaviour Research and Therapy , 59 , 40‑51. https://doi.org/10.1016/j.brat.2014.05.005 Neacsiu, A. D., Rizvi, S. L., & Linehan, M. M. (2010). Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder. Behaviour Research and Therapy , 48 (9), 832‑839. https://doi.org/10.1016/j.brat.2010.05.017 Nicastro, R., Jermann, F., Bondolfi, G., & McQuillan, A. (2010). Assessment of mindfulness with the French version of the Kentucky Inventory of Mindfulness Skills in community and borderline personality disorder samples. Assessment , 17 (2), 197‑205. https://doi.org/10.1177/1073191110363551 Nicastro, R., Prada, P., Kung, A.-L., Salamin, V., Dayer, A., Aubry, J.-M., Guenot, F., & Perroud, N. (2016). Psychometric properties of the French borderline symptom list, short form (BSL-23). Borderline Personality Disorder and Emotion Dysregulation , 3 (1), 4. https://doi.org/10.1186/s40479-016-0038-0 Pasieczny, N., & Connor, J. (2011). The effectiveness of dialectical behaviour therapy in routine public mental health settings : An Australian controlled trial. Behaviour Research and Therapy , 49 (1), 4‑10. https://doi.org/10.1016/j.brat.2010.09.006 Pearlstein, T. (2002). Eating disorders and comorbidity. Archives of Women’s Mental Health , 4 (3), 67‑78. https://doi.org/10.1007/s007370200002 Perroud, N., Nicastro, R., Jermann, F., & Huguelet, P. (2012). Mindfulness skills in borderline personality disorder patients during dialectical behavior therapy : Preliminary results. International Journal of Psychiatry in Clinical Practice , 16 (3), 189‑196. https://doi.org/10.3109/13651501.2012.674531 Prada, P., Zamberg, I., Bouillault, G., Jimenez, N., Zimmermann, J., Hasler, R., Aubry, J.-M., Nicastro, R., & Perroud, N. (2017). EMOTEO : A Smartphone Application for Monitoring and Reducing Aversive Tension in Borderline Personality Disorder Patients, a Pilot Study. Perspectives in Psychiatric Care , 53 (4), 289‑298. https://doi.org/10.1111/ppc.12178 Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for Implementation Research : Conceptual Distinctions, Measurement Challenges, and Research Agenda. Administration and Policy in Mental Health and Mental Health Services Research , 38 (2), 65‑76. https://doi.org/10.1007/s10488-010-0319-7 Quidé, Y., Witteveen, A. B., El-Hage, W., Veltman, D. J., & Olff, M. (2012). Differences between effects of psychological versus pharmacological treatments on functional and morphological brain alterations in anxiety disorders and major depressive disorder : A systematic review. Neuroscience & Biobehavioral Reviews , 36 (1), 626‑644. https://doi.org/10.1016/j.neubiorev.2011.09.004 Reinholt, N., Hvenegaard, M., Christensen, A. B., Eskildsen, A., Hjorthøj, C., Poulsen, S., Arendt, M. B., Rosenberg, N. K., Gryesten, J. R., Aharoni, R. N., Alrø, A. J., Christensen, C. W., & Arnfred, S. M. (2021). Transdiagnostic versus Diagnosis-Specific Group Cognitive Behavioral Therapy for Anxiety Disorders and Depression : A Randomized Controlled Trial. Psychotherapy and Psychosomatics , 91 (1), 36‑49. https://doi.org/10.1159/000516380 Rezaie, Z., Afshari, B., & Balagabri, Z. (2021). Effects of Dialectical Behavior Therapy on Emotion Regulation, Distress Tolerance, Craving, and Depression in Patients with Opioid Dependence Disorder. Journal of Contemporary Psychotherapy . https://doi.org/10.1007/s10879-020-09487-z Rozakou-Soumalia, N., Dârvariu, Ş., & Sjögren, J. M. (2021). Dialectical Behaviour Therapy Improves Emotion Dysregulation Mainly in Binge Eating Disorder and Bulimia Nervosa : A Systematic Review and Meta-Analysis. Journal of Personalized Medicine , 11 (9), Article 9. https://doi.org/10.3390/jpm11090931 Salsman, N. L. (2020). Chapter 7 - Dialectical behavior therapy for individuals with substance use problems : Theoretical adaptations and empirical evidence. In J. Bedics (Éd.), The Handbook of Dialectical Behavior Therapy (p. 141‑174). Academic Press. https://doi.org/10.1016/B978-0-12-816384-9.00007-5 Sepehri, S., Ghahari, S., & Zadeh, R. H. (2016). Efficacy of dialecticalical behavior therapy (DBT) techniques on improving Cognitive Emotion Regulation Strategies in Women with MS. The Social Science . Shafran, R., Clark, D. M., Fairburn, C. G., Arntz, A., Barlow, D. H., Ehlers, A., Freeston, M., Garety, P. A., Hollon, S. D., Ost, L. G., Salkovskis, P. M., Williams, J. M. G., & Wilson, G. T. (2009). Mind the gap : Improving the dissemination of CBT. Behaviour Research and Therapy , 47 (11), 902‑909. https://doi.org/10.1016/j.brat.2009.07.003 Smink, F. R. E., van Hoeken, D., & Hoek, H. W. (2012). Epidemiology of Eating Disorders : Incidence, Prevalence and Mortality Rates. Current Psychiatry Reports , 14 (4), 406‑414. https://doi.org/10.1007/s11920-012-0282-y Sparapani, E. M. (2015). Moderators of Treatment Outcome in Dialectical Behavior Therapy : The Role of Emotion Regulation and Impulsivity [Thesis, American University]. https://doi.org/10.57912/23843559.v1 Stellern, J., Xiao, K. B., Grennell, E., Sanches, M., Gowin, J. L., & Sloan, M. E. (2023). Emotion regulation in substance use disorders : A systematic review and meta-analysis. Addiction , 118 (1), 30‑47. https://doi.org/10.1111/add.16001 Stewart, S. H., Brown, C. G., Devoulyte, K., Theakston, J., & Larsen, S. E. (2006). Why Do Women with Alcohol Problems Binge Eat? : Exploring Connections between Binge Eating and Heavy Drinking in Women Receiving Treatment for Alcohol Problems. Journal of Health Psychology , 11 (3), 409‑425. https://doi.org/10.1177/1359105306063313 Storebø, O. J., Stoffers-Winterling, J. M., Völlm, B. A., Kongerslev, M. T., Mattivi, J. T., Jørgensen, M. S., Faltinsen, E., Todorovac, A., Sales, C. P., Callesen, H. E., Lieb, K., & Simonsen, E. (2020). Psychological therapies for people with borderline personality disorder. The Cochrane Database of Systematic Reviews , 2020 (5), CD012955. https://doi.org/10.1002/14651858.CD012955.pub2 Swales, M. A. (2010). Implementing Dialectical Behaviour Therapy : Organizational pre-treatment. The Cognitive Behaviour Therapist , 3 (4), 145‑157. https://doi.org/10.1017/S1754470X10000115 Tan, M. Y. L., Saw, Y. E., Keng, S.-L., & Lim, D. S. H. (2023). The impact of dialectical behaviour therapy training on therapists in Singapore : A mixed-methods study. Counselling and Psychotherapy Research , 23 (3), 672‑689. https://doi.org/10.1002/capr.12626 Tiffany, S. T., Friedman, L., Greenfield, S. F., Hasin, D. S., & Jackson, R. (2012). Beyond drug use : A systematic consideration of other outcomes in evaluations of treatments for substance use disorders. Addiction , 107 (4), 709‑718. https://doi.org/10.1111/j.1360-0443.2011.03581.x van den Bosch, L. M. C., Verheul, R., Schippers, G. M., & van den Brink, W. (2002). Dialectical Behavior Therapy of borderline patients with and without substance use problems : Implementation and long-term effects. Addictive Behaviors , 27 (6), 911‑923. https://doi.org/10.1016/S0306-4603(02)00293-9 Vastag, B. (2001). What’s the Connection? No Easy Answers for People With Eating Disorders and Drug Abuse. JAMA , 285 (8), 1006‑1007. https://doi.org/10.1001/jama.285.8.1006-JMN0228-3-1 Walton, C., & Comtois, K. A. (2018). Dialectical Behaviour Therapy in Routine Clinical Settings. In M. A. Swales (Éd.), The Oxford Handbook of Dialectical Behaviour Therapy (p. 0). Oxford University Press. https://doi.org/10.1093/oxfordhb/9780198758723.013.52 Whiteside, S. P., & Lynam, D. R. (2001). The Five Factor Model and impulsivity : Using a structural model of personality to understand impulsivity. Personality and Individual Differences , 30 (4), 669‑689. https://doi.org/10.1016/S0191-8869(00)00064-7 Wilfley, D. E., Friedman, M. A., Dounchis, J. Z., Stein, R. I., Welch, R. R., & Ball, S. A. (2000). Comorbid psychopathology in binge eating disorder : Relation to eating disorder severity at baseline and following treatment. Journal of Consulting and Clinical Psychology , 68 (4), 641‑649. https://doi.org/10.1037/0022-006X.68.4.641 Wilks, C. R., Korslund, K. E., Harned, M. S., & Linehan, M. M. (2016). Dialectical behavior therapy and domains of functioning over two years. Behaviour Research and Therapy , 77 , 162‑169. https://doi.org/10.1016/j.brat.2015.12.013 Wiser, S., & Telch, C. F. (1999). Dialectical behavior therapy for binge-eating disorder. Journal of Clinical Psychology , 55 (6), 755‑768. https://doi.org/10.1002/(SICI)1097-4679(199906)55:63.0.CO;2-R Wolf, M., Limberger, M. F., Kleindienst, N., Stieglitz, R.-D., Domsalla, M., Philipsen, A., Steil, R., & Bohus, M. (2009). Kurzversion der Borderline-Symptom-Liste (BSL-23) : Entwicklung und Überprüfung der psychometrischen Eigenschaften. PPmP - Psychotherapie · Psychosomatik · Medizinische Psychologie , 59 (8), 321‑324. https://doi.org/10.1055/s-0028-1104598 Zanello, A., Weber Rouget, B., Gex-Fabry, M., Maercker, A., & Guimon, J. (2006). Validation du Questionnaire de fonctionnement social (QFS), un autoquestionnaire mesurant la fréquence et la satisfaction des comportements sociaux d’une population adulte psychiatrique. L’Encéphale , 32 (1), 45‑59. https://doi.org/10.1016/S0013-7006(06)76136-X Zanello, A., Weber-Rouget, B., Gex-Fabry, M., Maercker, A., & Guimon, J. (2004). A new instrument to assess social functioning in mental health settings. European Journal of Psychiatry , 18 , 76‑84. Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial.docx Cite Share Download PDF Status: Published Journal Publication published 19 Jan, 2026 Read the published version in Substance Abuse Treatment, Prevention, and Policy → Version 1 posted Editorial decision: Revision requested 17 Dec, 2024 Editor assigned by journal 06 Nov, 2024 Submission checks completed at journal 06 Nov, 2024 First submitted to journal 04 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Cycle = Distress Tolerance/Interpersonal Effectiveness, Even Cycle = Emotional Regulation, T= Therapist\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5389668/v1/e5754cdc4558e232516436bc.png"},{"id":101151794,"identity":"257a117d-4c13-48e6-832c-6c47de08936a","added_by":"auto","created_at":"2026-01-26 16:05:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1187659,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5389668/v1/1e97719b-9020-4e72-8442-1ec259b9329c.pdf"},{"id":70959075,"identity":"156cc7cf-236b-4dbb-89a8-21c1e5f9306c","added_by":"auto","created_at":"2024-12-09 14:59:55","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17318,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-5389668/v1/a1a99a042e0fe6fa1df68361.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Does DBT affect emotional regulation and impulsivity from the beginning of implementation? A 3-year naturalistic study on transdiagnostic groups in addictology","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAddictions and eating disorders are the two deadliest psychiatric disorders\u0026nbsp;(Chesney et al., 2014; Harris \u0026amp; Barraclough, 1998), each disorder has a high organic impact and a high rate of violent deaths (suicide, car accidents, overdoses, settling scores, etc.). Their 10-year mortality rate reaches about 20% for addictions\u0026nbsp;(Hjems\u0026aelig;ter et al., 2019)\u0026nbsp;and 1 to 5% for eating disorders\u0026nbsp;(Arcelus et al., 2011; Smink et al., 2012). This rate increases in the case of comorbidity between them\u0026nbsp;(Courbasson et al., 2012a), which is relatively common (30-70% for bulimia, 12-18% for anorexia nervosa, and 8-33% for binge eating episodes\u0026nbsp;(Bahji et al., 2019; Holderness et al., 1994; Pearlstein, 2002; Vastag, 2001; Wilfley et al., 2000)). Eating disorders share so many common mediators with addictions that they are sometimes considered addictive behaviors\u0026nbsp;(Davis \u0026amp; Claridge, 1998; Kanarek et al., 2009; Meule, 2015): anorexia nervosa can be described like starvation and exercise addiction, bulimia nervosa and binge-eating disorder like food addiction. With a lifetime prevalence of approximatively 2-8% for addictions\u0026nbsp;(Merikangas \u0026amp; McClair, 2012)\u0026nbsp;and 2-5% for eating disorders\u0026nbsp;(Smink et al., 2012), they are involved in about 30% of deaths before the age of 65\u0026nbsp;(Battini \u0026amp; Perozziello, 2023). To improve the treatment of these disorders, current research emphasizes the importance of better considering mediators and focusing less exclusively on addictive or eating behaviors\u0026nbsp;(Tiffany et al., 2012).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo central processes of addictions and eating disorders are emotional dysregulation\u0026nbsp;(Brockmeyer et al., 2014; Cavicchioli et al., 2018; Lavender et al., 2015; Luijten et al., 2017; Stellern et al., 2023), classically defined as a pattern of emotional experience and /or expression that interferes with appropriate goal-directed behavior\u0026nbsp;(Beauchaine, 2015), and impulsivity, classically defined as a predisposition toward rapid and unplanned reactions to internal or external stimuli with diminished regard to the negative consequences\u0026nbsp;(Hamilton et al., 2015). Studies have shown that maladaptive emotion regulation strategies play an important role in the development and maintenance of eating disorders and addictions\u0026nbsp;(Evers et al., 2010; Heatherton \u0026amp; Baumeister, 1991; Stewart et al., 2006; Wiser \u0026amp; Telch, 1999). Both appear to stem from the desire for emotional reward, emotional relief of negative aversive states\u0026nbsp;(Stewart et al., 2006)\u0026nbsp;and an inability to control impulsive behavior\u0026nbsp;(Dawe \u0026amp; Loxton, 2004). Emotional regulation is critical to improve the duration of abstinence maintenance\u0026nbsp;(Cavicchioli, Movalli, \u0026amp; Maffei, 2019; Haktanır \u0026amp; Callender, 2020; Maffei et al., 2018)\u0026nbsp;and processes critical to recover from addiction, such as distress tolerance and reduced impulsivity\u0026nbsp;(Cavicchioli et al., 2020, 2023). Given this, ED and impulsivity should be considered more often as primary outcomes to study the effects of treatments targeting addictions and eating disorders, especially if we want to include weaned patients as ED and impulsivity may be involved in relapse\u0026nbsp;(Berking et al., 2011).\u003c/p\u003e\n\u003cp\u003eDialectical Behavior Therapy (DBT) is the gold standard treatment for emotional dysregulation, it reduces suicidality\u0026nbsp;(DeCou et al., 2019), addiction\u0026nbsp;(Flynn et al., 2019; Haktanır \u0026amp; Callender, 2020; Salsman, 2020), and eating disorders\u0026nbsp;(Rozakou-Soumalia et al., 2021). DBT promotes the use of effective emotion regulation strategies\u0026nbsp;(Neacsiu et al., 2010). DBT has accumulated the most data for its efficacy in Borderline Personality Disorder (BPD)\u0026nbsp;(Linehan et al., 1991; Storeb\u0026oslash; et al., 2020), and its efficacy for addiction has been studied primarily in cases of comorbidity with BPD\u0026nbsp;(Lee et al., 2015). Some studies have focused on the efficacy of DBT for addiction without BPD, including two randomized controlled trials: one evaluating opioid addiction\u0026nbsp;(Azizi et al., 2010)\u0026nbsp;and the other evaluating the comorbidity of substance use disorder (SUD) and eating disorder\u0026nbsp;(Asarnow et al., 2021; Courbasson et al., 2012a). In BPD, addiction improves during DBT by improving emotional dysregulation\u0026nbsp;(Axelrod et al., 2011), notably through the use of skills such as mindfulness\u0026nbsp;(Cavicchioli, Movalli, \u0026amp; Maffei, 2019; Cavicchioli, Movalli, Vassena, et al., 2019). The decrease of impulsivity during DBT also induces several improvements\u0026nbsp;for BPD, such as substance use or suicide attempts\u0026nbsp;(Sparapani, 2015).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile the effects of DBT are generally well studied, few data have been collected on its effects on emotional regulation and impulsivity during implementation\u0026nbsp;(Comtois \u0026amp; Landes, 2018), namely during application of therapy by a new team, nor on solutions to facilitate it such as the transdiagnostic format\u0026nbsp;(Durpoix, Lachaux, et al., 2023; Reinholt et al., 2021). Implementation is a particularly delicate moment because it requires transforming theoretical knowledge learned during training into practical skills. As this is a moment with high challenges, it\u0026apos;s difficult to collect analyzable clinical data. The knowledge we have on DBT implementation is acquired mainly through retrospective and declarative studies with practitioners. So we don\u0026apos;t really know the effects of DBT at that time. We can suppose that patients improve less because therapists lack automatisms, or conversely that they improve more related to a novelty effect. Answering these questions is important to help therapists implement DBT without abandoning it 2 to 5 years later, as happens in half of the teams\u0026nbsp;(King et al., 2018).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo complete the understanding of the DBT impact on addictive disorders, we conducted a naturalistic study evaluating the evolution of emotional dysregulation and impulsivity during transdiagnostic DBT groups recently implemented in addictology. Our hypothesis was that emotional dysregulation and impulsivity would improve as soon as DBT groups are implemented.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRecruitment \u0026amp; Design\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBesides research, to integrate DBT, patients had to meet several eligibility criteria: they had to regularly consult for an addiction or an eating disorder at the addiction medicine department in Strasbourg University Hospital, they had to have an associated emotional dysregulation and understand its link with the addictive/eating behaviors, and they had to be interested in participating in therapy. These criteria were assessed by a psychiatrist before the participation to therapy. Any addictive or eating disorder included in international classifications (DSM-5 or ICD-11) associated with emotional dysregulation was eligible. Screen addiction, although not included in the international classifications, was eligible for therapy if it caused clinical distress in the patient.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients who met the eligibility criteria were assigned on a waiting list with treatment as usual while awaiting enrollment in the DBT group. Patients who did not meet the eligibility criteria continued with treatment as usual and did not participate in the study. There were no specific exclusion criteria for therapy. Clinical assessment for enrollment to therapy was deferred if patients were unable to participate due to hospitalization for somatic or psychiatric emergencies. However, all patients were assessed for the program as soon as possible after the emergency was over and discharge from the hospital was complete.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants committed to one cycle of therapy and could then re-engage for the other cycle. They were invited to sign a therapeutic contract during the pre-therapy evaluation session. Participants were also informed that their data could be used for the research, that they could refuse and that this would not negatively affect the therapy. Approval was obtained from the Ethics Committee of the Faculty of Medicine of Strasbourg (CE 2023-121).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eParticipants\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBetween 2021 and 2023, therapy included 35 participants, composed of 23 women/ 12 men and aged 20 to 61 years (mean 41.0, SD 11.6). They consulted public addiction medicine department for substance addiction (86%), behavioral addiction (17%) and/or eating disorder (23%). The types of addiction or eating disorders were alcohol (71.4%), cannabis (17.1%), cocaine (5.7%), opiates (2.9%), chemsex by 3-MMC/GHB/poppers (2.9%), bulimia nervosa (14.3%), restrictive anorexia (5.7%), gambling addiction (5.7%), sex addiction (5.7%), and screen addiction (2.9%). Some (14%) had been abstinent for an average of 8.4 months at the beginning of the group.\u003c/p\u003e\n\u003cp\u003eMost patients (91.4%) had received at least one diagnosis of a psychiatric comorbidity (Table 1): borderline (42.9%) or obsessive (17.1%) or avoidant personality disorder (2.9%), bipolar disorder (17.1%), characterized depressive episode (8.6%), ADHD (11.4%), posttraumatic stress disorder (2.9%), social phobia (5.7%), generalized anxiety disorder (2.9%). The diagnoses were made by a psychiatrist.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eTable 1\u003c/u\u003e: Mental disorders and psychotropic medications of participants\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4371%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAddictions disorders\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9272%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychiatric comorbidities\u0026nbsp;\u003c/strong\u003e(91.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6358%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychotropic\u0026nbsp;\u003c/strong\u003e(71.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4371%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubstance use disorder\u0026nbsp;\u003c/strong\u003e(86%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9272%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersonality disorder\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6358%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAntidepressant\u0026nbsp;\u003c/strong\u003e(34.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4371%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eAlcohol (71.4%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9272%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eBorderline (42.9%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6358%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eSRI (31.4%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4371%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eCannabis (17.1%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9272%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eObsessive (17.1%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6358%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eSNRI (5.7%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4371%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eCocaine (5.7%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9272%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eAvoidant (2.9%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6358%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4371%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eOpiates (2.9%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9272%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMood disorder\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6358%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMood stabilizer\u0026nbsp;\u003c/strong\u003e(25.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4371%;\"\u003e\n \u003cul\u003e\n \u003cli\u003e3-MMC/GHB (2.9%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9272%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eBipolar (17.1%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6358%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eLithium (2.9%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4371%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEating disorder\u0026nbsp;\u003c/strong\u003e(23%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9272%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eDepressive episode (8.6%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6358%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eLamotrigine (17.1%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4371%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eBulimia nervosa (14.3%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9272%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6358%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eAntipsychotic 9\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4371%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eRestrictive anorexia (5.7%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9272%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6358%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOthers\u003c/strong\u003e (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4371%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBehavioral addiction\u003c/strong\u003e (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9272%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eADHD (11.4%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6358%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eMethylphenidate\u0026nbsp;(2.9%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4371%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eGambling addiction (5.7%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9272%;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePTSD (2.9%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6358%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eAnxiolytic (31.4%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4371%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eSex addiction (5.7%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9272%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eSocial phobia (5.7%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6358%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eMethadone (2.9%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4371%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eScreen addiction (2.9%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9272%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eGeneralized anxiety (2.9%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6358%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eAcamprosate (2.9%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4371%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35.9272%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6358%;\"\u003e\n \u003cul\u003e\n \u003cli\u003eBaclofen, Nalmefen\u0026nbsp;(17.1%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTransdiagnostic Dialectical and Behavioral Therapy skills training\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStandalone DBT skills training groups were implemented in 2021 at the addictology department of Strasbourg. Participants received DBT as described in the two reference manuals (Linehan, 1993a, 1993b) with adaptations made for transdiagnostic groups (Durpoix, Lachaux, et al., 2023; Neacsiu et al., 2014). The 4 modules of skills were covered: i.e., mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe skills training groups took place over 2 two-months and consisted of weekly sessions (2 h), and a weekly team consultation for therapists (1.5 h). There was only one group at a time. Thus, 2 x 4 cycles were conducted between 2021 and 2023. Participants were engaged for one cycle, and they could start with cycle 1 or cycle 2 depending on the progress in the program. Patients who missed approximately half of a cycle (\u0026ge; 4 sessions) were considered withdrawn from that cycle and could to re-engage if they wished to participate in a new cycle. Although individual DBT and telephone coaching were not offered, participants were motivated to use digital tools that have demonstrated interest (Durpoix et al., 2021; Prada et al., 2017).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll participants were required to attend regular appointments with their addiction specialist or psychiatrist through their department for medication review and treatment monitoring. No structured therapy or structured counseling was provided during these appointments.\u003cu\u003e\u003cbr\u003e\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eTable 2\u003c/u\u003e: List of DBT Skills taught\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eModules\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSessions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSkills\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 595px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eClinical assessment and engagement for cycle 1\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"9\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMindfulness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003eWise mind and \u0026ldquo;what\u0026rdquo; skills of mindfulness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u0026ldquo;How\u0026rdquo; skills of mindfulness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDistress Tolerance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003eSTOP \u0026amp; TIP skills\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003eACCEPTS skills\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003eIMPROVE and self-soothing skills\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003eRadical acceptance and willingness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterpersonal Effectiveness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003eDEAR MAN skill\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003eGIVE and FAST skills\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003eValidation others and self-validation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 595px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eDebriefing session and engagement for cycle 2\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCycle 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMindfulness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003eWise mind and \u0026ldquo;what\u0026rdquo; skills of mindfulness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003e\u0026ldquo;How\u0026rdquo; skills of mindfulness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmotional Regulation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003eUnderstand, identify and name emotions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003eFact-checking\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003eOpposite action\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003eProblem solving\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003eABC skills\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 293px;\"\u003e\n \u003cp\u003ePLEASE skills\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 595px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eDebriefing session of therapy\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTherapists\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFour therapists participated in the implementation of DBT groups in a French addictology department between 2021 and 2023. The four DBT therapists were a psychiatrist, a nurse, a clinical psychologist, and a CBT-trained psychiatric intern. Their participation depended on their availability. The level of DBT training ranged from low to medium and the level of DBT experience ranged from 0 to 10 cycles (Table 3, Supplementary Material). A DBT group was led by two to three therapists. An estimate of individual therapist adherence to DBT could not be made. Before to lead a group, therapists had observed at least one DBT group, read the reference manual, and watched YouTube videos summarizing the skills (Durpoix et al., 2021). Three therapists had also received one or more formal medium trainings (2 to 7 days), but none had be able to benefit from the intensive 2x5 days training. In addition to weekly team consultations, the therapists received an external team consultation as described by Gaglia (Gaglia, 2018) during the first 2 cycles.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eTable 3\u003c/u\u003e: Characteristics of the 4 professionals who implemented DBT\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 189px;\"\u003e\n \u003cp\u003eTherapists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eDBT training level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003eDBT experience level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eAnimated Cycles\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003ePsychiatrist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0-7 cycles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eCycles 1 to 8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eNurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eLow\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0-1 cycles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eCycles 3 to 4\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2-5 cycles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eCycles 5 to 8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eT3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eCBT Psychologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0-3 cycles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eCycles 3 to 6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003eT4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003ePsychiatry Intern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e7-10 cycles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eCycles 1-2 \u0026amp; 7-8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMeasures and procedure\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAttrition rate was recorded for each cycle. Attrition was considered when a patient missed approximately half of a cycle\u0026nbsp;(\u0026ge; 4 sessions).\u0026nbsp;This attrition was considered complete (called \u0026quot;drop-out\u0026quot;) if the patient did not return for another cycle, or partial (called \u0026quot;pause\u0026quot;) if the patient returned for another cycle.\u003c/p\u003e\n\u003cp\u003eDuring therapy, participants completed standardized questionnaires before therapy, after cycle 1, and after cycle 2. For the before-and-after analysis, we used the first and last completed questionnaires. As the targeted psychological process was a decrease in emotional dysregulation, we focused on the before-and-after development of the DERS. The other scales focused on the use of emotional regulation skills (cognitive emotional regulation with CERQ, mindfulness with KIMS), specific emotional difficulties (BPD symptoms with BSL-23, anxiety with BAI, and hopelessness with H), as well as the behavioral and social consequences of emotional dysregulation (impulsivity with UPPS, and social functioning with QFS). The characteristics of each questionnaire are listed below:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cu\u003eDERS\u003c/u\u003e (Gratz \u0026amp; Roemer, 2004): The Difficulties in Emotion Regulation Scale is a 36-item self-questionnaire, that assesses different facets of emotional dysregulation: non-acceptance of negative emotions, difficulty engaging in goal-directed behavior, lack of impulse control in emotional situations, lack of regulatory strategies, lack of emotional awareness and lack of emotional clarity. The higher the DERS score, the greater the emotional regulation difficulties. Psychometric analyses in a non-clinical population indicate good internal consistency (Cronbach\u0026apos;s \u0026alpha; = 0.93), and good test-retest reliability over a 4-8 week period (r = 0.88, p \u0026lt; 0.01). The French translation (Dan-Glauser \u0026amp; Scherer, 2013) showed high congruence with the original (\u0026alpha; = 0.92).\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eCERQ\u003c/u\u003e (Garnefski et al., 2001): The Cognitive Emotion Regulation Questionnaire is a 36-item self-questionnaire measuring 9 cognitive strategies used to cope with negative events (acceptance, positive refocusing, refocus on planning, positive reappraisal, putting into perspective, self-blame, catastrophizing, rumination, blaming others). Using a 5-point Likert scale, each strategy is measured by a 4-item subscale. As evaluated in adults (Garnefski \u0026amp; Kraaij, 2007), the CERQ subscales have good internal consistency (\u0026alpha; = 0.75-0.87) and test-retest reliability at 1-year intervals (r = 0.48-0.65).\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eKIMS\u003c/u\u003e (Baer et al., 2004): The Kentucky Inventory of Mindfulness Skills is a 39-item self-questionnaire with a 5-point scale. This questionnaire measures the general tendency to be fully aware in daily life. It includes 4 subscales: Observing (e.g., \u0026quot;I pay attention to how my emotions affect my thoughts and behavior\u0026quot;), Describing (e.g., \u0026quot;I know how to find the words to describe my feelings\u0026quot;), Acting with awareness (e.g., \u0026quot;When I do something, I\u0026apos;m only focused on what I\u0026apos;m doing and nothing else\u0026quot;) and Accepting without judgment (e.g., \u0026quot;I criticize myself for having irrational or inappropriate emotions\u0026quot; - reverse item). These subscales show good internal consistency (\u0026alpha; = 0.83-0.91) and test-retest reliability over a period of 14-17 days (r = 0.65-0.86). The French version has similar psychometric properties (Nicastro et al., 2010).\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eBSL-23\u003c/u\u003e (Wolf et al., 2009): The Borderline-Symptom List is a 23-item self-questionnaire with a 4-point scale that assesses BPD symptoms one week prior to the assessment. The items address both diagnostic criteria, such as affective instability and self-harming behavior, as well as borderline-typical empirical findings regarding self-criticism, trust issues, emotional vulnerability, and feelings of shame, loneliness, and helplessness (Kleindienst et al., 2020). BSL-23 has high internal consistency validity and test-retest reliability, notably in the French version (\u0026alpha; = 0.94, r=0.84 \u0026ndash; (Nicastro et al., 2016)).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eBAI\u003c/u\u003e (Beck et al., 1988): The Beck Anxiety Inventory is a 21-item self-questionnaire with a 4-point scale that assesses anxiety using a 2-factor model (somatic symptoms, and cognitive-affective symptoms). It showed excellent internal consistency (\u0026alpha; = 0.92), and good test-retest reliability over 1 week (r = 0.75). The BAI ranges from 0-20 (mild), through 21-30 (moderate), to 31+ (severe).\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eBHS\u003c/u\u003e (Beck et al., 1974, p. 197): The Beck Hopelessness Scale is a 20-item true/false self-questionnaire that assesses three major aspects of hopelessness: feelings about the future, loss of motivation, and expectations. Validity and reliability have been well established (\u0026alpha; = 0.93).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eUPPS\u003c/u\u003e (Whiteside \u0026amp; Lynam, 2001): The Urgency Perseverance Premeditation Sensation Seeking Impulsive Behavior scale is a 45-item self-questionnaire with a 4-point scale assessing impulsivity. It includes 4 subscales with good internal consistency: urgency (\u0026alpha; = 0.86), lack of perseverance (\u0026alpha; = 0.82), lack of premeditation (\u0026alpha; = 0.91), sensation seeking (\u0026alpha; = 0.90). A shorter 20-items version translated into French (Billieux et al., 2012) contains 5 subscales with correct internal consistency and test-retest reliability: negative urgency (\u0026alpha; = 0,78, r = 0,87), positive urgency (\u0026alpha; = 0.70, r = 0.84), lack of premeditation (\u0026alpha; = 0.79, r = 0.85), lack of perseverance (\u0026alpha; = 0.84, r = 0.85), sensation seeking (\u0026alpha; = 0,83, r = 0,92).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cu\u003eQFS\u003c/u\u003e (Zanello et al., 2004, 2006): The Social Functioning Questionnaire is a 16-item self-questionnaire with a 5-point scale that assesses two facets of social functioning (frequency of behaviors, and satisfaction with them). Psychometric analyses in a population combining healthy and sick subjects, such as anxiety and depressive disorders, personality disorders, psychotic disorders, indicate correct internal consistency and 15-day test-retest reliability (\u0026alpha; = 0,65-0,83, r = 0,69-0,71).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStatistical analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analyzed using SPSS (version 27). We performed a descriptive analysis of cycle participation and the evolution of emotional dysregulation and impulsivity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThen, we compared the evolution of questionnaires between before and after DBT using a Student\u0026rsquo;s T-test. Statistical significance was considered for p-values \u0026lt;.05. Effect sizes were calculated using Cohen\u0026apos;s d and considered strong if greater than 0.8, medium if greater than 0.5, and small if greater than 0.3. The conditions for the application of the tests were respected for each questionnaire (normal distribution and homogeneity of variances).\u003c/p\u003e\n\u003cp\u003eFinally, we studied the relationships between clinical outcomes and therapists\u0026rsquo; level. We analyzed the influence of experience level on DERS progression with Pearson correlation and on attrition with T-test. We also analyzed the influence of training level on DERS progression with T-test and on attrition with \u0026chi;2 test. Because the distribution of DERS progression was not normal, the T-test was replaced with the Mann-Whitney test, and Pearson correlation was replaced with the Spearman correlation.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDescriptive statistics\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 35 patients who have engaged in therapy to date, 80% completed one cycle (28/35) and 49% have completed both cycles (17/35). As the DBT groups continue, some patients will soon participate in the 2nd cycle. On 17 occasions, 29% of patients (10/35) started a cycle but did not complete it. This amounts to 62 participations in a cycle. The rate of complete attrition or \u0026quot;drop-out\u0026quot;, i.e. stopping the cycle without subsequent participation, was 21% (13/62). The rate of partial attrition or \u0026quot;pause\u0026quot;, i.e. stopping the cycle and rejoining in a subsequent cycle, was 6% (4/62). Questionnaires were completed by 57% of participants (20/35) after the 1st cycle, and by 43% (15/35) after the 2nd cycle. Twenty-four participants (69%) completed at least one of the 2 questionnaires in addition to the pretherapy questionnaire.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eChanges in before-and-after questionnaires\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe DERS and 5 other questionnaires showed a statistically significant improvement (Table 4). The effect sizes were large for DERS, CERQ+ and CERQ- and medium for KIMS and UPPS.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eTable 4\u003c/u\u003e: Evolution of self-questionnaires\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e24/35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore Therapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 201px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAfter Therapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEffect Size\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(Cohen\u0026rsquo;s d)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDERS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e118.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e23.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e95.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e30.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.900***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCERQ+\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e49.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e11.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e60.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e13.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.978***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCERQ-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e49.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e8.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e41.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e10.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e1.040***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKIMS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e110.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e19.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e127.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e23.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.766***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBSL-23\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.196\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBAI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e24.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e12.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e21.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e17.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.283\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBHS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e10.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e4.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e8.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e5.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.332\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUPPS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e52.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e9.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e46.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e10.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.586 **\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQFS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e54.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e9.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e57.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e9.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.407*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e*p\u0026lt;.05, **p\u0026lt;.005, ***p\u0026lt;.001\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eImprovement in DERS score was 25.6% for participants with BPD and 16.5% for participants without BPD, but the difference was not statistically significant (d = 0.429, p=.102). The attrition rate per cycle averaged 26.6% for patient with BPD and 25% for patient without BPD, their difference was not statistically significant (\u0026chi;=0.0225, p=.881).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInfluence of therapists\u0026rsquo; level on clinical outcomes\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRetention and improvement rates in DERS varied over the 8 cycles performed between 2021 and 2023 (Figure 1, Supplementary Material). Retention reached its lowest level in cycle 4. The decrease in improvement was greatest in cycles 3 and 4 when the groups were led by therapists with experience \u0026lt;3 cycles. Between cycles 4 and 5, one of the therapists underwent formal medium training and the rate of improvement and retention increased again. Therapists had an average attrition rate of 32.2% (including 26.2% dropouts) when their level of training was low, and 19.9% (including 19% dropouts) when their level of training was medium, but there was no significant difference between both (\u0026chi;\u0026nbsp;= 1.71, p=.191). Patients who interrupted their participation had on average therapists with an experience of 2.74 cycles, and those who remained had an average of therapists with an experience of 4.40 cycles, their difference was significant between the two (effect size = 0.320, p=.001).\u003c/p\u003e\n\u003cp\u003eParticipants\u0026apos; improvement in DERS averaged 19.1% for therapists with low training, and 19.3% for therapists with medium training, the difference between the two was not significant (effect size = 0.0211, p=.859). There was also no statistically significant correlation between DERS improvement and therapist experience (rho=-0.068, p=.494).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur naturalistic study aimed to investigate the effects of transdiagnostic DBT groups at the beginning of implementation in addictology on emotional regulation and impulsivity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur results showed that from the start of implementation, transdiagnostic DBT groups were effective in reducing emotional (dys)regulation with a high effect size and impulsivity with a medium effect size, two processes important in addictology. Transdiagnostic DBT is poorly studied, its effect on DERS has been analyzed once in the only available randomized controlled trial\u0026nbsp;(Neacsiu et al., 2014)). Their effect size of 1.86 was higher than our effect size of 0.9, but their patients were included for anxiety or depressive disorders and only 13,6% had a comorbidity with addictive disorders. In contrast, the evolution of DERS has often been studied during unidiagnostic DBT groups, notably in substance addictions with effect sizes close to ours at 1.08\u0026nbsp;(Cavicchioli, Movalli, Vassena, et al., 2019)\u0026nbsp;or at 0.54\u0026nbsp;(Cavicchioli et al., 2023), or in eating disorders with an effect size of 0.69 according to a recent meta-analysis\u0026nbsp;(Rozakou-Soumalia et al., 2021).\u0026nbsp;To our knowledge, our study is the first to investigate the effects of transdiagnostic DBT for addictive disorders on emotional dysregulation and impulsivity.\u003c/p\u003e\n\u003cp\u003eRegarding the other questionnaires, fewer studies are available to compare their evolution during DBT. The evolution of CERQ and KIMS during DBT groups has already been studied, but not yet in patients with addictive disorders. We found an effect size of 0.978 for CERQ +, 1.040 for CERQ- and 0.766 for KIMS, which is consistent with the significant changes found during DBT in other clinical populations for both CERQ\u0026nbsp;(Abdullahi \u0026amp; Nouri, 2024; Kalantarian et al., 2024; Sepehri et al., 2016)\u0026nbsp;and KIMS\u0026nbsp;(Klodnick et al., 2021; Perroud et al., 2012, p. 201). The evolution of UPPS had not yet been studied during transdiagnostic DBT groups, but was sometimes studied during unidiagnostic DBT groups for substance addiction: the effect size of 0.586 found in our study was quite close to the evolution present in the study by Cavicchioli et al\u0026nbsp;(Cavicchioli et al., 2023). The evolution of QFS had never been studied during DBT to our knowledge, even though we know the effect of DBT on social functioning\u0026nbsp;(Wilks et al., 2016).\u003c/p\u003e\n\u003cp\u003eOur results are consistent with the literature on DBT, effect sizes were generally in line with other studies. When they were lower, this may be linked to differences in the population because our results are in line with those found in DBT groups implemented in addictology for longer. The attrition rate observed in our study was close to the 20% rate found in a study on DBT for SUD-eating disorder comorbidity\u0026nbsp;(Courbasson et al., 2012b). Further studies are needed to know the influence of diagnosis on DERS progression. Our study didn\u0026rsquo;t find significant differences depending on BPD diagnostics, like van den Bosh et al\u0026nbsp;(van den\u0026nbsp;Bosch et al., 2002)\u0026nbsp;didn\u0026rsquo;t find differences in BPD population depending on addiction comorbidity.\u0026nbsp;At long-term, a study showed that regardless their diagnosis, participants improved their emotional instability and substance use one year after transdiagnostic DBT for BPD, bipolar disorder, and/or ADHD\u0026nbsp;(Durpoix, Lachaux, et al., 2023).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDBT has an important place in addictology to reduce the impact of emotional dysregulation and impulsivity. This therapy is particularly suitable to treat life-threatening behaviors (suicide behavior, overdose\u0026hellip;) which are frequent in patients with addictive behaviors. Unlike CBT, DBT teaches acceptance-oriented emotional regulation skills in addition to change-oriented skills. These different skills make it suitable for improving the distress tolerance in suicidal patients\u0026nbsp;(Durpoix, Rolling, et al., 2023). Their learning acts on the emotions generated by the limbic system by improving its connectivity with the prefrontal cortex through a top-down mechanism, thus complementing pharmacotherapy that acts on the limbic system through a bottom-up mechanism\u0026nbsp;(Luo et al., 2023; Quid\u0026eacute; et al., 2012). Their combination has sometimes been studied in addictology, DBT has been shown to be effective in opioid addiction in combination with methadone replacement treatment\u0026nbsp;(Rezaie et al., 2021)\u0026nbsp;or levomethadyl acetate hydrochloride\u0026nbsp;(Linehan et al., 2002). Anti-craving drugs such as baclofen could also be interesting to combine with DBT, but no studies exist on the effectiveness of their combination to our knowledge.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLike any treatment, DBT can be difficult to implement in a new healthcare team. On average, half of teams stop DBT, usually after 2 to 5 years\u0026nbsp;(King et al., 2018).\u0026nbsp;As a high level of distress in emotional dysregulation affects 135 million people worldwide\u0026nbsp;(DuBose et al., 2018), it is important to assess potential solutions to the challenges encountered during the implementation of DBT. A paradox is that training requires funding, but funding often comes only once the effectiveness of DBT has been proven at the local level\u0026nbsp;(Tan et al., 2023). Non-intensive DBT training makes the principles of therapy more affordable and the transdiagnostic format facilitates patient recruitment\u0026nbsp;(Durpoix, Lachaux, et al., 2023; Reinholt et al., 2021). Our study suggests that these solutions preserve the effects of DBT on emotional dysregulation and impulsivity in addictology. This finding is consistent with the study by Pasciezny \u0026amp; Conor\u0026nbsp;(Pasieczny \u0026amp; Connor, 2011)\u0026nbsp;which showed that the effect of DBT on psychometric criteria did not vary according to the intensity of therapist training.\u003c/p\u003e\n\u003cp\u003eDBT therefore acts on the emotional regulation and impulsivity of addictions despite the many challenges of implantation. These results can help other teams to dare to implement DBT, there is no need to wait several years before obtaining results. As our study shows, results can vary over time, especially at the beginning of implementation. These results reminder that the implementation of a therapy is not a passive process\u0026nbsp;(Fairburn \u0026amp; Wilson, 2013). Responsibility of implementation doesn\u0026rsquo;t only depend on\u0026nbsp;therapists, good institutional cohesion is necessary in order not to give up\u0026nbsp;(Swales, 2010). Several authors warn about the lack of implementation studies that prevent us from correctly discerning whether a negative result comes from therapy failure or implementation failure\u0026nbsp;(Comtois \u0026amp; Landes, 2018; Proctor et al., 2011). Our study provides arguments to avoid deeming a therapy implementation ineffective and abandoning it, as a lack of effectiveness can be corrected notably with an increase in therapists\u0026rsquo; level of experience. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe\u003cstrong\u003e\u0026nbsp;strength\u003c/strong\u003e of our study lay in its naturalistic design with sufficient data to analyze in practice the effect of DBT groups on emotional dysregulation and impulsivity in a population of patients comorbid with addictive disorders. Naturalistic studies have the advantage to know better the effects of an intervention in practice reality. A problem is that the most of these studies on DBT are conducted with intensively trained therapists\u0026nbsp;(Walton \u0026amp; Comtois, 2018), like for randomized controlled trials\u0026nbsp;(Miga et al., 2019; Shafran et al., 2009), although the implementation is often done by inexperienced DBT therapists with non-intensive training. Our study fills this data gap by showing the reality of DBT therapists. The cycle-by-cycle evaluation of evolution of emotional dysregulation, impulsivity, attrition, and therapist levels provided a detailed picture of the successes and difficulties encountered during DBT implementation. We succeed to have enough data, even if naturalistic studies have often a lot of missing data\u0026nbsp;(Shafran et al., 2009). Except Pasciezny \u0026amp; Connor\u0026nbsp;(Pasieczny \u0026amp; Connor, 2011), we didn\u0026rsquo;t know none other studies which investigated the effects of the level of DBT therapists on patients\u0026rsquo; evolution.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe strength of our study was also its\u003cstrong\u003e\u0026nbsp;limitation\u003c/strong\u003e. The naturalistic design of our study does not allow us to state that the improvement of emotion dysregulation and impulsivity would be the same or different with groups implemented since longer, as we do not have a comparison with a randomized control group. Furthermore, while we analyzed the theoretical and practical level in DBT, the low adherence to therapeutic principles and other obstacles referenced in the literature (therapist burnout, philosophical attitude hostile to evidence-based practices, etc.) were more difficult to study. It would have been interesting to know the influence of these factors on the evolution of emotional dysregulation and impulsivity, particularly during cycles with declining results. Similarly, we were unable to assess the influence of non-DBT professional experience on the evolution of emotional dysregulation and impulsivity. We don\u0026rsquo;t know whether this experience before starting DBT is an advantage or disadvantage. Precautions should be taken given the small samples.\u003c/p\u003e\n\u003cp\u003eIn \u003cstrong\u003econclusion\u003c/strong\u003e, while we know the effectiveness of DBT on emotional dysregulation and impulsivity, two particularly important functions in addictology, we found that their improvement can occur as soon as the therapy is implemented despite challenges present. In addictology, few therapies act on emotional regulation and impulsivity: CBT is less suitable for severe cases and pharmacotherapy does not provide top-down learning. It is therefore important to improve the implementation of DBT by assessing barriers to implementation. Our study found that the results could be irregular depending on the period of implantation but improved with the experience of the therapists. This highlights the importance of good institutional cohesion to overcome these challenges of implementation. Comparative studies are necessary to verify if patient improvement would be different with groups implemented since longer or with highly trained and experienced therapists.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the ethics committee of the Strasbourg\u0026rsquo;s Medicine Faculty (CE-2023-121). Participants were individually informed in written that their data could be used anonymously to evaluate the program and that they were allowed to refuse to participate. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll of the material is owned by the authors and/or no permissions are required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results/data/figures in this manuscript have not been published elsewhere, nor are they under consideration (from you or one of your Contributing Authors) by another publisher.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOpen access funding provided by University Hospitals of Strasbourg. The authors received no specific funding for this work.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. D., L. W., S. W., LM. D. and L. L. designed the research protocol. S. W., L. W. and A. D. developed the intervention program and therapy materials for patients. A. D., C. P., M. W., and LM. D. recruited participants and conducted therapy sessions together. L. L., L. W. and S. W provided support for therapy. A. D. and F. S. conducted the statistical analyses and wrote the first draft of the manuscript, which was then reviewed by L. L and L. W.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe want to thank the clinicians who helped us to implement these DBT groups in Strasbourg: Ms Saliha Derrouazi, Ms Val\u0026eacute;rie Poussardin and Ms Doha Bemmouna.\u003c/p\u003e\n\u003cp\u003eWe also want to thank the professionals who trained us to DBT: Pr Nader Perroud, Pr Shelley McMain\u0026nbsp;and Pr Michaela Swales.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbdullahi, R., \u0026amp; Nouri, T. (2024). Dialectical Behavior Therapy : Impact on Self-Harming Behaviors, Bullying, and Cognitive Emotion Regulation in Delinquent Teenagers. \u003cem\u003eJournal of Adolescent and Youth Psychological Studies (JAYPS)\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e(5), 14‑20. https://doi.org/10.61838/kman.jayps.5.5.3\u003c/li\u003e\n\u003cli\u003eArcelus, J., Mitchell, A. J., Wales, J., \u0026amp; Nielsen, S. (2011). Mortality Rates in Patients With Anorexia Nervosa and Other Eating Disorders : A Meta-analysis of 36 Studies. \u003cem\u003eArchives of General Psychiatry\u003c/em\u003e, \u003cem\u003e68\u003c/em\u003e(7), 724‑731. https://doi.org/10.1001/archgenpsychiatry.2011.74\u003c/li\u003e\n\u003cli\u003eAsarnow, J. R., Berk, M. S., Bedics, J., Adrian, M., Gallop, R., Cohen, J., Korslund, K., Hughes, J., Avina, C., Linehan, M. M., \u0026amp; McCauley, E. (2021). Dialectical Behavior Therapy for Suicidal Self-Harming Youth : Emotion Regulation, Mechanisms, and Mediators. \u003cem\u003eJournal of the American Academy of Child and Adolescent Psychiatry\u003c/em\u003e, \u003cem\u003e60\u003c/em\u003e(9), 1105-1115.e4. https://doi.org/10.1016/j.jaac.2021.01.016\u003c/li\u003e\n\u003cli\u003eAxelrod, S. R., Perepletchikova, F., Holtzman, K., \u0026amp; Sinha, R. (2011). Emotion Regulation and Substance Use Frequency in Women with Substance Dependence and Borderline Personality Disorder Receiving Dialectical Behavior Therapy. \u003cem\u003eThe American journal of drug and alcohol abuse\u003c/em\u003e, \u003cem\u003e37\u003c/em\u003e(1), 37‑42. https://doi.org/10.3109/00952990.2010.535582\u003c/li\u003e\n\u003cli\u003eAzizi, A., Borjali, A., \u0026amp; Golzari, M. (2010). The effectiveness of emotion regulation training and cognitive therapy on the emotional and addictional problems of substance abusers. \u003cem\u003eIranian Journal of Psychiatry\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e(2), 60‑65.\u003c/li\u003e\n\u003cli\u003eBaer, R. A., Smith, G. T., \u0026amp; Allen, K. B. (2004). Assessment of mindfulness by self-report : The Kentucky inventory of mindfulness skills. \u003cem\u003eAssessment\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(3), 191‑206. https://doi.org/10.1177/1073191104268029\u003c/li\u003e\n\u003cli\u003eBahji, A., Mazhar, M. N., Hudson, C. C., Nadkarni, P., MacNeil, B. A., \u0026amp; Hawken, E. (2019). Prevalence of substance use disorder comorbidity among individuals with eating disorders : A systematic review and meta-analysis. \u003cem\u003ePsychiatry Research\u003c/em\u003e, \u003cem\u003e273\u003c/em\u003e, 58‑66. https://doi.org/10.1016/j.psychres.2019.01.007\u003c/li\u003e\n\u003cli\u003eBattini, T., \u0026amp; Perozziello, A. (2023). Epid\u0026eacute;miologie des addictions. In \u003cem\u003eLes Addictions\u003c/em\u003e. Elsevier Health Sciences.\u003c/li\u003e\n\u003cli\u003eBeauchaine, T. P. (2015). Future Directions in Emotion Dysregulation and Youth Psychopathology. \u003cem\u003eJournal of Clinical Child \u0026amp; Adolescent Psychology\u003c/em\u003e, \u003cem\u003e44\u003c/em\u003e(5), 875‑896. https://doi.org/10.1080/15374416.2015.1038827\u003c/li\u003e\n\u003cli\u003eBeck, A. T., Epstein, N., Brown, G., \u0026amp; Steer, R. A. (1988). An inventory for measuring clinical anxiety : Psychometric properties. \u003cem\u003eJournal of Consulting and Clinical Psychology\u003c/em\u003e, \u003cem\u003e56\u003c/em\u003e, 893‑897. https://doi.org/10.1037/0022-006X.56.6.893\u003c/li\u003e\n\u003cli\u003eBeck, A. T., Weissman, A., Lester, D., \u0026amp; Trexler, L. (1974). The measurement of pessimism : The Hopelessness Scale. \u003cem\u003eJournal of Consulting and Clinical Psychology\u003c/em\u003e, \u003cem\u003e42\u003c/em\u003e(6), 861‑865. https://doi.org/10.1037/h0037562\u003c/li\u003e\n\u003cli\u003eBerking, M., Margraf, M., Ebert, D., Wupperman, P., Hofmann, S. G., \u0026amp; Junghanns, K. (2011). Deficits in Emotion-Regulation Skills Predict Alcohol Use During and After Cognitive Behavioral Therapy for Alcohol Dependence. \u003cem\u003eJournal of consulting and clinical psychology\u003c/em\u003e, \u003cem\u003e79\u003c/em\u003e(3), 307‑318. https://doi.org/10.1037/a0023421\u003c/li\u003e\n\u003cli\u003eBillieux, J., Rochat, L., Ceschi, G., Carr\u0026eacute;, A., Offerlin-Meyer, I., Defeldre, A.-C., Khazaal, Y., Besche-Richard, C., \u0026amp; Van der Linden, M. (2012). Validation of a short French version of the UPPS-P Impulsive Behavior Scale. \u003cem\u003eComprehensive Psychiatry\u003c/em\u003e, \u003cem\u003e53\u003c/em\u003e(5), 609‑615. https://doi.org/10.1016/j.comppsych.2011.09.001\u003c/li\u003e\n\u003cli\u003eBrockmeyer, T., Skunde, M., Wu, M., Bresslein, E., Rudofsky, G., Herzog, W., \u0026amp; Friederich, H.-C. (2014). Difficulties in emotion regulation across the spectrum of eating disorders. \u003cem\u003eComprehensive Psychiatry\u003c/em\u003e, \u003cem\u003e55\u003c/em\u003e(3), 565‑571. https://doi.org/10.1016/j.comppsych.2013.12.001\u003c/li\u003e\n\u003cli\u003eCavicchioli, M., Movalli, M., Bruni, A., Terragni, R., Maria Elena, G., Borgia, E., Begarani, M., \u0026amp; Ogliari, A. (2023). The Initial Efficacy of Stand-Alone DBT Skills Training for Treating Impulsivity Among Individuals With Alcohol and Other Substance Use Disorders. \u003cem\u003eBehavior Therapy\u003c/em\u003e, \u003cem\u003e54\u003c/em\u003e(5), 809‑822. https://doi.org/10.1016/j.beth.2023.02.006\u003c/li\u003e\n\u003cli\u003eCavicchioli, M., Movalli, M., \u0026amp; Maffei, C. (2019). Difficulties with emotion regulation, mindfulness, and substance use disorder severity : The mediating role of self-regulation of attention and acceptance attitudes. \u003cem\u003eThe American Journal of Drug and Alcohol Abuse\u003c/em\u003e. https://www.tandfonline.com/doi/full/10.1080/00952990.2018.1511724\u003c/li\u003e\n\u003cli\u003eCavicchioli, M., Movalli, M., Ramella, P., Vassena, G., Prudenziati, F., \u0026amp; Maffei, C. (2020). Feasibility of dialectical behavior therapy skills training as an outpatient program in treating alcohol use disorder : The role of difficulties with emotion regulation and experiential avoidance. \u003cem\u003eAddiction Research \u0026amp; Theory\u003c/em\u003e, \u003cem\u003e28\u003c/em\u003e(2), 103‑115. https://doi.org/10.1080/16066359.2019.1590558\u003c/li\u003e\n\u003cli\u003eCavicchioli, M., Movalli, M., Vassena, G., Ramella, P., Prudenziati, F., \u0026amp; Maffei, C. (2019). The therapeutic role of emotion regulation and coping strategies during a stand-alone DBT Skills training program for alcohol use disorder and concurrent substance use disorders. \u003cem\u003eAddictive Behaviors\u003c/em\u003e, \u003cem\u003e98\u003c/em\u003e, 106035. https://doi.org/10.1016/j.addbeh.2019.106035\u003c/li\u003e\n\u003cli\u003eCavicchioli, M., Vassena, G., Movalli, M., \u0026amp; Maffei, C. (2018). Addictive behaviors in alcohol use disorder : Dysregulation of reward processing systems and maladaptive coping strategies. \u003cem\u003eJournal of Addictive Diseases\u003c/em\u003e, \u003cem\u003e37\u003c/em\u003e(3‑4), 173‑184. https://doi.org/10.1080/10550887.2019.1643211\u003c/li\u003e\n\u003cli\u003eChesney, E., Goodwin, G. M., \u0026amp; Fazel, S. (2014). Risks of all-cause and suicide mortality in mental disorders : A meta-review. \u003cem\u003eWorld Psychiatry: Official Journal of the World Psychiatric Association (WPA)\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e(2), 153‑160. https://doi.org/10.1002/wps.20128\u003c/li\u003e\n\u003cli\u003eComtois, K. A., \u0026amp; Landes, S. J. (2018). Implementing DBT : An Implementation Science Perspective. In M. A. Swales (\u0026Eacute;d.), \u003cem\u003eThe Oxford Handbook of Dialectical Behaviour Therapy\u003c/em\u003e (p. 0). Oxford University Press. https://doi.org/10.1093/oxfordhb/9780198758723.013.54\u003c/li\u003e\n\u003cli\u003eCourbasson, C., Nishikawa, Y., \u0026amp; Dixon, L. (2012a). Outcome of Dialectical Behaviour Therapy for Concurrent Eating and Substance Use Disorders. \u003cem\u003eClinical Psychology \u0026amp; Psychotherapy\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(5), 434‑449. https://doi.org/10.1002/cpp.748\u003c/li\u003e\n\u003cli\u003eCourbasson, C., Nishikawa, Y., \u0026amp; Dixon, L. (2012b). Outcome of dialectical behaviour therapy for concurrent eating and substance use disorders. \u003cem\u003eClinical Psychology \u0026amp; Psychotherapy\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(5), 434‑449. https://doi.org/10.1002/cpp.748\u003c/li\u003e\n\u003cli\u003eDan-Glauser, E. S., \u0026amp; Scherer, K. R. (2013). The Difficulties in Emotion Regulation Scale (DERS) : Factor structure and consistency of a French translation. \u003cem\u003eSwiss Journal of Psychology\u003c/em\u003e, \u003cem\u003e72\u003c/em\u003e, 5‑11. https://doi.org/10.1024/1421-0185/a000093\u003c/li\u003e\n\u003cli\u003eDavis, C., \u0026amp; Claridge, G. (1998). The eating disorders as addiction : A psychobiological perspective. \u003cem\u003eAddictive Behaviors\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(4), 463‑475. https://doi.org/10.1016/S0306-4603(98)00009-4\u003c/li\u003e\n\u003cli\u003eDawe, S., \u0026amp; Loxton, N. J. (2004). The role of impulsivity in the development of substance use and eating disorders. \u003cem\u003eNeuroscience \u0026amp; Biobehavioral Reviews\u003c/em\u003e, \u003cem\u003e28\u003c/em\u003e(3), 343‑351. https://doi.org/10.1016/j.neubiorev.2004.03.007\u003c/li\u003e\n\u003cli\u003eDeCou, C. R., Comtois, K. A., \u0026amp; Landes, S. J. (2019). Dialectical Behavior Therapy Is Effective for the Treatment of Suicidal Behavior : A Meta-Analysis. \u003cem\u003eBehavior Therapy\u003c/em\u003e, \u003cem\u003e50\u003c/em\u003e(1), 60‑72. https://doi.org/10.1016/j.beth.2018.03.009\u003c/li\u003e\n\u003cli\u003eDuBose, A. P., Botanov, Y., \u0026amp; Ivanoff, A. (2018). International Implementation of Dialectical Behaviour Therapy : The Challenge of Training Therapists Across Cultures. In M. A. Swales (\u0026Eacute;d.), \u003cem\u003eThe Oxford Handbook of Dialectical Behaviour Therapy\u003c/em\u003e (p. 0). Oxford University Press. https://doi.org/10.1093/oxfordhb/9780198758723.013.58\u003c/li\u003e\n\u003cli\u003eDurpoix, A., Lachaux, E., Weiner, L., \u0026amp; Weibel, S. (2023). Transdiagnostic Skills Training Group of Dialectical Behavior Therapy : A Long-Term Naturalistic Study. \u003cem\u003eBorderline Personality Disorder and Emotion Dysregulation\u003c/em\u003e. https://doi.org/10.21203/rs.3.rs-2845259/v1\u003c/li\u003e\n\u003cli\u003eDurpoix, A., Rolling, J., Coutelle, R., \u0026amp; Lalanne, L. (2023). Psychotherapies in opioid use disorder : Toward a step-care model. \u003cem\u003eJournal of Neural Transmission\u003c/em\u003e. https://doi.org/10.1007/s00702-023-02720-8\u003c/li\u003e\n\u003cli\u003eDurpoix, A., Weiner, L., Bemmouna, D., Lachaux, E., Krasny-Pacini, A., \u0026amp; Weibel, S. (2021). Psycho\u0026eacute;ducation et r\u0026eacute;gulation \u0026eacute;motionnelle en temps de confinement : Faisabilit\u0026eacute; et int\u0026eacute;r\u0026ecirc;t de vid\u0026eacute;os YouTube de th\u0026eacute;rapie comportementale dialectique. \u003cem\u003eAnnales M\u0026eacute;dico-psychologiques, revue psychiatrique\u003c/em\u003e. https://doi.org/10.1016/j.amp.2021.10.016\u003c/li\u003e\n\u003cli\u003eEvers, C., Marijn Stok, F., \u0026amp; de Ridder, D. T. D. (2010). Feeding Your Feelings : Emotion Regulation Strategies and Emotional Eating. \u003cem\u003ePersonality and Social Psychology Bulletin\u003c/em\u003e, \u003cem\u003e36\u003c/em\u003e(6), 792‑804. https://doi.org/10.1177/0146167210371383\u003c/li\u003e\n\u003cli\u003eFairburn, C. G., \u0026amp; Wilson, G. T. (2013). The dissemination and implementation of psychological treatments : Problems and solutions. \u003cem\u003eInternational Journal of Eating Disorders\u003c/em\u003e, \u003cem\u003e46\u003c/em\u003e(5), 516‑521. https://doi.org/10.1002/eat.22110\u003c/li\u003e\n\u003cli\u003eFlynn, D., Joyce, M., Spillane, A., Wrigley, C., Corcoran, P., Hayes, A., Flynn, M., Wyse, D., Corkery, B., \u0026amp; Mooney, B. (2019). Does an adapted Dialectical Behaviour Therapy skills training programme result in positive outcomes for participants with a dual diagnosis? A mixed methods study. \u003cem\u003eAddiction Science \u0026amp; Clinical Practice\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(1), 28. https://doi.org/10.1186/s13722-019-0156-2\u003c/li\u003e\n\u003cli\u003eGaglia, A. (2018). Shaping Therapists Towards Adherence : A How-to Guide. In M. A. Swales (\u0026Eacute;d.), \u003cem\u003eThe Oxford Handbook of Dialectical Behaviour Therapy\u003c/em\u003e (p. 0). Oxford University Press. https://doi.org/10.1093/oxfordhb/9780198758723.013.60\u003c/li\u003e\n\u003cli\u003eGarnefski, N., \u0026amp; Kraaij, V. (2007). The Cognitive Emotion Regulation Questionnaire. \u003cem\u003eEuropean Journal of Psychological Assessment\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(3), 141‑149. https://doi.org/10.1027/1015-5759.23.3.141\u003c/li\u003e\n\u003cli\u003eGarnefski, N., Kraaij, V., \u0026amp; Spinhoven, P. (2001). Negative life events, cognitive emotion regulation and emotional problems. \u003cem\u003ePersonality and Individual Differences\u003c/em\u003e, \u003cem\u003e30\u003c/em\u003e(8), 1311‑1327. https://doi.org/10.1016/S0191-8869(00)00113-6\u003c/li\u003e\n\u003cli\u003eGratz, K. L., \u0026amp; Roemer, L. (2004). Multidimensional Assessment of Emotion Regulation and Dysregulation : Development, Factor Structure, and Initial Validation of the Difficulties in Emotion Regulation Scale. \u003cem\u003eJournal of Psychopathology and Behavioral Assessment\u003c/em\u003e, \u003cem\u003e26\u003c/em\u003e(1), 41‑54. https://doi.org/10.1023/B:JOBA.0000007455.08539.94\u003c/li\u003e\n\u003cli\u003eHaktanır, A., \u0026amp; Callender, K. A. (2020). Meta-Analysis of Dialectical Behavior Therapy (DBT) for Treating Substance Use. \u003cem\u003eResearch on Education and Psychology\u003c/em\u003e, \u003cem\u003e4\u003c/em\u003e(Special Issue), Article Special Issue.\u003c/li\u003e\n\u003cli\u003eHamilton, K. R., Mitchell, M. R., Wing, V. C., Balodis, I. M., Bickel, W. K., Fillmore, M., Lane, S. D., Lejuez, C. W., Littlefield, A. K., Luijten, M., Mathias, C. W., Mitchell, S. H., Napier, T. C., Reynolds, B., Sch\u0026uuml;tz, C. G., Setlow, B., Sher, K. J., Swann, A. C., Tedford, S. E., \u0026hellip; Moeller, F. G. (2015). Choice impulsivity : Definitions, measurement issues, and clinical implications. \u003cem\u003ePersonality Disorders: Theory, Research, and Treatment\u003c/em\u003e, \u003cem\u003e6\u003c/em\u003e(2), 182‑198. https://doi.org/10.1037/per0000099\u003c/li\u003e\n\u003cli\u003eHarris, C., \u0026amp; Barraclough, B. (1998). Excess mortality of mental disorder. \u003cem\u003eThe British Journal of Psychiatry\u003c/em\u003e, \u003cem\u003e173\u003c/em\u003e(1), 11‑53. https://doi.org/10.1192/bjp.173.1.11\u003c/li\u003e\n\u003cli\u003eHeatherton, T. F., \u0026amp; Baumeister, R. F. (1991). Binge eating as escape from self-awareness. \u003cem\u003ePsychological Bulletin\u003c/em\u003e, \u003cem\u003e110\u003c/em\u003e(1), 86‑108. https://doi.org/10.1037/0033-2909.110.1.86\u003c/li\u003e\n\u003cli\u003eHjems\u0026aelig;ter, A. J., Bramness, J. G., Drake, R., Skeie, I., Monsbakken, B., Benth, J. \u0026Scaron;., \u0026amp; Landheim, A. S. (2019). Mortality, cause of death and risk factors in patients with alcohol use disorder alone or poly-substance use disorders : A 19-year prospective cohort study. \u003cem\u003eBMC Psychiatry\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(1), 101. https://doi.org/10.1186/s12888-019-2077-8\u003c/li\u003e\n\u003cli\u003eHolderness, C. C., Brooks-Gunn, J., \u0026amp; Warren, M. P. (1994). Co-morbidity of eating disorders and substance abuse review of the literature. \u003cem\u003eInternational Journal of Eating Disorders\u003c/em\u003e, \u003cem\u003e16\u003c/em\u003e(1), 1‑34. https://doi.org/10.1002/1098-108X(199407)16:1\u0026lt;1::AID-EAT2260160102\u0026gt;3.0.CO;2-T\u003c/li\u003e\n\u003cli\u003eKalantarian, E., Homaei, R., \u0026amp; Bozorgi, Z. D. (2024). Effects of Emotional Schema Therapy and Dialectical Behavior Therapy on Cognitive Emotion Regulation in Patients with Bipolar II Disorder. \u003cem\u003eModern Care Journal\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(1), Article 1. https://doi.org/10.5812/mcj-138135\u003c/li\u003e\n\u003cli\u003eKanarek, R. B., D\u0026rsquo;Anci, K. E., Jurdak, N., \u0026amp; Mathes, W. F. (2009). Running and addiction : Precipitated withdrawal in a rat model of activity-based anorexia. \u003cem\u003eBehavioral neuroscience\u003c/em\u003e, \u003cem\u003e123\u003c/em\u003e(4), 905‑912. https://doi.org/10.1037/a0015896\u003c/li\u003e\n\u003cli\u003eKing, J. C., Hibbs, R., Saville, C. W. N., \u0026amp; Swales, M. A. (2018). The survivability of dialectical behaviour therapy programmes : A mixed methods analysis of barriers and facilitators to implementation within UK healthcare settings. \u003cem\u003eBMC Psychiatry\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(1), Article 1. https://doi.org/10.1186/s12888-018-1876-7\u003c/li\u003e\n\u003cli\u003eKleindienst, N., Jungkunz, M., \u0026amp; Bohus, M. (2020). A proposed severity classification of borderline symptoms using the borderline symptom list (BSL-23). \u003cem\u003eBorderline Personality Disorder and Emotion Dysregulation\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(1), 11. https://doi.org/10.1186/s40479-020-00126-6\u003c/li\u003e\n\u003cli\u003eKlodnick, V. V., Kissane, B., Johnson, R. P., Malina, C., Ewing, A., \u0026amp; Fagan, M. A. (2021). Adapting Dialectical Behavior Therapy for Young Adults Diagnosed with Serious Mental Health Conditions in Residential Care : A Feasibility Study. \u003cem\u003eResidential Treatment for Children \u0026amp; Youth\u003c/em\u003e. https://www.tandfonline.com/doi/full/10.1080/0886571X.2020.1751017\u003c/li\u003e\n\u003cli\u003eLavender, J. M., Wonderlich, S. A., Engel, S. G., Gordon, K. H., Kaye, W. H., \u0026amp; Mitchell, J. E. (2015). Dimensions of emotion dysregulation in anorexia nervosa and bulimia nervosa : A conceptual review of the empirical literature. \u003cem\u003eClinical Psychology Review\u003c/em\u003e, \u003cem\u003e40\u003c/em\u003e, 111‑122. https://doi.org/10.1016/j.cpr.2015.05.010\u003c/li\u003e\n\u003cli\u003eLee, N. K., Cameron, J., \u0026amp; Jenner, L. (2015). A systematic review of interventions for co-occurring substance use and borderline personality disorders. \u003cem\u003eDrug and Alcohol Review\u003c/em\u003e, \u003cem\u003e34\u003c/em\u003e(6), 663‑672. https://doi.org/10.1111/dar.12267\u003c/li\u003e\n\u003cli\u003eLinehan, M. M. (1993a). \u003cem\u003eCognitive-behavioral treatment of borderline personality disorder\u003c/em\u003e (p. xvii, 558). Guilford Press.\u003c/li\u003e\n\u003cli\u003eLinehan, M. M. (1993b). \u003cem\u003eSkills training manual for treating borderline personality disorder\u003c/em\u003e (p. xii, 180). Guilford Press.\u003c/li\u003e\n\u003cli\u003eLinehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., \u0026amp; Heard, H. L. (1991). Cognitive-Behavioral Treatment of Chronically Parasuicidal Borderline Patients. \u003cem\u003eArchives of General Psychiatry\u003c/em\u003e, \u003cem\u003e48\u003c/em\u003e(12), 1060‑1064. https://doi.org/10.1001/archpsyc.1991.01810360024003\u003c/li\u003e\n\u003cli\u003eLinehan, M. M., Dimeff, L. A., Reynolds, S. K., Comtois, K. A., Welch, S. S., Heagerty, P., \u0026amp; Kivlahan, D. R. (2002). Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. \u003cem\u003eDrug and Alcohol Dependence\u003c/em\u003e, \u003cem\u003e67\u003c/em\u003e(1), 13‑26. https://doi.org/10.1016/s0376-8716(02)00011-x\u003c/li\u003e\n\u003cli\u003eLuijten, M., Schellekens, A. F., K\u0026uuml;hn, S., Machielse, M. W. J., \u0026amp; Sescousse, G. (2017). Disruption of Reward Processing in Addiction : An Image-Based Meta-analysis of Functional Magnetic Resonance Imaging Studies. \u003cem\u003eJAMA Psychiatry\u003c/em\u003e, \u003cem\u003e74\u003c/em\u003e(4), 387‑398. https://doi.org/10.1001/jamapsychiatry.2016.3084\u003c/li\u003e\n\u003cli\u003eLuo, J., Liang, M., Yi, P., \u0026amp; Li, X. (2023). The Neuropsychological Mechanisms of Treatment of Bipolar Disorder and Borderline Personality Disorder : Activation Likelihood Estimation Meta-Analysis of Brain Imaging Research. \u003cem\u003eThe Journal of Clinical Psychiatry\u003c/em\u003e, \u003cem\u003e84\u003c/em\u003e(3), 46362. https://doi.org/10.4088/JCP.22r14463\u003c/li\u003e\n\u003cli\u003eMaffei, C., Cavicchioli, M., Movalli, M., Cavallaro, R., \u0026amp; Fossati, A. (2018). Dialectical Behavior Therapy Skills Training in Alcohol Dependence Treatment : Findings Based on an Open Trial. \u003cem\u003eSubstance Use \u0026amp; Misuse\u003c/em\u003e, \u003cem\u003e53\u003c/em\u003e(14), 2368‑2385. https://doi.org/10.1080/10826084.2018.1480035\u003c/li\u003e\n\u003cli\u003eMerikangas, K. R., \u0026amp; McClair, V. L. (2012). Epidemiology of substance use disorders. \u003cem\u003eHuman Genetics\u003c/em\u003e, \u003cem\u003e131\u003c/em\u003e(6), 779‑789. https://doi.org/10.1007/s00439-012-1168-0\u003c/li\u003e\n\u003cli\u003eMeule, A. (2015). Back by Popular Demand : A Narrative Review on the History of Food Addiction Research. \u003cem\u003eThe Yale Journal of Biology and Medicine\u003c/em\u003e, \u003cem\u003e88\u003c/em\u003e(3), 295‑302.\u003c/li\u003e\n\u003cli\u003eMiga, E. M., Neacsiu, A. D., Lungu, A., Heard, H. L., \u0026amp; Dimeff, L. A. (2019). Dialectical behaviour therapy from 1991-2015 : What do we know about clinical efficacy and research quality? In \u003cem\u003eThe Oxford handbook of dialectical behaviour therapy\u003c/em\u003e (p. 415‑465). Oxford University Press.\u003c/li\u003e\n\u003cli\u003eNeacsiu, A. D., Eberle, J. W., Kramer, R., Wiesmann, T., \u0026amp; Linehan, M. M. (2014). Dialectical behavior therapy skills for transdiagnostic emotion dysregulation : A pilot randomized controlled trial. \u003cem\u003eBehaviour Research and Therapy\u003c/em\u003e, \u003cem\u003e59\u003c/em\u003e, 40‑51. https://doi.org/10.1016/j.brat.2014.05.005\u003c/li\u003e\n\u003cli\u003eNeacsiu, A. D., Rizvi, S. L., \u0026amp; Linehan, M. M. (2010). Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder. \u003cem\u003eBehaviour Research and Therapy\u003c/em\u003e, \u003cem\u003e48\u003c/em\u003e(9), 832‑839. https://doi.org/10.1016/j.brat.2010.05.017\u003c/li\u003e\n\u003cli\u003eNicastro, R., Jermann, F., Bondolfi, G., \u0026amp; McQuillan, A. (2010). Assessment of mindfulness with the French version of the Kentucky Inventory of Mindfulness Skills in community and borderline personality disorder samples. \u003cem\u003eAssessment\u003c/em\u003e, \u003cem\u003e17\u003c/em\u003e(2), 197‑205. https://doi.org/10.1177/1073191110363551\u003c/li\u003e\n\u003cli\u003eNicastro, R., Prada, P., Kung, A.-L., Salamin, V., Dayer, A., Aubry, J.-M., Guenot, F., \u0026amp; Perroud, N. (2016). Psychometric properties of the French borderline symptom list, short form (BSL-23). \u003cem\u003eBorderline Personality Disorder and Emotion Dysregulation\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e(1), 4. https://doi.org/10.1186/s40479-016-0038-0\u003c/li\u003e\n\u003cli\u003ePasieczny, N., \u0026amp; Connor, J. (2011). The effectiveness of dialectical behaviour therapy in routine public mental health settings : An Australian controlled trial. \u003cem\u003eBehaviour Research and Therapy\u003c/em\u003e, \u003cem\u003e49\u003c/em\u003e(1), 4‑10. https://doi.org/10.1016/j.brat.2010.09.006\u003c/li\u003e\n\u003cli\u003ePearlstein, T. (2002). Eating disorders and comorbidity. \u003cem\u003eArchives of Women\u0026rsquo;s Mental Health\u003c/em\u003e, \u003cem\u003e4\u003c/em\u003e(3), 67‑78. https://doi.org/10.1007/s007370200002\u003c/li\u003e\n\u003cli\u003ePerroud, N., Nicastro, R., Jermann, F., \u0026amp; Huguelet, P. (2012). Mindfulness skills in borderline personality disorder patients during dialectical behavior therapy : Preliminary results. \u003cem\u003eInternational Journal of Psychiatry in Clinical Practice\u003c/em\u003e, \u003cem\u003e16\u003c/em\u003e(3), 189‑196. https://doi.org/10.3109/13651501.2012.674531\u003c/li\u003e\n\u003cli\u003ePrada, P., Zamberg, I., Bouillault, G., Jimenez, N., Zimmermann, J., Hasler, R., Aubry, J.-M., Nicastro, R., \u0026amp; Perroud, N. (2017). EMOTEO : A Smartphone Application for Monitoring and Reducing Aversive Tension in Borderline Personality Disorder Patients, a Pilot Study. \u003cem\u003ePerspectives in Psychiatric Care\u003c/em\u003e, \u003cem\u003e53\u003c/em\u003e(4), 289‑298. https://doi.org/10.1111/ppc.12178\u003c/li\u003e\n\u003cli\u003eProctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., \u0026amp; Hensley, M. (2011). Outcomes for Implementation Research : Conceptual Distinctions, Measurement Challenges, and Research Agenda. \u003cem\u003eAdministration and Policy in Mental Health and Mental Health Services Research\u003c/em\u003e, \u003cem\u003e38\u003c/em\u003e(2), 65‑76. https://doi.org/10.1007/s10488-010-0319-7\u003c/li\u003e\n\u003cli\u003eQuid\u0026eacute;, Y., Witteveen, A. B., El-Hage, W., Veltman, D. J., \u0026amp; Olff, M. (2012). Differences between effects of psychological versus pharmacological treatments on functional and morphological brain alterations in anxiety disorders and major depressive disorder : A systematic review. \u003cem\u003eNeuroscience \u0026amp; Biobehavioral Reviews\u003c/em\u003e, \u003cem\u003e36\u003c/em\u003e(1), 626‑644. https://doi.org/10.1016/j.neubiorev.2011.09.004\u003c/li\u003e\n\u003cli\u003eReinholt, N., Hvenegaard, M., Christensen, A. B., Eskildsen, A., Hjorth\u0026oslash;j, C., Poulsen, S., Arendt, M. B., Rosenberg, N. K., Gryesten, J. R., Aharoni, R. N., Alr\u0026oslash;, A. J., Christensen, C. W., \u0026amp; Arnfred, S. M. (2021). Transdiagnostic versus Diagnosis-Specific Group Cognitive Behavioral Therapy for Anxiety Disorders and Depression : A Randomized Controlled Trial. \u003cem\u003ePsychotherapy and Psychosomatics\u003c/em\u003e, \u003cem\u003e91\u003c/em\u003e(1), 36‑49. https://doi.org/10.1159/000516380\u003c/li\u003e\n\u003cli\u003eRezaie, Z., Afshari, B., \u0026amp; Balagabri, Z. (2021). Effects of Dialectical Behavior Therapy on Emotion Regulation, Distress Tolerance, Craving, and Depression in Patients with Opioid Dependence Disorder. \u003cem\u003eJournal of Contemporary Psychotherapy\u003c/em\u003e. https://doi.org/10.1007/s10879-020-09487-z\u003c/li\u003e\n\u003cli\u003eRozakou-Soumalia, N., D\u0026acirc;rvariu, Ş., \u0026amp; Sj\u0026ouml;gren, J. M. (2021). Dialectical Behaviour Therapy Improves Emotion Dysregulation Mainly in Binge Eating Disorder and Bulimia Nervosa : A Systematic Review and Meta-Analysis. \u003cem\u003eJournal of Personalized Medicine\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(9), Article 9. https://doi.org/10.3390/jpm11090931\u003c/li\u003e\n\u003cli\u003eSalsman, N. L. (2020). Chapter 7 - Dialectical behavior therapy for individuals with substance use problems : Theoretical adaptations and empirical evidence. In J. Bedics (\u0026Eacute;d.), \u003cem\u003eThe Handbook of Dialectical Behavior Therapy\u003c/em\u003e (p. 141‑174). Academic Press. https://doi.org/10.1016/B978-0-12-816384-9.00007-5\u003c/li\u003e\n\u003cli\u003eSepehri, S., Ghahari, S., \u0026amp; Zadeh, R. H. (2016). Efficacy of dialecticalical behavior therapy (DBT) techniques on improving Cognitive Emotion Regulation Strategies in Women with MS. \u003cem\u003eThe Social Science\u003c/em\u003e.\u003c/li\u003e\n\u003cli\u003eShafran, R., Clark, D. M., Fairburn, C. G., Arntz, A., Barlow, D. H., Ehlers, A., Freeston, M., Garety, P. A., Hollon, S. D., Ost, L. G., Salkovskis, P. M., Williams, J. M. G., \u0026amp; Wilson, G. T. (2009). Mind the gap : Improving the dissemination of CBT. \u003cem\u003eBehaviour Research and Therapy\u003c/em\u003e, \u003cem\u003e47\u003c/em\u003e(11), 902‑909. https://doi.org/10.1016/j.brat.2009.07.003\u003c/li\u003e\n\u003cli\u003eSmink, F. R. E., van Hoeken, D., \u0026amp; Hoek, H. W. (2012). Epidemiology of Eating Disorders : Incidence, Prevalence and Mortality Rates. \u003cem\u003eCurrent Psychiatry Reports\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(4), 406‑414. https://doi.org/10.1007/s11920-012-0282-y\u003c/li\u003e\n\u003cli\u003eSparapani, E. M. (2015). \u003cem\u003eModerators of Treatment Outcome in Dialectical Behavior Therapy : The Role of Emotion Regulation and Impulsivity\u003c/em\u003e [Thesis, American University]. https://doi.org/10.57912/23843559.v1\u003c/li\u003e\n\u003cli\u003eStellern, J., Xiao, K. B., Grennell, E., Sanches, M., Gowin, J. L., \u0026amp; Sloan, M. E. (2023). Emotion regulation in substance use disorders : A systematic review and meta-analysis. \u003cem\u003eAddiction\u003c/em\u003e, \u003cem\u003e118\u003c/em\u003e(1), 30‑47. https://doi.org/10.1111/add.16001\u003c/li\u003e\n\u003cli\u003eStewart, S. H., Brown, C. G., Devoulyte, K., Theakston, J., \u0026amp; Larsen, S. E. (2006). Why Do Women with Alcohol Problems Binge Eat? : Exploring Connections between Binge Eating and Heavy Drinking in Women Receiving Treatment for Alcohol Problems. \u003cem\u003eJournal of Health Psychology\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(3), 409‑425. https://doi.org/10.1177/1359105306063313\u003c/li\u003e\n\u003cli\u003eStoreb\u0026oslash;, O. J., Stoffers-Winterling, J. M., V\u0026ouml;llm, B. A., Kongerslev, M. T., Mattivi, J. T., J\u0026oslash;rgensen, M. S., Faltinsen, E., Todorovac, A., Sales, C. P., Callesen, H. E., Lieb, K., \u0026amp; Simonsen, E. (2020). Psychological therapies for people with borderline personality disorder. \u003cem\u003eThe Cochrane Database of Systematic Reviews\u003c/em\u003e, \u003cem\u003e2020\u003c/em\u003e(5), CD012955. https://doi.org/10.1002/14651858.CD012955.pub2\u003c/li\u003e\n\u003cli\u003eSwales, M. A. (2010). Implementing Dialectical Behaviour Therapy : Organizational pre-treatment. \u003cem\u003eThe Cognitive Behaviour Therapist\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e(4), 145‑157. https://doi.org/10.1017/S1754470X10000115\u003c/li\u003e\n\u003cli\u003eTan, M. Y. L., Saw, Y. E., Keng, S.-L., \u0026amp; Lim, D. S. H. (2023). The impact of dialectical behaviour therapy training on therapists in Singapore : A mixed-methods study. \u003cem\u003eCounselling and Psychotherapy Research\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(3), 672‑689. https://doi.org/10.1002/capr.12626\u003c/li\u003e\n\u003cli\u003eTiffany, S. T., Friedman, L., Greenfield, S. F., Hasin, D. S., \u0026amp; Jackson, R. (2012). Beyond drug use : A systematic consideration of other outcomes in evaluations of treatments for substance use disorders. \u003cem\u003eAddiction\u003c/em\u003e, \u003cem\u003e107\u003c/em\u003e(4), 709‑718. https://doi.org/10.1111/j.1360-0443.2011.03581.x\u003c/li\u003e\n\u003cli\u003evan den Bosch, L. M. C., Verheul, R., Schippers, G. M., \u0026amp; van den Brink, W. (2002). Dialectical Behavior Therapy of borderline patients with and without substance use problems : Implementation and long-term effects. \u003cem\u003eAddictive Behaviors\u003c/em\u003e, \u003cem\u003e27\u003c/em\u003e(6), 911‑923. https://doi.org/10.1016/S0306-4603(02)00293-9\u003c/li\u003e\n\u003cli\u003eVastag, B. (2001). What\u0026rsquo;s the Connection? No Easy Answers for People With Eating Disorders and Drug Abuse. \u003cem\u003eJAMA\u003c/em\u003e, \u003cem\u003e285\u003c/em\u003e(8), 1006‑1007. https://doi.org/10.1001/jama.285.8.1006-JMN0228-3-1\u003c/li\u003e\n\u003cli\u003eWalton, C., \u0026amp; Comtois, K. A. (2018). Dialectical Behaviour Therapy in Routine Clinical Settings. In M. A. Swales (\u0026Eacute;d.), \u003cem\u003eThe Oxford Handbook of Dialectical Behaviour Therapy\u003c/em\u003e (p. 0). Oxford University Press. https://doi.org/10.1093/oxfordhb/9780198758723.013.52\u003c/li\u003e\n\u003cli\u003eWhiteside, S. P., \u0026amp; Lynam, D. R. (2001). The Five Factor Model and impulsivity : Using a structural model of personality to understand impulsivity. \u003cem\u003ePersonality and Individual Differences\u003c/em\u003e, \u003cem\u003e30\u003c/em\u003e(4), 669‑689. https://doi.org/10.1016/S0191-8869(00)00064-7\u003c/li\u003e\n\u003cli\u003eWilfley, D. E., Friedman, M. A., Dounchis, J. Z., Stein, R. I., Welch, R. R., \u0026amp; Ball, S. A. (2000). Comorbid psychopathology in binge eating disorder : Relation to eating disorder severity at baseline and following treatment. \u003cem\u003eJournal of Consulting and Clinical Psychology\u003c/em\u003e, \u003cem\u003e68\u003c/em\u003e(4), 641‑649. https://doi.org/10.1037/0022-006X.68.4.641\u003c/li\u003e\n\u003cli\u003eWilks, C. R., Korslund, K. E., Harned, M. S., \u0026amp; Linehan, M. M. (2016). Dialectical behavior therapy and domains of functioning over two years. \u003cem\u003eBehaviour Research and Therapy\u003c/em\u003e, \u003cem\u003e77\u003c/em\u003e, 162‑169. https://doi.org/10.1016/j.brat.2015.12.013\u003c/li\u003e\n\u003cli\u003eWiser, S., \u0026amp; Telch, C. F. (1999). Dialectical behavior therapy for binge-eating disorder. \u003cem\u003eJournal of Clinical Psychology\u003c/em\u003e, \u003cem\u003e55\u003c/em\u003e(6), 755‑768. https://doi.org/10.1002/(SICI)1097-4679(199906)55:6\u0026lt;755::AID-JCLP8\u0026gt;3.0.CO;2-R\u003c/li\u003e\n\u003cli\u003eWolf, M., Limberger, M. F., Kleindienst, N., Stieglitz, R.-D., Domsalla, M., Philipsen, A., Steil, R., \u0026amp; Bohus, M. (2009). Kurzversion der Borderline-Symptom-Liste (BSL-23) : Entwicklung und \u0026Uuml;berpr\u0026uuml;fung der psychometrischen Eigenschaften. \u003cem\u003ePPmP - Psychotherapie \u0026middot; Psychosomatik \u0026middot; Medizinische Psychologie\u003c/em\u003e, \u003cem\u003e59\u003c/em\u003e(8), 321‑324. https://doi.org/10.1055/s-0028-1104598\u003c/li\u003e\n\u003cli\u003eZanello, A., Weber Rouget, B., Gex-Fabry, M., Maercker, A., \u0026amp; Guimon, J. (2006). Validation du Questionnaire de fonctionnement social (QFS), un autoquestionnaire mesurant la fr\u0026eacute;quence et la satisfaction des comportements sociaux d\u0026rsquo;une population adulte psychiatrique. \u003cem\u003eL\u0026rsquo;Enc\u0026eacute;phale\u003c/em\u003e, \u003cem\u003e32\u003c/em\u003e(1), 45‑59. https://doi.org/10.1016/S0013-7006(06)76136-X\u003c/li\u003e\n\u003cli\u003eZanello, A., Weber-Rouget, B., Gex-Fabry, M., Maercker, A., \u0026amp; Guimon, J. (2004). A new instrument to assess social functioning in mental health settings. \u003cem\u003eEuropean Journal of Psychiatry\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e, 76‑84.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"substance-abuse-treatment-prevention-and-policy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"satp","sideBox":"Learn more about [Substance Abuse Treatment, Prevention, and Policy](http://substanceabusepolicy.biomedcentral.com)","snPcode":"13011","submissionUrl":"https://submission.nature.com/new-submission/13011/3","title":"Substance Abuse Treatment, Prevention, and Policy","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"dialectical behavior therapy, emotion regulation, skills training, transdiagnostic, substance use disorder, eating disorder, behavioral addiction, emotion dysregulation","lastPublishedDoi":"10.21203/rs.3.rs-5389668/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5389668/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/em\u003e. Addictions and eating disorders are the 2 deadliest psychiatric disorders. Central processes in both disorders are emotional dysregulation and impulsivity, maladaptive emotion regulation strategies have an important role in the development and maintenance of eating disorders and addictions. The standard treatment for emotion regulation is Dialectical Behavioral Therapy (DBT), its implementation is often a challenge but can be facilitated by transdiagnostic groups. As few data are available on these groups in addictology, the aim of our study was to check that emotional dysregulation and impulsivity are improved as soon as transdiagnostic DBT groups are implemented.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethod\u003c/strong\u003e\u003c/em\u003e. Eight two-month cycles of transdiagnostic DBT groups were led between 2021 and 2023. The 35 participants had substance addiction (89%), behavioral addiction (14%), or eating disorder (20%). Other psychiatric comorbidities, especially borderline personality disorder (42.9%), were also present. The evolution of questionnaires completed by the participants and the attrition rate were analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/em\u003e. The average dropout rate was 21%. During DBT, the improvement reached high effect sizes for emotional dysregulation (d=0.9), positive cognitive emotional regulation (d=0.978) and negative cognitive emotional regulation (d=1.04), and medium effect sizes for impulsivity (d=0.586) and mindfulness (d=0.766). Depending on the cycle, clinical outcomes ranged from 0% to 31% improvement in emotional dysregulation and from 12% to 100% retention. An association was found between attrition rate and therapists' level of experience (effect size = 0.320, p=.001).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e\u003c/em\u003e. While we know the effectiveness of DBT on emotional dysregulation and impulsivity, two particularly important functions in addictology, we found that their improvement can occur as soon as this therapy is implemented despite challenges present. These results suggest that transdiagnostic format, which is a solution to facilitate DBT implementation, preserves the effects of DBT. In addictology, few therapies address emotional regulation and impulsivity: CBT is less suitable for severe cases because change and acceptance skills are not dialectically balanced, and pharmacotherapy does not act on limbic system by top-down mechanisms because it does not teach skills. Therefore, to improve emotion regulation of patients with addictions, it is necessary to study solutions more often to facilitate implementation of DBT such as transdiagnostic groups.\u003c/p\u003e","manuscriptTitle":"Does DBT affect emotional regulation and impulsivity from the beginning of implementation? A 3-year naturalistic study on transdiagnostic groups in addictology","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-09 14:59:51","doi":"10.21203/rs.3.rs-5389668/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-17T15:59:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-06T23:54:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-06T23:54:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"Substance Abuse Treatment, Prevention, and Policy","date":"2024-11-04T16:16:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"substance-abuse-treatment-prevention-and-policy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"satp","sideBox":"Learn more about [Substance Abuse Treatment, Prevention, and Policy](http://substanceabusepolicy.biomedcentral.com)","snPcode":"13011","submissionUrl":"https://submission.nature.com/new-submission/13011/3","title":"Substance Abuse Treatment, Prevention, and Policy","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"30394423-7f4b-4daa-a0b9-c991b3126682","owner":[],"postedDate":"December 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-26T16:02:06+00:00","versionOfRecord":{"articleIdentity":"rs-5389668","link":"https://doi.org/10.1186/s13011-025-00698-y","journal":{"identity":"substance-abuse-treatment-prevention-and-policy","isVorOnly":false,"title":"Substance Abuse Treatment, Prevention, and Policy"},"publishedOn":"2026-01-19 15:58:48","publishedOnDateReadable":"January 19th, 2026"},"versionCreatedAt":"2024-12-09 14:59:51","video":"","vorDoi":"10.1186/s13011-025-00698-y","vorDoiUrl":"https://doi.org/10.1186/s13011-025-00698-y","workflowStages":[]},"version":"v1","identity":"rs-5389668","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5389668","identity":"rs-5389668","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}