May 6, 2025

expert reaction to trial of online dialectical behavioural theory for emotion dysregulation in people with chronic pain

Results from a trial published in JAMA Network Open looks at online dialectical behavioural theory for emotion dysregulation in people with chronic pain.

Dr Whitney Scott, Senior Lecturer in Clinical Health Psychology, IoPPN, King’s College London, said:

“This is an interesting trial that further highlights the importance of psychologically-based treatments to support the well-being of people with persistent pain. The online delivery format builds on a growing trend towards digital therapeutics to address significant challenges with treatment accessibility.

“This is a relatively small trial that provides support for a larger study. It’s great to see that a larger trial is planned which can help to further understand the impact of the intervention, including in the longer-term. At present, while promising, there is a limit to what we can conclude from this study in terms of its impacts on future practice.

 “If the larger trial shows similar results, this will add to an established body of evidence showing the efficacy of psychologically-based treatments for people with pain. For example, there is already moderate quality evidence from a number of randomized-controlled trials (RCTs) that cognitive-behavioural therapy (CBT) improves distress in people with pain when compared to treatment as usual. The current RCT also uses a treatment as usual control group.

 “It’s also important to say that the iDBT-Pain treatment overlaps with elements of traditional CBT and other cognitive-behavioural approaches (mindfulness-based stress reduction, ACT). These treatments have already been widely studied and used in clinical practice to support people with persistent pain to respond more effectively to emotions. So, iDBT very much builds on the tools we already have to support people with pain.

 “The study reported good effects for emotion dysregulation, depression, and pain intensity that were maintained at 21-week follow-up. However, effects for anxiety and sleep problems were not maintained. No significant improvements were observed for pain interference with daily life. This is another key outcome in the pain field and one that is often the target of cognitive-behavioural treatments for people with persistent pain.

 “The online delivery format has the potential to increase accessibility for many people. However, this may not be true for everyone. It’s plausible that people with very high levels of emotion dysregulation, the key target of this intervention, may struggle with the remote format and may need an in-person format. Notably, people with ‘personality disorders’ were excluded which may represent individuals that particularly struggle with emotion dysregulation.”

Dr Franziska Denk, Reader in Neuroscience, King’s College London, said:

“To my mind, this paper will not significantly change our understanding of how to treat people with pain.

“It has faced the same challenge faced by almost all behavioural intervention trials: how to placebo control effectively.

“As it was carried out, this study ends up comparing apples and oranges: in the treatment group, we have people who are being listened to, affirmed and guided by medical professionals and their peers as part of an intensive 8-week treatment programme; in the ‘placebo’ group, we have people to whom nothing happens (as that is what ‘treatment in the community’ basically means). Obviously, the ones who are being cared for actively will fare better.”

‘Online Dialectical Behavioral Therapy for Emotion Dysregulation in People
With Chronic Pain’ by Nell Norman-Nott et al. was published in JAMA Network Open at 16:00 UK time on Tuesday 6th May. 

DOI: 10.1001/jamanetworkopen.2025.6908

Declared interests

Dr Whitney Scott:I have received research funding from the International Association for the Study of Pain and National Institute for Health and Care Research for projects investigating online delivery of psychological treatment (specifically acceptance and commitment therapy) for people with persistent pain. I have received funds for travel to conferences where I have presented on some of this work. I also provide teaching on psychosocial aspects of persistent pain management as part of my paid employment.

Dr Franziska Denk: I have no conflicts in relation to this paper.