# Clarifying conceptualization of emotional dysregulation: Differences with emotional lability during 4-month DBT skills training – A naturalistic study

Amaury Durpoix, Martin Blay, Christophe Moog, Julie Rolling, Luisa Weiner, Laurence Lalanne, Sébastien Weibel

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Amaury Durpoix, Martin Blay, Christophe Moog, Julie Rolling, Luisa Weiner, et al.. Clarifying conceptualization of emotional dysregulation: Differences with emotional lability during 4-month DBT skills training – A naturalistic study. Journal of Affective Disorders, 2026, 392, pp.120199. 10.1016/j.jad.2025.120199. inserm-05508824

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Research paper

# Clarifying conceptualization of emotional dysregulation: Differences with emotional lability during 4-month DBT skills training – A naturalistic study

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Amaury Durpoix<sup>a,d,f,*</sup>, Martin Blay<sup>i,j</sup>, Christophe Moog<sup>b,d,g</sup>, Julie Rolling<sup>c,d</sup>, Luisa Weiner<sup>b,e,h</sup>, Laurence Lalanne<sup>a,d,f</sup>, Sébastien Weibel<sup>b,d,g</sup>

## ARTICLE INFO

**Keywords:**

Emotional dysregulation

Emotional lability

Dialectical behavior therapy

Transdiagnostic

Borderline personality disorder

Bipolar disorder

## ABSTRACT

**Introduction:** Emotion dysregulation is common in many different psychiatric disorders and it can be effectively treated with the well-established Dialectical Behavioral Therapy (DBT). Despite its clinical relevance and increasing scientific interest, emotional dysregulation (ED) is sometimes conflated with emotional lability (EL). However, these constructs differ: ED involves top-down neurobiological processes, while EL involves bottom-up processes. As psychotherapy essentially influences top-down processes compared to pharmacotherapy, this study aimed to investigate whether ED is more sensitive to DBT than EL.

**Method:** Our naturalistic study involved the 39 participants (sex ratio = 9 m/30w, mean age = 33.23) who completed questionnaires assessing ED (DERS-36) and EL (ALS-18) before then after transdiagnostic DBT skills training (DBT-ST). The diagnoses of participants included BPD (64 %), BD (23 %), ADHD (23 %), addiction (17 %) or eating disorder (17 %). DBT was performed in a transdiagnostic group over 4 months.

**Result:** After DBT-ST, ED improved significantly with a medium effect size (d = 0.73), while EL showed no significant change (d = 0.13). The percentages of improvement on DERS were significantly higher than on ALS (p < 0.002, d = 0.50). The correlation between these both measures decreased during therapy from r = 0.37 to r = 0.32.

**Discussion:** Our findings indicate that ED improved more than EL after DBT and that their correlation diminished during therapy. These results suggest that ED is a different process from EL and that ED is more sensitive to treatments like DBT Skills Training. To confirm these findings, further studies are needed ideally with larger sample size, long-term follow-up and a controlled design.

## 1. Introduction

Emotional dysregulation (ED) is a transdiagnostic construct observed in many different disorders (Blay et al., 2024; Sloan et al., 2017). Research suggests that ED may affect up to 85 % of individuals with psychiatric conditions (Kring and Sloan, 2009). Its strong association

with poor mental and physical health outcomes, such as psychiatric diagnoses (Dork et al., 2024) and self-harming behaviors (Wolff et al., 2019), has led to substantial scientific attention. Models of psychopathology propose a distinction based on the form of ED: emotional under-regulation linked to externalizing disorders (e.g., Borderline Personality Disorder [BPD], Bipolar Disorder [BD], ADHD, Addictive Disorder) and

<footnote><sup>a</sup> Department of addiction medicine, Strasbourg University Hospitals, France</footnote>

<footnote><sup>b</sup> Department of Psychiatry, Strasbourg University Hospitals, France</footnote>

<footnote><sup>c</sup> Department of Child and Adolescent Psychiatry, Strasbourg University Hospitals, France</footnote>

<footnote><sup>d</sup> Faculty of Medicine, Maieutic and Health Sciences, University of Strasbourg, France</footnote>

<footnote><sup>e</sup> Faculty of Psychologie, University of Strasbourg, France</footnote>

<footnote><sup>f</sup> Inserm UMR_S 1329, Team Addictions, Centre de recherche en biomédecine de Strasbourg, France</footnote>

<footnote><sup>g</sup> INSERM UMR_S 1329, Team Psychiatry, Department of Psychiatry, Strasbourg, France</footnote>

<footnote><sup>h</sup> Laboratory of Psychology of Cognitions, Strasbourg, France</footnote>

<footnote><sup>i</sup> ADDIPSY, Santé Basque Développement group, Lyon, France</footnote>

<footnote><sup>j</sup> Paris-Saclay University, UVSQ, INSERM, Centre de Recherche en Epidémiologie et Santé des Populations Team « DevPsy », p4807, Villejuif, France</footnote>

<footnote>* Corresponding author at: Amaury Durpoix, MD, University Hospitals of Strasbourg, 1 place de l'Hôpital, 67000 Strasbourg, France.</footnote>

<footnote>E-mail addresses: amaury.durpoix@chru-strasbourg.fr (A. Durpoix), christophe.moog@chru-strasbourg.fr (C. Moog), julie.rolling@chru-strasbourg.fr (J. Rolling), luisa.weiner@chru-strasbourg.fr (L. Weiner), sebastien.weibel@chru-strasbourg.fr (S. Weibel).</footnote>
emotional over-regulation associated with internalizing disorders (e.g., Anorexia Nervosa, Anxiety Disorder, Autism Spectrum Disorder) (Beauchaine, 2015; Lynch, 2018). This dimensional framework resonates with Linehan's original conceptualization of BPD as involving alternating episodes of emotional over-regulation (e.g., emotional suppression, dissociation) and under-regulation (e.g., impulsivity, anger outbursts) (M. M. Linehan, 1993a).

A key challenge in studying ED lies in its frequent confusion with related constructs (Agapoff et al., 2023; Faraone et al., 2019; Juarascio et al., 2020; Marwaha et al., 2014), partly because ED lacks a clear and universally accepted definition (Marwaha et al., 2014). Two main conceptualizations on ED emerge in the literature (D'Agostino et al., 2017; Gratz et al., 2020): (1) a first conceptualization describes ED as characterized by hyperreactive emotional responses and a slow return to baseline, and (2) a second conceptualization describes ED as the absence of effective emotional regulation strategies. The first conceptualization of ED closely resembles to the concept of emotional lability (EL), which is classically defined by unpredictable, intense, and rapid emotions, as well as by frequent changes in emotions (Cole et al., 2008; Leaberry et al., 2020). In contrast, the second conceptualization proposes that labile emotions are not inherently dysregulated, because ED depends on responses to emotions rather than the quality of these emotions (Gratz et al., 2020). Although often used interchangeably with EL or ED, the term 'affective instability' may refer more broadly to fluctuations in both mood and emotion, and is therefore conceptually broader. For clarity, we deliberately chose to focus here on EL and ED. The therapeutic approach to EL and ED depends on the extent to which these constructs overlap: if EL and ED are conceptually similar, treatments may target shared mechanisms; however, if they differ, distinct therapeutic strategies might be required.

To evaluate ED and EL, psychometric measures remain the standard: Difficulties in Emotion Regulation Scale (DERS) is used for ED, while Affective Lability Scale (ALS) for EL (Gratz et al., 2020). Psychometric studies in non-clinical populations have reported a link between ALS and DERS scores, with correlations ranging from moderate (Contardi et al., 2018) to strong (Dork et al., 2024), although this link has yet to be studied in clinical samples. Neuroimaging studies directly examining the correlates of these psychometric constructs showed different associations: ED is associated with top-down mechanisms originating in the prefrontal cortex during tasks of emotional reactivity, although EL is associated with bottom-up mechanisms originating in the amygdala during tasks of emotional regulation (Phillips et al., 2008; Silvers et al., 2016). These findings are in line with process models of emotion regulation, which links ED with a problem of regulation, and EL with a problem of emotion generation (Crowell et al., 2020; Ramsook et al., 2020). Notably, regulation processes are thought to occur after emotion generation processes (Cole et al., 2004; Faraone et al., 2019).

As psychotherapy primarily targets top-down processes and pharmacotherapy primarily targets bottom-up processes (Boccia et al., 2016; Luo et al., 2023; Quidé et al., 2012), that suggests a potential differential efficacy: pharmacotherapy may be more suited for EL, while psychotherapy may be more effective for ED. Among psychotherapies targeting ED, Dialectical Behavior Therapy (DBT) remains the most established intervention. Originally developed for chronically suicidal patients, DBT combines skills training, individual therapy, telephone coaching, and therapist consultation (M. M. Linehan, 1993b). Its efficacy has been studied in over 40 clinical trials on various pathologies by over 20 independent research teams (Neacsiu et al., 2014a; Stoffers-Winterling et al., 2022; Storebø et al., 2020). While the full model is comprehensive, several studies have demonstrated that DBT Skills-Training groups (DBT-ST) can be effective for certain difficulties, even in the absence of individual DBT therapy (Lyng et al., 2020; Valentine et al., 2015). For example, although all arms in Linehan et al. (2015) included therapist consultation and structured risk management, the study showed that skills training played a central role in clinical improvement.

In practice, DBT-ST is often the first or most feasible component to

implement. Navarro-Haro et al. (2019) found that among trained teams, DBT Skills Groups were the most adopted component, possibly due to their structured format and transdiagnostic relevance. DBT-ST groups have been shown to reduce ED across diverse samples and study designs, with measurable improvements on the Difficulties in Emotion Regulation Scale (DERS) (Azevedo et al., 2024; Harvey et al., 2019; Neacsiu et al., 2014b). In addition, neuroimaging studies suggest that DBT may modulate emotion regulation circuits, such as reduced amygdala reactivity and enhanced prefrontal control (Goodman et al., 2014; Schmitt et al., 2016). Finally, as DBT often included participants with many comorbidities and showed efficacy on comorbidities (Harned et al., 2009). For this reason, several teams now implement transdiagnostic groups targeting ED across diagnostic categories, with promising outcomes (Durpoix et al., 2023; Neacsiu et al., 2014b).

Several studies have analyzed the evolution of ED during DBT (Harvey et al., 2019) reporting improvements both in comprehensive DBT (Azevedo et al., 2024; Goodman et al., 2014) and in DBT-ST (Neacsiu et al., 2014b). While ED is increasingly recognized as a transdiagnostic treatment target, its distinction from related constructs such as EL remains insufficiently addressed. To date, few empirical studies have examined these two constructs simultaneously during treatment. Altogether, although ED and EL are conceptually related, they appear to represent distinct clinical constructs that may benefit from tailored therapeutic approaches. Investigating these differences could provide valuable insights into their underlying mechanisms and inform more precise clinical management.

To address these gaps, the aim of this naturalistic study was therefore to compare changes in both constructs during a 4-month DBT-ST program in a clinical transdiagnostic sample. Given that psychotherapy – particularly DBT – primarily targets top-down mechanisms, we hypothesized that ED would show greater improvement than EL during to DBT-ST.

## 2. Methods

### 2.1. Population

We included patients who participated in DBT skills training groups provided in the Psychiatric Department of the University Hospitals of Strasbourg between 2018 and 2021. These DBT Skills Training groups were conducted in an outpatient setting, within specialized psychotherapy unit for patients suffering from ED, independently of the underlying diagnosis (i.e., BPD, ADHD, BD...). Participants are referred when, during a follow-up, a mental health professional in or near Strasbourg deems it necessary to treat ED. Psychiatric diagnoses were established by senior psychiatrists using clinical interviews based on DSM-5 criteria. No standardized semi-structured diagnostic tool was used.

For the present study, the inclusion criteria were: 1°) To have attended to our transdiagnostic emotional regulation DBT groups (GREMO, University Hospitals of Strasbourg) 2°) To have completed the pre-post evaluation and 3°) To have given consent for data collection for research purposes. It was specified that a refusal or agreement would not induce any change in therapy. There were no exclusion criteria. This study was approved by the Strasbourg Ethics Committee (2023–121 CE).

In total, among the 66 participants of the skills training groups between 2018 and 2021, 6 stopped therapy prematurely (9.1 %), 21 completed therapy but did not fill out the questionnaires correctly (31.8 %), and 39 completed the questionnaires and were included in the study (59.1 %) (Fig. 1).

### 2.2. Transdiagnostic DBT skills training groups

The intervention consisted in a transdiagnostic 18-week DBT skills training (DBT-ST) group with 7–8 participants, a format previously described and evaluated at short and long term (Durpoix et al., 2023;
<figure><img src="image_4.png" /><figcaption>Fig. 1. Flow chart.</figcaption></figure>

Neacsiu et al., 2014b). As in these previous studies, participants participated in DBT Skills training groups without individual therapy or systematic telephone support. We used the French translation of the DBT Manual developed by Perroud et al. (Linehan, 2017), which has been applied in multiple studies (Bemmouna et al., 2025; Durpoix et al., 2023; Perroud et al., 2010). The weekly sessions lasted 2 h and 15 min and included the 4 DBT modules: mindfulness, distress tolerance, interpersonal effectiveness and emotional regulation, as well as a debriefing in the middle and at the end of therapy (Table 1). The program followed a semi-open group format: new participants were allowed to join only during mindfulness teaching modules (sessions 1 or 10), ensuring consistent skill progression for all members within each cycle. Following DBT protocol, each session proposed mindfulness practice (~5–10 min), review of last session’s homework (~50–60 min),

<table><caption>**Table 1**
List of taught DBT skills.</caption><thead><tr><th>Cycle</th><th>Modules</th><th>Sessions</th><th>Skills</th></tr></thead><tbody><tr><td rowspan="7">Cycle 1</td><td>Mindfulness</td><td>1</td><td>Wise mind and the “what” skills of mindfulness</td></tr><tr><td rowspan="5">Distress tolerance</td><td>2</td><td>The “How” skills of mindfulness</td></tr><tr><td>3</td><td>STOP &amp; TIP skills</td></tr><tr><td>4</td><td>ACCEPTS skills</td></tr><tr><td>5</td><td>IMPROVE and self-soothing skills</td></tr><tr><td>6</td><td>Radical acceptance and willingness</td></tr><tr><td>Interpersonal effectiveness</td><td>7</td><td>DEAR MAN skill</td></tr><tr><td></td><td>8</td><td>GIVE and FAST skills</td></tr><tr><td></td><td>9</td><td>Validation others and self-validation</td></tr><tr><td colspan="4" style="text-align: left;">Debriefing session of cycle 1</td></tr><tr><td rowspan="7">Cycle 2</td><td>Mindfulness</td><td>10</td><td>Mindfulness Skills Review</td></tr><tr><td rowspan="6">Emotional regulation</td><td>11</td><td>Understand, identify and name emotions</td></tr><tr><td>12</td><td>Fact-checking</td></tr><tr><td>13</td><td>Opposite action</td></tr><tr><td>14</td><td>Problem solving</td></tr><tr><td>15</td><td>ABC skills</td></tr><tr><td>16</td><td>PLEASE skills</td></tr><tr><td colspan="4" style="text-align: left;">Debriefing session of cycle 2</td></tr></tbody></table>

new skills instruction (~50–60 min) and homework assignment (~5–10 min). If a participant had not completed homework, a missing links analysis was conducted. Two debriefing group sessions were held at the end of each cycle to review the skills learned in the previous sessions, assist participants in noticing their progress, address questions, and gather feedback from participants regarding their experiences in the group sessions. This approach was previously described in Durpoix et al. (2023).

All group leaders were psychiatrists or clinical psychologists who had received formal training and supervision in DBT. Each had completed at least 2–5 days of formal DBT workshop, read the French version of the DBT Skills Training Manual, observed a full DBT group prior to leading. Therapists also participated in regular clinical supervision provided by experienced DBT clinicians. Groups were led by two providers ensuring the balance between acceptance and change according to DBT principles. In addition to running DBT skills training groups, therapists participated in a weekly team consultation. These meetings focused on adherence to the DBT model, discussion of complex clinical cases, and mutual support, consistent with standard DBT practices (M. M. Linehan et al., 2015; Neacsiu et al., 2014b). These provisions helped to carry out the therapy as closely as possible to the DBT model. However, no formal treatment integrity rating was conducted, which should be considered a methodological limitation.

## 2.3. Measures

For the present study, we included two scales completed by participants before and after group to assess their progress, one for ED (the Difficulties in Emotion Regulation Scale – 36 items (Gratz and Roemer, 2004)), and one for EL (the Affective Lability Scale – 18 items (Oliver and Simons, 2004)).

Briefly, the DERS is a self-administered questionnaire that assesses different facets of ED: non-acceptance of negative emotions, difficulty pursuing goal-oriented behaviors, lack of impulse control in emotional situations, lack of regulation strategies, lack of emotional awareness and lack of emotional clarity. 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 and Scherer, 2013) showed a high congruence with the original (Tucker's phi = 0.98). The higher the DERS score, the greater the emotional regulation difficulties, with a total mean score found in general population of 74.80 (Côté et al., 2013). ED is considered absent below 84, mild over 89.9, moderate over 101.12 and severe over 116.13 (Burton et al., 2022).

The ALS-18 is a short version of the original ALS and assesses EL by distinguishing 5 affective states (euthymia, depression, euphoria, anger, anxiety). ALS demonstrates correct internal consistency (α = 0.72–0.89) and test-retest reliability (r = 0.48–0.86, p < 0.01). The 18-item scale (Oliver and Simons, 2004) shows a good correlation with the original (r = 0.94) in a non-clinical sample. This correlation was then studied in clinical populations: personality disorders (r = 0.97; (Look et al., 2010)), bipolarity (r = 0.97; (Aas et al., 2015)) and ADHD (r = 0.96; (Weibel et al., 2019)). General population's mean score is 0.62 (Contardi et al., 2018).

Furthermore, psychiatric disorders were assessed at baseline according to the DSM-5 criteria.

## 2.4. Statistical analysis

Statistical analyses were conducted using Jamovi 2.3.21. To compare sociodemographic and psychometric differences at baseline between included and non-included participants, we used t-test for numeric variables and chi-2 for categorical variables. Pearson's correlations were calculated to assess the relationship between DERS and ALS score, both before and after the DBT group intervention. To evaluate changes in emotional dysregulation and emotional lability over time, paired Student's t-test were conducted to compare pre and post intervention scores. Effect sizes were calculated using Cohen's d (Cohen, 1969) and interpreted as strong (d > 0.8), medium (d > 0.5), or small (d > 0.3). To verify if changes are clinically significant, we also calculated Reliable Change Indices (RCI; (Jacobson and Truax, 1991)). RCI indicates whether a change that occurred over time in an individual score (e.g., between a patient's pre-intervention and post-intervention assessment) is significantly greater than a difference that could have occurred due to random measurement error alone. A RCI below –1.96 is considered as a negative reliable change (Jacobson and Truax, 1991). The calculation formula is:

$$ RCI = \frac{X_{post} - X_{pre}}{\sqrt{2(SD^2)(1 - r)}} $$

where: Xpost = post-treatment individual score, Xpre = pretreatment individual score, SD = Standard deviation of pretreatment score in the clinical sample, and r = test-rest reliability of the measure.

## 3. Results

Thirty-nine participants were included in the study (9men/30women, mean age = 33.23, SD = 8.64) (Table 2). The primary

diagnosis(es) were BPD (64 %), bipolar disorder (23 %), ADHD (23 %), substance use disorder (18 %) or eating disorder (18 %). BPD was comorbid with bipolar disorder for 2 patients (5.7 %), with ADHD for 5 patients (14.3 %), with substance use disorder for 7 patients (20 %), and with eating disorder for 6 patients (17.1 %). At baseline, our sample showed high levels of emotional dysregulation and lability (DERS mean score = 124.51; ALS mean score: 1.63), with a significant positive correlation between the two dimensions (r = 0.369, p = 0.007). We found no significant differences in sociodemographic and psychometric criteria between these 39 participants and 27 participants who didn't complete the therapy or questionnaires (Table 3).

Following DBT-ST (Table 4, Fig. 2), emotional dysregulation significantly improved, as evidenced by a reduction in DERS total score, indicating a medium effect size (post-group mean score: 99.85, d = 0.73, p ≤ 0.001). All subscales of the DERS had a significant improvement with a low effect size for the “goals” subscale (d = 0.39), a high effect size for the “non-acceptance” subscale (d = 0.91) and a moderate effect size for the others. However, no significant change was observed in emotional lability (ALS post-group mean: 1.54, d = 0.13, p = 0.21), nor in its subscales. The percentage change in DERS score (M = 18.75 %, SD = 26.10) and ALS (M = –3.14 %, SD = 47.00) was significantly different (p < 0.002, d = 0.50). At the intra-individual level, DERS total scores showed reliable change for 21 (42.9 %) of 49 post-treatment participants, indicating reduced self-reported emotion regulation difficulties. Reliable change in emotion lability occurred in 6 participants (12.2 %). Notably, the correlation between DERS and ALS scores decreased after treatment (r = 0.32, p = 0.05).

<caption>**Table 3**</caption>

Sociodemographic & psychometric comparisons between included and non-included participants.

<table><caption>**Table 2**</caption><thead><tr><th></th><th>Included participants<br>(n = 39)</th><th>Non-included participants<br>(n = 27)</th><th>Effect (p)</th></tr></thead><tbody><tr><td>Sex</td><td>9 m/30w</td><td>5 m/22w</td><td>X<sup>2</sup> = 0.198 (p =<br>0.656)</td></tr><tr><td>Age</td><td>33.03 (SD = 8.6)</td><td>31.11 (SD = 9.5)</td><td>d = -0.213 (p =<br>0.397)</td></tr><tr><td>BPD</td><td>64.1 %</td><td>51.9 %</td><td>X<sup>2</sup> = 0.991 (p =<br>0.320)</td></tr><tr><td>BD</td><td>23.1 %</td><td>33.3 %</td><td>X<sup>2</sup> = 0.846 (p =<br>0.358)</td></tr><tr><td>ADHD</td><td>23.1 %</td><td>44.4 %</td><td>X<sup>2</sup> = 3.36 (p =<br>0.067)</td></tr><tr><td>ED</td><td>23.1 %</td><td>18.5 %</td><td>X<sup>2</sup> = 0.198 (p =<br>0.656)</td></tr><tr><td>SUD</td><td>17.9 %</td><td>7.4 %</td><td>X<sup>2</sup> = 1.51 (p =<br>0.220)</td></tr><tr><td>DERS</td><td>124.51 (SD = 21.6)</td><td>128.2 (SD = 19.9)</td><td>d = 0.175 (p =<br>0.568)</td></tr><tr><td>ALS</td><td>1.62 (SD = 0.5)</td><td>1.9 (SD = 0.5)</td><td>d = 0.530 (p =<br>0.088)</td></tr></tbody></table>

Sample characteristics at baseline.

<table><thead><tr><th rowspan="2">Total (N = 39)</th><th>Sex ratio</th><th>Age</th><th colspan="4">Comorbidity</th><th>DERS</th><th>ALS</th></tr><tr><th>9 m/30w</th><th>33.23<br>(SD = 8.6)</th><th>BPD</th><th>BD</th><th>ADHD</th><th>SUD</th><th>ED</th><th>124.51<br>(SD = 99.9)</th><th>1.62<br>(SD = 0.6)</th></tr></thead><tbody><tr><td>- BPD (N = 25)</td><td>5 m/20w</td><td>33.1<br>(SD = 8.2)</td><td>-</td><td>2</td><td>5</td><td>5</td><td>5</td><td>129.1<br>(SD = 17.9)</td><td>1.75<br>(SD = 0.4)</td></tr><tr><td>- BD (N = 9)</td><td>3 m/6w</td><td>32.1<br>(SD = 6.9)</td><td>2</td><td>-</td><td>1</td><td>1</td><td>0</td><td>122.6<br>(SD = 28.4)</td><td>1.56<br>(SD = 0.7)</td></tr><tr><td>- ADHD (N = 9)</td><td>3 m/6w</td><td>34.6 (SD = 6.0)</td><td>5</td><td>1</td><td>-</td><td>0</td><td>2</td><td>131.4 (SD = 15.4)</td><td>1.61 (SD = 0.7)</td></tr><tr><td>- SUD (N = 7)</td><td>2 m/5w</td><td>45.4<br>(SD = 6.4)</td><td>5</td><td>1</td><td>0</td><td>-</td><td>1</td><td>121<br>(SD = 11.2)</td><td>1.65<br>(SD = 0.6)</td></tr><tr><td>- ED (N = 8)</td><td>0 m/8w</td><td>32<br>(SD = 8.6)</td><td>5</td><td>0</td><td>2</td><td>1</td><td>-</td><td>132.9 (SD = 22.0)</td><td>1.48 (SD = 0.4)</td></tr></tbody></table>
<table><caption>**Table 4**
Change in DERS and ALS during DBT skills training.</caption><thead><tr><th rowspan="2"></th><th colspan="2">Before</th><th colspan="2">After</th><th rowspan="2">Effect size<br>(d)</th></tr><tr><th>Mean</th><th>SD</th><th>Mean</th><th>SD</th></tr></thead><tbody><tr><td>Emotional dysregulation<br>(DERS)</td><td>124.51</td><td>21.6</td><td>99.9</td><td>26.5</td><td>0.73***</td></tr><tr><td>- Non-acceptance</td><td>22.33</td><td>5.6</td><td>15.54</td><td>6.9</td><td>0.91***</td></tr><tr><td>- Goals</td><td>20.36</td><td>4.2</td><td>18.15</td><td>4.9</td><td>0.39*</td></tr><tr><td>- Impulse</td><td>20.18</td><td>5.7</td><td>15.54</td><td>5.7</td><td>0.60***</td></tr><tr><td>- Awareness</td><td>18.26</td><td>5.2</td><td>15.10</td><td>4.1</td><td>0.56***</td></tr><tr><td>- Strategies</td><td>27.87</td><td>6.1</td><td>23.41</td><td>6.8</td><td>0.55***</td></tr><tr><td>- Clarity</td><td>15.51</td><td>4.7</td><td>12.15</td><td>4.0</td><td>0.57***</td></tr><tr><td>Emotional lability (ALS-18)</td><td>1.62</td><td>0.54</td><td>1.53</td><td>0.58</td><td>0.13</td></tr><tr><td>- Depression-olation</td><td>1.56</td><td>0.7</td><td>1.57</td><td>0.69</td><td>-0.009</td></tr><tr><td>- Anxiety-depression</td><td>1.99</td><td>0.6</td><td>1.81</td><td>0.92</td><td>0.20</td></tr><tr><td>- Anger</td><td>1.34</td><td>0.3</td><td>1.12</td><td>0.8</td><td>0.23</td></tr></tbody></table>

<figure><img src="image_5.png" /><figcaption>**Fig. 2.** Improvements (%) of DERS and ALS for each participant during 4-months DBT-ST.</figcaption></figure>

## 4. Discussion

In the present study, we found that ED was improved during DBT-ST, whereas EL did not. These findings align with the theoretical mechanisms underlying DBT and psychotherapy in general, DBT is thought to reduce ED through the acquisition and repeated use of skills targeting attention, distress tolerance, and emotional modulation. Skills use has been associated with better treatment engagement and clinical improvement (Barnicot et al., 2016; Neacsiu et al., 2010). Neurobiological models suggest that DBT may enhance top-down regulation by strengthening prefrontal control over limbic reactivity (Goodman et al., 2014; Schmitt et al., 2016). This is consistent with our results, which support the hypothesis that DBT-ST exerts its primary effects on ED — a transdiagnostic dimension closely linked to impaired top-down regulation. Although the magnitude of DERS change in our naturalistic study is lower than that observed in randomized controlled trials (Azevedo et al., 2024; Neacsiu et al., 2014b), it was comparable to findings from other real-world studies (Azevedo et al., 2024). In contrast, DBT appears to have a minimal direct impact on EL, supporting a conceptual distinction between ED and EL. One notable finding was the lack of a spillover effect from improvement in ED to EL, despite the moderate correlation between these constructs observed in both our study and prior research

(Contardi et al., 2018).

This suggests that while ED and EL are interrelated, changes in one do not necessarily translate to changes in the other. Although DBT teaches strategies to manage emotional fluctuations, it does not inherently suppress their generation. Bottom-up processes, which drives EL, are rarely directly addressed by psychotherapy (Luo et al., 2023; Quidé et al., 2012). One explanation may be that the indirect influence of top-down regulation on bottom-up processes requires more time to emerge than the duration of this study. For instance, mindfulness-based research indicates that top-down effects manifest relatively quickly, whereas bottom-up modulation requires sustained practice over a year or more (Chiesa et al., 2013; Wheeler et al., 2017). Psychotherapeutic interventions may influence amygdala reactivity indirectly over time via top-down regulation processes (Agapoff et al., 2023; Iskric and Barkley-Levenson, 2021; Luo et al., 2023; Neacsiu et al., 2010). Some authors propose that behavioral strategies might have a greater impact on bottom-up processes than cognitive strategies (Ochsner et al., 2009).

Conversely, pharmacotherapy, which targets bottom-up processes (Luo et al., 2023; Quidé et al., 2012), may have improved EL in several studies, notably in BPD after 3 months of Quetiapine (Van den Eynde et al., 2008) or Lamotrigine (Reich et al., 2009). If the effect of Lamotrigine on BPD symptoms was not replicated in a larger trial (Crawford et al., 2018), the effect of Lamotrigine on EL has not been explored again to our knowledge. Although pharmacotherapy cannot directly address ED, it may act indirectly by mitigating excessive EL, which can interfere with emotional regulation learning. Combining psychotherapy and pharmacotherapy has shown efficacy (Huhn et al., 2014), particularly in DBT in cases of excessive attentional difficulties (Prada et al., 2015) and sometimes to decrease irritability or aggressiveness (M. M. Linehan et al., 2008; Soler et al., 2005). However, its effectiveness for addressing excessive EL remains underexplored.

The strengths and limitations of this study are closely tied to its naturalistic design. This approach enhances clinical representativeness but lacks a control group, limiting our ability to determine how ED and EL would have evolved in untreated patients or those receiving pharmacotherapy alone. Control group data from other studies suggest that over 4 months, DERS and ALS scores typically show minimal improvement or even worsening trend (Neacsiu et al., 2014b; Rahmani et al., 2018; Reich et al., 2009). However, we don't know trials analyzing simultaneously evolution of DERS and ALS, further studies should ideally include a comparison between pharmacotherapy and psychotherapy to verify simultaneously the sensitivity to change of ALS and DERS. Another limitation is missing data for several respondents and the small sample size, which precluded subgroups analyses, such as comparisons between EL-predominant disorders (e.g., bipolar disorder) and ED-predominant disorders (e.g., BPD). Moreover, the lack of long-term data limits our ability to assess whether DBT might eventually influence bottom-up processes like EL, as observed in mindfulness-based therapies. Lastly, the absence of a formal treatment integrity assessment limits the precision of conclusions regarding treatment delivery quality (Onken et al., 2014; Waltz et al., 1993), even if procedures were followed to maintain fidelity — including co-therapy, consultation teams, and supervision.

In conclusion, our study found that ED improved more than EL following DBT-ST and that their correlation decreased during therapy. This finding supports the notion that emotion dysregulation is a different process than emotion lability as it is more sensitive to top-down therapeutics like DBT. However, given the study's limitations, further research is needed to confirm these results. Future studies should include larger sample sizes, long-term follow-up, and control group, for example with medication, to better delineate the respective trajectories of ED and EL. Additionally, integrating neurobiological measures such as neuroimaging, epigenetics, and vagal activity would also provide deeper insight into the mechanisms of change underlying emotion regulation improvements facilitated by DBT skills training programs.

<footnote>* *p* < 0.05.</footnote>

<footnote>*** *p* < 0.001.</footnote>
CRediT authorship contribution statement

**Amaury Durpoix:** Writing – original draft, Methodology, Formal analysis, Data curation, Conceptualization. **Martin Blay:** Writing – original draft, Validation, Methodology, Formal analysis. **Christophe Moog:** Writing – review & editing, Validation. **Julie Rolling:** Writing – review & editing, Validation, Supervision. **Luisa Weiner:** Writing – review & editing, Validation, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. **Laurence Lalanne:** Writing – review & editing, Validation, Supervision, Project administration, Data curation, Conceptualization. **Sébastien Weibel:** Writing – review & editing, Validation, Supervision, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.

Funding

Open access funding provided by University Hospitals of Strasbourg.
The authors received no specific funding for this work.

Declaration of competing interest

The authors declare that they have no competing interests.

Acknowledgements

We want to thank the clinicians who helped us to implement these DBT groups in Strasbourg: Ms. Saliha Derrouazi, Ms. Valérie Poussard 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.

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