Dialectical Behavioral Therapy in the Treatment of Eating Disorders
By Anna M. Karam, Ph.D. and Tiffany Brown, Ph.D.
What is DBT for Eating Disorders & Why is it Used?
Both research and clinical experience suggest that eating disorders and challenging emotions go hand in hand. For example, anxiety or depressed mood may precede an episode of restriction or binge eating, and difficult emotions like guilt, anger, anxiety, and depression may pop up after eating or ruminating about one’s body image. Given this, researchers and clinicians have increasingly focused on targeting emotions in the treatment of eating disorders. One such treatment is dialectical behavior therapy (DBT), which was originally developed by Dr. Marsha Linehan to treat patients with Borderline Personality Disorder (BPD) and chronic suicidality (Linehan, 1991). The theoretical model underlying DBT is termed the skills deficits model, which proposes that individuals engage in harmful behaviors, such as self-harm, to reduce or avoid emotion dysregulation due to lack of knowledge of or mastery with more effective methods to regulate distressing emotions. Thus, DBT is a skills-based behavioral treatment with four modules: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. Full package DBT includes weekly individual therapy, skills groups, phone coaching, and therapist consultation (Linehan, 1991), although some have modified full DBT to only include some of these components.
DBT has been modified for treating eating disorders, and there are two major adaptations: The Stanford Model for Binge Eating Disorder (BED) and Bulimia Nervosa (BN) (i.e., DBT-BED/DBT-BN), and Multidiagnostic Eating Disorder-DBT (MED-DBT). For more details on these models, please see Ben-Porath et al. (2020). DBT-BED/DBT-BN formulates that, similar to the function of self-injurious behavior, eating disorder behaviors are thought to be a method used to attempt to regulate painful emotions. DBT-BED/DBT-BN helps patients learn and utilize more effective coping skills rather than engaging in eating disorder behaviors (Linehan & Chen, 2005). MED-DBT was adapted to treat patients with complex eating disorders either with comorbidities (substance use, BPD) and/or in higher levels of care settings (Federici, Wisniewski, & Ben-Porath, 2012).
DBT has also been adapted for adolescent populations in general and specifically for eating disorders. Generally, DBT adaptations for teens include family members, shortened treatment length, and materials with simplified language (Miller, Rathus, Linehan, Wetzler, & Leigh, 1997). Rathusand Miller (2015) published a 24-week treatment which includes individual therapy, multi-family skills groups, phone coaching for adolescent patients and their parents, family sessions as needed, and a supplementary skill training module called “walking the middle path” which teaches validation, behavioral principles, and dialectical dilemmas common to adolescent and family issues.
DBT for adolescents with eating disorders has been used both as the primary treatment intervention, and has also been used as a supplemental treatment. Family-Based Treatment is an evidence-based treatment for adolescents with Anorexia Nervosa (APA Presidential Task Force on Evidence-Based Practice, 2006), and has substantial research support backing its use across many eating disorder diagnoses (Gorrell, Loeb, & Le Grange, 2019). Thus, DBT for adolescents with eating disorders is commonly used as an adjunct treatment over the course of FBT to help the teen on a more individual level, while the focus of FBT is on empowering parents to refeed their child, monitor and help them eliminate compensatory behaviors, and normalize their pattern of eating (see Anderson et al., 2015 for more information on blended DBT-FBT).
Evidence for DBT in Adults and Adolescents with Eating Disorders
Research on DBT has been ongoing for the last 20 years. The following is a very brief summary of the evidence for DBT in treating eating disorders. For more specific details, please see comprehensive reviews on this topic for adults (Ben-Porath et al., 2020; Bankoff et al., 2012) and adolescents (Reilly et al., 2020).
Several studies in adults support that the Stanford model or DBT-BED/BN helps improve eating disorder symptoms in open or uncontrolled trials (Klein et al., 2012; Chen et al., 2008; Safer et al., 2002; Safer et al., 2001; Telch et al., 2000; Rahmani et al., 2018) and controlled trials (Chen et al., 2017; Safer et al., 2010). This has included improvements in body image and eating concerns, and binge eating and purging behaviors, with abstinence rates from binge eating rates ranging from 64% to 89% (Safer et al., 2010; Telch et al., 2001). To help make treatment more accessible to individuals who need it, recent research has also started to investigate DBT-based guided self-help interventions for patients with BED (Masson et al., 2013; Carter et al., 2020), with initial results supporting greater reductions in binge eating compared to control conditions at post-treatment and 6-month follow-up (Masson et al., 2013). Notably, most of these studies have examined outcomes for patients with BED, versus BN, so more research on DBT individuals diagnosed exclusively with BN are needed.
Within the DBT-MED model for adults, several studies support the utility of DBT for co-occurring eating disorders and BPD (Ben-Porath et al., 2009; Chen et al., 2008; Kröger et al., 2010; Palmer et al., 2003; Navarro-Haro et al., 2018), however, many of these studies have been limited by smaller sample sizes and so more research is needed. Research has also shown that individuals with ED and co-occurring substance use show improvements in their ability to regulate their emotions, improvements in emotional eating, and increased ability to resist substance use urges (Courbasson et al., 2012). Given the increased use of higher levels of care for eating disorder treatment, several recent studies have examined DBT-MED in higher levels of care (partial hospital programs, inpatient). These studies have demonstrated improvements in eating disorder symptoms (Federici & Wisniewski, 2013; Ben-Porath, et al., 2014; Brown et al., 2018), DBT skills use (Brown et al., 2019), emotion regulation (Ben-Porath et al., 2014; Brown et al., 2019), suicidal and self-injurious behaviors, therapy-interfering behaviors, psychiatric and medical hospitalizations, and clinician burnout (Federici & Wisniewski, 2013) post-treatment.
Overall, much less research has focused on DBT for adolescents with eating disorders. DBT for adolescents has been used as both a primary treatment (Salbach-Andrae et al., 2007; 2008; Safer et al., 2007; Fischer & Peterson, 2015) and as an adjunctive treatment for patients with eating disorders (Johnston et al., 2015; Murray et al., 2015; Pennell et al., 2019; Peterson et al., 2019; Reilly et al., 2020). Of those using DBT as a primary treatment, results demonstrate significant improvements in eating disorder behaviors, cognitive symptoms such as body image disturbance, and weight in inpatient samples (Salbach-Andrae et al., 2007) and eating disorder symptoms and general psychopathology in outpatient samples (Salbach-Andrae et al., 2008; Fischer & Peterson, 2015). Research examining DBT as an adjunct to FBT has demonstrated improvements in cognitive eating disorder symptoms and emotion regulation strategies for adolescents with BN (Murray et al., 2015) and improvements in weight (Reilly et al., 2020; Johnston et al., 2015; Pennell et al., 2019), adaptive skills use (Peterson et al, 2019), anxiety and depression (Reilly et al., 2020; Peterson et al., 2019), cognitive eating disorder symptoms (Reilly et al., 2020; Johnston et al., 2015; Peterson et al., 2019) and binge eating and purging behaviors (Reilly et al., 2020; Pennell et al., 2019) in mixed diagnostic samples.
What We Still Need to Know
Although the research on DBT for eating disorders has grown substantially in recent years, much is still unknown and should be the target of future research. Specifically, much of the research conducted on DBT for eating disorders to date has varied in rigor, setting, and treatment length. Relatedly, much of the research has occurred in naturalistic settings, and while this method may enhance generalizability of results, randomized controlled trials are needed for more conclusive evidence on the efficacy of all forms of DBT for eating disorders in samples of adults and youth. Moreover, research on moderators (who treatment works best for) and mediators (why treatments work) of DBT could help the field to better understand for whom DBT is most appropriate, and how DBT achieves its therapeutic effects. By better understanding moderators of DBT, clinicians could understand which patients (based on patient characteristics) or under what circumstances patients most benefit from DBT, which could guide clinicians to understand whether DBT is likely to benefit the patient or whether it would be in their best interest to be referred a different therapeutic modality. Treatment mediators help to uncover the mechanisms in which a treatment achieves its effects. Understanding this could help clinicians and researchers to understand the “active ingredients” of treatment. No published research to date has examined treatment mediators of DBT for eating disorders, however, authors are currently preparing a manuscript with results which showed that DBT skill usage 1 month into treatment mediated the relation between difficulties in emotion regulation at treatment admission and global eating disorder psychopathology at end-of-treatment among adults with eating disorders in a partial hospitalization program (Karam, Wierenga, Anderson, Kaye, & Brown, in preparation). This suggests that DBT skill use is a mechanism of how DBT works. Additional research on DBT treatment mediators could lead to clinicians and researchers using this treatment strategically to maximize efficacy.
In conclusion, substantial research highlights the benefits of DBT for eating disorders, and additional research will help the field of eating disorders to better understand its efficacy and how best to help patients reach eating disorder recovery.
About the authors:
Anna M. Karam, Ph.D.
Dr. Anna Karam is a Postdoctoral Fellow at the UC San Diego Health’s Eating Disorders Center for Treatment and Research (EDC). Dr. Karam received her Bachelor’s in Psychology and Women’s and Gender Studies in 2013 from the University of North Carolina at Chapel Hill and received her PhD in Clinical Psychology from Washington University in St. Louis in 2020. She completed her predoctoral clinical internship at UCSD. Dr. Karam has received broad and comprehensive training in the evidence-based treatment of psychological disorders including eating disorders, anxiety disorders, and mood disorders, with an emphasis in the areas of eating and weight-related disorders. Her research interests include examining predictors, moderators, and mechanisms of evidence-based treatment for eating disorders, as well as the best methods for dissemination and implementation of evidence-based treatments for eating disorders, with the ultimate goal to enhance and increase access to eating disorder care. Dr. Karam is passionate about combining her research and clinical interests in the area of eating disorders.
Tiffany A. Brown, Ph.D.
Dr. Tiffany Brown is a licensed clinical psychologist and Assistant Project Scientist at the UCSD Eating Disorders Center. She graduated from Villanova University with her BA and from Florida State University with her PhD in Clinical Psychology. She has extensive clinical experience working with pediatric, adolescent, and adult patients with eating disorders using DBT, Cognitive Behavioral Therapy (CBT), Exposure and Response Prevention (EXRP), and Family Based Therapy (FBT) and enjoys working with patients from diverse backgrounds. In particular, she is an advocate for patients who have typically been underrepresented in the eating disorder field, including LGBTQ+ and male patients. Her research interests focus on eating disorder prevention in male and LGBTQ+ populations and treatments for body image and eating disorders, particularly those targeting altered interoception – the brain-body relationship – and anxiety about body sensations. Dr. Brown has received research funding from the National Institute of Minority Heath and Health Disparities, the Arlene and Michael Rosen Foundation, the Global Foundation for Eating Disorders, and the Academy for Eating Disorders. Her current research focuses on reducing eating disorder and muscle dysmorphia risk for LGBTQ+ and male populations, understanding factors related to treatment outcome across gender and sexual identity, the effectiveness of DBT for eating disorders, and how interoception and gastric specific anxiety can be targeted in eating disorder treatment (e.g., interoceptive exposure).
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