Dialectical behavior therapy for binge eating disorder

An acceptance-based behavioral intervention for weight loss: a pilot study

On average, participants in behavioral weight-loss interventions lose 8 kilograms (kg) at 6 months, but there is marked variability in outcomes with some participants losing little or no weight. Individuals with difficulties with internal disinhibition (i.e., eating in response to emotions or thoughts) typically lose less weight in such programs and may require an innovative, specialized approach. This pilot study examined the preliminary acceptability and efficacy of a 24-week acceptance-based behavioral intervention for weight loss among overweight and obese adults reporting difficulty with eating in response to emotions and thoughts. Participants were 21 overweight or obese men and women (mean age=52.2±7.6 years; baseline mean body mass index=32.8±3.4). Eighty-six percent completed the 6-month program and a 3-month follow-up assessment. Ratings of program satisfaction averaged 4.9 on a five-point scale. Multilevel modeling analyses indicated participants lost an average of 12.0 kg (SE=1.4) after 6 months of treatment and 12.1 kg (SE=1.9) at 3-month follow-up, thus exceeding the weight losses typically seen in behavioral treatment programs. Decreases in internal disinhibition and weight-related experiential avoidance were found at 6- and 3-months follow-up. Greater decreases in weight-related experiential avoidance were associated with greater weight loss at the end of the program (r=.64, p=.002), suggesting a potential mechanism of action. Although there have been a few preliminary studies using acceptance-based approaches for obesity, this is the first study to specifically target emotional overeaters, a subgroup that might be particularly responsive to this new approach. Our findings provide initial support for the feasibility, efficacy, and acceptability of this approach for this subgroup of participants. Further study with longer follow-up, a more diverse sample, and comparison to a standard behavioral program is clearly warranted.

Psychosocial preventive interventions for obesity and eating disorders in youths

Abstract The rates of paediatric obesity have risen dramatically. Given the challenge of successful weight loss and maintenance, preventive interventions are sorely needed. Furthermore, since a substantial proportion of individuals do not respond to traditional behavioural weight loss therapy, alternative approaches are required. Psychological treatments for binge eating disorder have been generally effective at reducing binge episodes and producing weight maintenance or modest weight loss in obese adults. Given the strong link between loss of control eating and obesity in youths, binge eating disorder treatment may serve as a viable form of excess weight gain prevention. An adapted version of interpersonal psychotherapy for binge eating disorder is one such intervention that we have considered. A description of the theoretical basis and proposed mechanism is described. Adaptations of interpersonal psychotherapy and other established therapies for binge eating disorder may serve as platforms from which to develop and disseminate obesity and eating disorder prevention programs in children and adolescents.

Cultural adaptation of the difficulties in emotion regulation scale: reliability and validity of an Italian version

OBJECTIVE

The aim of this study was to evaluate the reliability and validity of an Italian version of the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004).

METHOD

Three studies were completed. First, factorial structure, internal consistency, and concurrent validity of our Italian version of the DERS were examined with a sample of 323 students (77% female; mean age 25.6). Second, test-retest analyses were completed using a different sample of 61 students (80% female; mean age 24.7). Third, the scores produced by a small clinical sample of participants (N = 38; mean age = 24.2) affected by anorexia, binge eating disorder, or bulimia were compared to those of an age-matched, nonclinical female sample (N = 38; mean age = 24.7).

RESULTS

The factorial structure replicated quite well the six-factor structure proposed by Gratz and Roemer. The internal consistency and test-retest reliability were adequate and comparable to previous findings. The validity was good, as indicated by both the concurrent validity analysis and the clinical-nonclinical sample comparison.

CONCLUSIONS

These studies provide further support for the multidimensional model of emotion regulation postulated by Gratz and Roemer and strengthen the rationale for cross-cultural utilization of the DERS.

Prolonged Exposure, Mindfulness, and Emotion Regulation for the Treatment of PTSD

Although several studies have demonstrated the efficacy of prolonged exposure (PE) for the treatment of posttraumatic stress disorder (PTSD), there are concerns regarding its clinical applications. The exacerbation of symptoms during exposure, poor adherence to treatment, and early treatment dropout are suggested to occur because of an unwillingness for some PTSD clients to confront feared trauma-relevant stimuli and experience anxious arousal during exposure. The application of mindfulness and emotion regulation skills during PE may be a useful substitute for clients’ attempts to escape, avoid, or control anxious arousal during treatment. Presented is the clinical case of a 19-year-old college student with severe PTSD resulting from a childhood sexual assault. The article discusses the client’s success with the mindfulness, emotion regulation, and PE approach, in addition to reductions in anxiety sensitivity over the course of treatment, as well as implications for practice and further research.

Emotion regulation deficits in eating disorders: a marker of eating pathology or general psychopathology?

Preliminary evidence indicates that individuals with eating disorders (ED) show emotion regulation (ER) difficulties. However, it is yet unclear whether different types of ED differ in their ER profile and whether certain ER difficulties are specific for ED or rather a transdiagnostic factor. Twenty women with anorexia nervosa (AN), 18 with bulimia nervosa (BN), 25 with binge eating disorder (BED), 15 with borderline personality disorder (BPD), 16 with major depressive disorder (MDD) and 42 female healthy controls (HC) were administered the Emotion Regulation Questionnaire, the Inventory of Cognitive Affect Regulation Strategies, the Difficulties in Emotion Regulation Scale and the Affect Intensity Measure. The ED groups reported significantly higher levels of emotion intensity, lower acceptance of emotions, less emotional awareness and clarity, more self-reported ER problems as well as decreased use of functional and increased use of dysfunctional emotion regulation strategies when compared to HC. No significant differences between the ED groups emerged for most ER variables. However, there were indications that the BED group may show a slightly more adaptive pattern of ER than the two other ED groups. As a whole, all clinical groups performed very similar on most ER variables and reported more difficulties regulating their emotions than HC. The findings suggest that ER difficulties are not linked to a particular diagnostic category. Instead, ER difficulties appear to be a transdiagnostic risk and/or maintenance factor rather than being disorder-specific.

Dialectical behaviour therapy with adolescents

BACKGROUND

  Dialectical behaviour therapy (DBT) is the first empirically validated treatment for chronically suicidal patients diagnosed with borderline personality disorder (BPD). Numerous randomised clinical trials conducted with adults with BPD have demonstrated that DBT is effective in reducing suicidal and non-suicidal self-injurious (NSSI) behaviours. Other research on the use of DBT for adults has shown that the treatment is effective in reducing a variety of problem behaviours in a range of therapeutic settings. In the last decade, a number of studies have evaluated DBT as a promising treatment for adolescents with different psychological disorders and behaviours, including borderline personality disorder (BPD), eating disorders, externalising disorders, and suicidal and NSSI behaviours. This article reviews the literature on the use of DBT with adolescents.

RESULTS

  Overall findings indicate some empirical support for the conclusion that DBT is a promising treatment for adolescents with BPD symptomatology, suicidal ideation and comorbid depression, bipolar disorder, disordered eating behaviours and aggressive and impulsive behaviours. Adolescents in these studies were also hospitalised less frequently when treated with DBT. Moreover, studies conducted with these populations suggest that DBT may be adapted for use in outpatient, inpatient, community, and residential treatment settings.

CONCLUSIONS

  The authors conclude that DBT may be effective in treating adolescents with additional disorders and dysfunctional behaviours not yet examined. Data from soon to be completed randomised controlled trials need to be published.

Moderators of dialectical behavior therapy for binge eating disorder: results from a randomized controlled trial

OBJECTIVE

Investigate moderators of a randomized clinical trial of group Dialectical Behavior Therapy for Binge Eating Disorder (DBT-BED) compared to an active comparison group control (ACGT) on the post-treatment outcome of binge frequency after twenty 2-h weekly sessions.

METHOD

Moderation analyses.

RESULTS

Participants were 101 adults with BED [mean (SD) age, 52.2 (10.6) years and BMI, 36.4 (8.6)]. Analyses identified two moderators of post-treatment outcome. Participants with (1) Avoidant Personality Disorder or (2) an earlier onset of overweight and dieting (<15 years old) evidenced significantly worsened outcome when treated with ACGT versus DBT-BED.

DISCUSSION

Participants with certain indicators of higher baseline pathology respond better to DBT-BED than ACGT at post-treatment.

Cognitive Behavior Therapy and Dialectical Behavior Therapy for Treating Obese Emotional Eaters

This study describes the treatment of obese individuals who rated high on emotional eating using four case studies that involved 22 sessions of either cognitive behavioral therapy (CBT) or dialectical behavioral therapy (DBT). Outcomes measures relating to weight, body mass index, emotional eating, depression, anxiety, and stress were all assessed with each participant prior to each baseline (three weekly sessions), during treatment and posttherapy. At the 8-week follow-up, the two cases that had received DBT had lost 10.1% and 7.6% of their initial body weight, whereas the two cases that had received CBT had lost 0.7% and 0.6% of their initial body weight. The two DBT cases also exhibited reductions in emotional distress, frequency of emotional eating or quantity of food eating in response to emotions, whereas the two CBT cases showed no overall reductions in these areas. Important processes from all four cases are described as are the implications to clinicians for developing more effective interventions for obese clients who engage in emotional eating.

Current and emerging directions in the treatment of eating disorders

Eating disorders are a significant source of psychiatric morbidity in young women and demonstrate high comorbidity with mood, anxiety, and substance use disorders. Thus, clinicians may encounter eating disorders in the context of treating other conditions. This review summarizes the efficacy of current and emerging treatments for anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Treatment trials were identified using electronic and manual searches and by reviewing abstracts from conference proceedings. Family based therapy has demonstrated superiority for adolescents with AN but no treatment has established superiority for adults. For BN, both 60 mg fluoxetine and cognitive behavioral therapy (CBT) have well-established efficacy. For BED, selective serotonin reuptake inhibitors, CBT, and interpersonal psychotherapy have demonstrated efficacy. Emerging directions for AN include investigation of the antipsychotic olanzapine and several novel psychosocial treatments. Future directions for BN and BED include increasing CBT disseminability, targeting affect regulation, and individualized stepped-care approaches.

Adapted group-based dialectical behaviour therapy for binge eating in a practicing clinic: clinical outcomes and attrition

Research evidence has been accumulating for the efficacy of dialectical behaviour therapy (DBT) for binge eating. However, support for its effectiveness and transportability beyond efficacy trials is lacking. The current study evaluated the feasibility of group-based DBT for binge eating within the context of an operating community clinic. Women ages 24-49 (M = 39.60, SD = 9.53) with either subthreshold and full-threshold binge eating disorder or bulimia nervosa formed the group and comprised the sample (n = 5 treatment completers). Positive outcomes included significant improvement in both binge eating and secondary outcomes with the Eating Disorder Inventory subscales of Bulimia, Ineffectiveness, Perfectionism and Interpersonal Distrust. Attrition was elevated compared with previous efficacy trials, suggesting the need for increased attention to how to improve retention within routine practice settings. Given our limited sample size, these findings are viewed as promising but preliminary.

Dialectical behavior therapy group skills training in a community mental health setting: a pilot study

Effective and affordable therapies are needed for treating people with severe and persistent mental illness in a community mental health setting. In this pilot study, we evaluated the effectiveness of a modified dialectical behavior therapy (DBT) protocol for improving symptoms and functioning in a cohort of persons with severe and persistent mental illness. We provided six months of weekly DBT skills training in a group setting. Depression symptoms decreased significantly after treatment. There was a wide range of number of sessions attended, with a minority of the participants completing the full course of treatment. Increased attendance was correlated with improvements in depression symptoms, overall symptoms, quality of life, and community functioning. The study findings suggest that the group skills training component of DBT can be successfully implemented in a community mental health center and that further research to determine its efficacy in comparison to other treatments is warranted.

[Psychotherapy and obesity: strategies, challenges and possibilities]

One fifth of the German population is obese with increasing prevalence. Psychotherapy plays an important role in weight loss programmes. Cognitive behaviour therapy, targeting lifestyle changes, including exercise and eating behaviour, is the evidence-based treatment of choice. Especially the lack of motivation or absence of weight loss, further weight gain or psychosocial burden makes psychotherapy essential. The treatment of a comorbid binge eating disorder should be initiated prior to focusing on weight loss. Remarkably difficult stages in the treatment of obesity are the initiation of changes as well as the maintenance of the achieved weight loss. Internet-based attempts will become increasingly important.

Emerging Approaches to Counseling Intervention

Dialectical Behavior Therapy (DBT) is a comprehensive, multimodal cognitive behavioral treatment originally developed for individuals who met criteria for borderline personality disorder (BPD) who displayed suicidal tendencies. DBT is based on behavioral theory but also includes principles of acceptance, mindfulness, and validation. Since its development, DBT has been adapted to various populations and has been successfully used in a wide array of settings. This article presents the approaches used in DBT with a particular emphasis on (a) the philosophy and assumptions on which the treatment is based, (b) the major theoretical constructs and the DBT conceptualization of the client, (c) the intervention and specific techniques used, (d) research supporting the theory and treatment, and (e) the integration of diversity, culture, and social justice.

An overview of treatments for obesity in a population with mental illness

Obesity is associated with early mortality and has overtaken smoking as the health problem with the greatest impact on quality of life, mortality, and morbidity. Despite public health initiatives and numerous commercial enterprises focusing on weight loss, obesity rates continue to rise. In part, this is because obesity is a multifaceted, complex illness, impacted by numerous social, psychological, and behavioural factors that are unrecognized in most current initiatives. One significant factor associated with obesity is mental illness. While having a psychiatric illness does not make weight gain inevitable, it does often require that additional tools be added to lifestyle recommendations around diet and exercise. The following article reviews the common approaches to obesity management and addresses how these strategies can be implemented in psychiatric care. It is important that health professionals involved in the care of people with a mental illness become familiar with the interventions available to control and treat the obesity epidemic, as this will improve treatment compliance and ultimately lead to improved physical and psychological outcomes.

A systematic review of dialectical behavior therapy for the treatment of eating disorders

Dialectical behavior therapy (DBT) has been proposed as an effective treatment for eating disorders (EDs). We conducted a systematic literature review to locate refereed journal articles testing DBT for the treatment of EDs. We identified 13 studies empirically evaluating treatment efficacy across various settings. Findings, based on mostly uncontrolled trials, indicate that DBT treatments appear effective in addressing ED behaviors and other forms of psychopathology in ED samples. The expectation that improvements in emotion regulation capabilities drive reductions in ED pathology was not fully supported. Further research is necessary to confirm the efficacy of modified DBT treatments for EDs.

Treatment of binge eating disorder

The two specialty psychological therapies of CBT and IPT remain the treatments of choice for the full range of BED patients, particularly those with high levels of specific eating disorder psychopathology such as overvaluation of body shape and weight. They produce the greatest degree of remission from binge eating as well as improvement in specific eating disorder psychopathology and associated general psychopathology such as depression. The CBT protocol evaluated in the research summarized above was the original manual from Fairburn and colleagues. Fairburn has subsequently developed a more elaborate and sophisticated form of treatment, namely, enhanced CBT (CBT-E) for eating disorders. Initial research suggests that CBT-E may be more effective than the earlier version with bulimia nervosa and Eating Disorder Not Otherwise Specified patients. CBT-E has yet to be evaluated for the treatment of BED, although it would currently be the recommended form of CBT. Of relevance in this regard is that the so-called broad form of the new protocol includes 3 optional treatment modules that could be used to address more complex psychopathology in BED patients. One of the modules targeted at interpersonal difficulties is IPT, as described earlier in this chapter. Thus, the broader protocol could represent a combination of the two currently most effective therapies for BED. Whether this combined treatment proves more effective than either of the components alone, particularly for a subset of BED patients with more complex psychopathology, remains to be tested. CBT-E also includes a module designed to address what Fairburn terms “mood intolerance” (problems in coping with negative affect) that can trigger binge eating and purging. The content and strategies of this mood intolerance module overlap with the emotional regulation and distress tolerance skills training of Linehan's dialectical behavior therapy (DBT). Two randomized controlled trials have tested the efficacy of an adaptation of DBT for the treatment of BED (DBT-BED) featuring mindfulness, emotion regulation, and distress tolerance training. A small study by Telch and colleagues found that modified DBT-BED was more effective than a wait list control in eliminating binge eating. A second study showed that DBT-BED resulted in a significantly greater remission rate from binge eating at posttreatment than a group comparison treatment designed to control for nonspecific therapeutic factors such as treatment alliance and expectations.50 This difference between the two treatments disappeared over a 12-month follow-up, indicating the absence of DBT-BED-specific influences on long-term outcomes. Both CBT and IPT have been shown to be more effective in eliminating binge eating than BWL in controlled, comparative clinical trials. Nonetheless, BWL has been effective in reducing binge eating and associated eating problems in BED patients in some studies and might be suitable for treatment of BED patients without high levels of specific eating disorder psychopathology. A finding worthy of future research is the apparent predictive value of early treatment response to BWL, indicating when BWL is likely to prove effective or not. No evidence supports the concern that BWL's emphasis on moderate caloric restriction either triggers or exacerbates binge eating in individuals with BED. Initially, CBTgsh was recommended as a feasible first-line treatment that might be sufficient treatment for a limited subset of patients in a stepped care approach. More recent research, however, has shown that CBTgsh seems to be as effective as a specialty therapy, such as IPT, with a majority of BED patients. The subset of patients that did not respond well to CBTgsh in this research were those with a high level of specific eating disorder psychopathology, as noted. A plausible explanation for this moderator effect is that the original Fairburn CBTgsh manual does not include an explicit emphasis on body shape and weight concerns. Subsequent implementation of this treatment has incorporated a module that directly addresses overvaluation of body shape and weight. Future research should determine whether an expanded form of CBTgsh is suitable for the full range of patients with BED. CBTgsh is recommended as a treatment for BED on two other counts. First, its brief and focused nature makes it cost effective. Second, its structured format makes it more readily disseminable than other longer, multicomponent psychological therapies. It can be implemented by a wider range of treatment providers than more technically complex, time-consuming, and clinical expertise-demanding specialty therapies such as CBT-E and IPT. The latter evidence-based therapies are rarely available to patients with BED in routine clinical care settings. Nevertheless, it must be noted that much of the research on CBTgsh to date has been conducted in an eating disorder specialty clinic setting. The degree to which the treatment can be adapted to a range of clinical service settings remains to be determined. In addition, little is known about the specific provider qualifications and level of expertise required to implement CBTgsh successfully. Despite its brief and focal nature, specific provider skills regarding what and what not to address in treatment are required. Currently available pharmacologic treatments cannot be recommended for treatment of BED. Aside from the inconsistent results of existing studies, the striking absence of controlled long-term evaluation of such treatment argues against its use.As summarized, the evidence-based treatments of CBT, IPT, and CBTgsh result in significant improvement and large treatment effects on multiple outcome measures aside from binge eating in overweight and obese patients. These include specific eating disorder psychopathology (eg, overvaluation of body shape and weight), general psychopathology (eg, depression), and psychosocial functioning. Moreover, these changes are typically well-maintained over 1 to 2 years of follow-up. The exception to this profile of improvement remains weight loss and its maintenance over time. These specialty psychological treatments do not produce weight loss, although successfully eliminating binge eating might protect against future weight gain. BWL consistently produces short-term weight loss, the extent of which has varied across different studies. Long-term weight loss has yet to be demonstrated, however. In this regard, the findings with obese patients with BED are not different than those on the treatment of obesity in general, in which there is little robust evidence of enduring weight loss effects of BWL.

Mindfulness Moderates the Relationship Between Disordered Eating Cognitions and Disordered Eating Behaviors in a Non-Clinical College Sample

Psychological flexibility and mindfulness are two related, but distinct, regulation processes that have been shown to be at the core of psychological wellbeing. The current study investigated whether these two processes independently moderated the association between disordered eating cognitions and psychological distress as well as the relation between disordered eating cognitions and disordered eating behaviors. Non-clinical, ethnically diverse college undergraduates completed a web-based survey. Of 278 participants (nfemale=208; nmale=70) aged 18-24 years old, disordered eating cognitions, mindfulness, and psychological flexibility were related to psychological distress after controlling for gender, ethnicity, and body mass index. Disordered eating cognitions and mindfulness accounted for unique variance in disordered eating behaviors. Finally, mindfulness was found to moderate the association between disordered eating cognitions and disordered eating behaviors.

Effects of mindfulness on psychological health: a review of empirical studies

Within the past few decades, there has been a surge of interest in the investigation of mindfulness as a psychological construct and as a form of clinical intervention. This article reviews the empirical literature on the effects of mindfulness on psychological health. We begin with a discussion of the construct of mindfulness, differences between Buddhist and Western psychological conceptualizations of mindfulness, and how mindfulness has been integrated into Western medicine and psychology, before reviewing three areas of empirical research: cross-sectional, correlational research on the associations between mindfulness and various indicators of psychological health; intervention research on the effects of mindfulness-oriented interventions on psychological health; and laboratory-based, experimental research on the immediate effects of mindfulness inductions on emotional and behavioral functioning. We conclude that mindfulness brings about various positive psychological effects, including increased subjective well-being, reduced psychological symptoms and emotional reactivity, and improved behavioral regulation. The review ends with a discussion on mechanisms of change of mindfulness interventions and suggested directions for future research.

Open, aware, and active: contextual approaches as an emerging trend in the behavioral and cognitive therapies

A wave of new developments has occurred in the behavioral and cognitive therapies that focuses on processes such as acceptance, mindfulness, attention, or values. In this review, we describe some of these developments and the data regarding them, focusing on information about components, moderators, mediators, and processes of change. These "third wave" methods all emphasize the context and function of psychological events more so than their validity, frequency, or form, and for these reasons we use the term "contextual cognitive behavioral therapy" to describe their characteristics. Both putative processes, and component and process evidence, indicate that they are focused on establishing a more open, aware, and active approach to living, and that their positive effects occur because of changes in these processes.

Beyond alcohol and drug addiction. Does the negative trait of low distress tolerance have an association with overeating?

Low distress tolerance is an inability to withstand negative emotions. The connection between low distress tolerance and addiction to cigarettes, alcohol, and illegal drugs has been established. The purpose of the current study was to extend this work to overeating, which is an important symptom of food addiction. We investigated whether low distress tolerance was related to overeating as measured by the emotional and external eating scales of the Dutch Eating Behavior Questionnaire and the disinhibition scale of the Three-Factor Eating Questionnaire. Participants were 225 college students with a median age of 19; 32% were overweight or obese. Linear regression models adjusting for sex and BMI demonstrated significant inverse associations among distress tolerance and emotional eating (P = 0.001), external eating (P = 0.002), and disinhibition (P < 0.001). These initial results suggest the importance of additional research in the area of low distress tolerance, overeating, and food addiction.

How to deal with sociocultural pressures in daily life: reflections of adolescent girls suffering from eating disorders

Adolescent girls with eating disorders experience unattainable and contradictory expectations in daily life, which create stress and negatively affect their self-evaluation. Disordered eating may function as a way of seeking control and consistency. In order to make progress in the understanding of eating disorders, the aim of this study was to describe how adolescent girls with eating disorders reflect upon ways of dealing with sociocultural pressures in daily life. Eighteen interviews with girls aged 15-19 years were analyzed using a phenomenographic approach. The results were summarized into three conceptions: "Striving to be oneself " (conception A) was described as the most desirable, but also the hardest. "Adapting to various situations" (conception B) was used without much reflection, as long as it worked, but when this way of dealing with everyday expectations was unsuccessful it was evaluated negatively. "Presenting oneself in a positive light" (conception C) was described negatively even when it was successful. Within these conceptions, the participants described various strategies that could be used more or less effectively depending on the circumstances. A common theme was their difficulties in finding a balance between trying harder to live up to perceived expectations from others on one hand, and trying to accept the situation as it was, without trying to change themselves or the situation, on the other hand. The participants believed that their eating disorder was partly a result of being unable to deal with sociocultural pressures in an effective way, and they experienced a conflict between societal values of being assertive and values of being interpersonally oriented. Implications for treatment are discussed.

Dialectical behavior therapy for suicidal adolescents with borderline personality disorder

Although research to date on dialectical behavior therapy (DBT) for adolescents has its limitations, growing evidence suggests that DBT is a promising treatment for adolescents with a range of problematic behaviors, including but not limited to suicidal and nonsuicidal self-injury. This article introduces dialectical behavior therapy's theoretical underpinnings, describes its adaptation for suicidal adolescents, and provides a brief review of the empirical literature evaluating DBT with adolescents.

The role of psychological flexibility in the relationship between self-concealment and disordered eating symptoms

The present cross-sectional study investigated whether psychological flexibility mediates the association between self-concealment and disordered eating (DE) symptoms among non-clinical college students. Data of 209 male and female participants (nfemale =165), aged 18-22 years old, were used for analyses. Self-concealment was found to be positively associated with DE symptoms (i.e., general eating disorder symptoms and eating disorder-related cognitions) and negatively associated with psychological flexibility. Psychological flexibility was inversely associated with DE symptoms. Finally, psychological flexibility was found to mediate the association between self-concealment and DE symptoms after accounting for gender, ethnic background, and body mass index (BMI).

Appetite-focused dialectical behavior therapy for the treatment of binge eating with purging: a preliminary trial

OBJECTIVE

This treatment development study investigated the acceptability and efficacy of a modified version of dialectical behavior therapy (DBT) for bulimia nervosa (BN), entitled appetite focused DBT (DBT-AF).

METHOD

Thirty-two women with binge/purge episodes at least one time per week were randomly assigned to 12 weekly sessions of DBT-AF (n = 18) or to a 6-week delayed treatment control (n = 14). Participants completed the EDE interview and self-report measures at baseline, 6 weeks, and posttreatment.

RESULTS

Treatment attrition was low, and DBT-AF was rated highly acceptable. At 6 weeks, participants who were receiving DBT-AF reported significantly fewer BN symptoms than controls. At posttest, 26.9% of the 26 individuals who entered treatment (18 initially assigned and 8 from the delayed treatment control) were abstinent from binge/purge episodes for the past month; 61.5% no longer met full or subthreshold criteria for BN. Participants demonstrated a rapid rate of response to treatment and achieved clinically significant change.

DISCUSSION

Results suggest that DBT-AF warrants further investigation as an alternative to DBT or cognitive behavior therapy for BN.

Outcome of dialectical behaviour therapy for concurrent eating and substance use disorders

AIM

The current study examined the preliminary efficacy of dialectical behaviour therapy (DBT) adapted for concurrent eating disorders (EDs) and substance use disorders (SUDs).

METHOD

A matched randomized controlled trial was carried out with 25 female outpatients diagnosed with concurrent ED and SUD. Participants randomized to the intervention condition received DBT, whereas those randomized to the control condition received treatment as usual (TAU), both for a period of 1 year. A series of measures related to disordered eating, substance use and depression were administered to the participants at the beginning of treatment and at 3, 6, 9 and 12 months into treatment, followed by 3-month and 6-month follow-up assessments.

FINDINGS

Participants randomized to the DBT condition evidenced a superior retention rate relative to their counterparts in the TAU condition at various study time points, including post-treatment (80% versus 20%) and follow-up (60% versus 20%). Due to the unexpected elevated dropout rates and the worsening of ED-SUD symptomatology in the TAU condition, recruitment efforts were terminated early. Results from the DBT condition revealed that the intervention had a significant positive effect on behavioural and attitudinal features of disordered eating, substance use severity and use, negative mood regulation and depressive symptoms. Finally, increases in participants' perceived ability to regulate and cope with negative emotional states were significantly associated with decreases in emotional eating and increases in levels of confidence in ability to resist urges for substance use.

CONCLUSION

Results suggest that the adapted DBT might hold promise for treating individuals with concurrent ED and SUD.

KEY PRACTITIONER MESSAGE

The current study is the first study to report positive effects of DBT on individuals with concurrent eating and substance use disorders. Although the results require replication and extension, they suggest that the DBT may be promising for this population. The results suggest that clinicians treating individuals with concurrent eating and substance use problems should be particularly cautious of poor treatment retention and treatment complications. The results bear upon the highly salient and important issue of whether individuals with concurrent substance use need to be excluded from research studies and treatment programmes.

Does rapid response to two group psychotherapies for binge eating disorder predict abstinence?

OBJECTIVE

Extend understanding of a rapid response (RR) to treatment by examining its prognostic significance at end-of-treatment (EOT) and 1 year follow-up within two group treatments for binge eating disorder (BED): Dialectical Behavior Therapy for BED (DBT-BED) and an active comparison group therapy (ACGT).

METHODS

101 adults with BED randomized to 20-weeks DBT-BED versus ACGT (Safer, Robinson, & Jo, 2010). RR defined as ≥65% reduction in the frequency of days of binge eating by week 4. RR across and within treatment conditions used to predict binge eating abstinence and secondary outcomes (e.g., binge eating pathology, treatment attrition) at EOT and 1 year follow-up.

RESULTS

(1) Significantly higher binge eating abstinence for rapid responders (RR; n = 41) vs. non-rapid responders (non-RRs; n = 60) at EOT (70.7% vs. 33.3%) and 1 year follow-up (70.7% vs. 40.0%), respectively, as well as improvement on most secondary measures (2) Significantly less attrition among RRs vs. non-RRs (3) Significantly higher binge eating abstinence rates at both time points for DBT-RRs vs. DBT-non-RRs, but not for ACGT-RRs vs. ACGT-non-RRs.

CONCLUSIONS

Current study extends prognostic significance of RR to 1 year follow-up. RR more prominent for those randomly assigned to DBT-BED than ACGT. Implications discussed.

Using mindful eating to treat food restriction: a case study

This case study describes the application of the principles of mindful eating to the treatment of a case of anorexia nervosa. While many clinicians currently use mindful eating in their treatment of binge eating disorder and bulimia, it also may benefit clients who restrict. The client in this case study is a 19-year-old college student with a BMI of 17.9 and daily restriction of approximately 900-1000 calories who exercises 1 hour daily. Over 15 sessions, she was introduced to the principle of mindful eating. There was an overall decline in restriction, her BMI raised to 19.5, and her caloric intake increased to approximately 1,500-2,000.

Response style and vulnerability to anger-induced eating in obese adults

Emotional eating appears to contribute to weight gain, but the characteristics that make one vulnerable to emotional eating remain unclear. The present study examined whether two negative affect response styles, rumination and distraction, influenced palatable food intake following an anger mood induction in normal weight and obese adults. We hypothesized that higher rumination and lower distraction would be associated with greater vulnerability to anger-induced eating, particularly among obese individuals. Sixty-one participants (74% female, mean age=34.6) underwent neutral and anger mood inductions in counterbalanced order. Directly following each mood induction, participants were provided with 2400 kcal of highly palatable snack foods in the context of a laboratory taste test. Results revealed that distraction influenced energy intake following the mood induction for obese but not normal weight individuals. Obese participants who reported greater use of distraction strategies consumed fewer calories than those reporting less use of distraction strategies. These findings were independent of subjective hunger levels, individual differences in mood responses and trait anger, and other factors. Rumination did not account for changes in energy intake among obese or normal weight participants. Among obese individuals, the tendency to utilize fewer negative affect distraction strategies appears to be associated with vulnerability to eating in response to anger. Future research should determine whether coping skills training can reduce emotional eating tendencies.

Mindfulness-Action Based Cognitive Behavioral Therapy for concurrent Binge Eating Disorder and Substance Use Disorders

Individuals with Binge Eating Disorder (BED) often evidence comorbid Substance Use Disorders (SUD), resulting in poor outcome. This study is the first to examine treatment outcome for this concurrent disordered population. In this pilot study, 38 individuals diagnosed with BED and SUD participated in a 16-week group Mindfulness-Action Based Cognitive Behavioral Therapy (MACBT). Participants significantly improved on measures of objective binge eating episodes; disordered eating attitudes; alcohol and drug addiction severity; and depression. Taken together, MACBT appears to hold promise in treating individuals with co-existing BED-SUD.

Psychological inflexibility and symptom expression in anorexia nervosa

The purpose of this article is to outline a model of anorexia nervosa (AN) as a disorder of psychological inflexibility, motivated by an insatiable desire for prediction and control with related intolerance for uncertainty. We describe preliminary data that provide initial support for this conceptualization and point to the ways in which mindfulness and acceptance-based strategies might be particularly useful for treating AN. This article is not intended to be an exhaustive literature review, rather a conceptual framework to guide future research and treatment development.

A Randomized Controlled Trial of Acceptance-Based Behavior Therapy and Cognitive Therapy for Test Anxiety: A Pilot Study

Many university students suffer from test anxiety that is severe enough to impair performance. Given mixed efficacy results of previous cognitive-behavior therapy (CBT) trials and a theoretically driven rationale, an acceptance-based behavior therapy (ABBT) approach was compared to traditional CBT (i.e., Beckian cognitive therapy; CT) for the treatment of test anxiety. In this pilot study, 16 university students with test anxiety were randomly assigned to receive either a CT or ABBT 2-hr group workshop. The two treatments produced markedly different effects on test performance (measured by exam scores), with those receiving ABBT experiencing improvements in performance, whereas those receiving CT exhibited reduced performance. In addition, there was a suggestion that ABBT might have been more effective at reducing subjectively experienced test anxiety (i.e., a nonsignificant but medium-sized group by time interaction effect). Implications of these results for the treatment of test anxiety and for theoretical notions related to cognitive change strategies are discussed.

Dialectical behaviour therapy and an added cognitive behavioural treatment module for eating disorders in women with borderline personality disorder and anorexia nervosa or bulimia nervosa who failed to respond to previous treatments. An open trial with a 15-month follow-up

There is evidence from case studies suggesting that adapted dialectical behavior therapy (DBT) for borderline personality disorder (BPD) and eating disorders (ED) might improve disorder related complaints. Twenty-four women with BPD (9 with comorbid anorexia nervosa [AN] and 15 with bulimia nervosa [BN]), who already had failed to respond to previous eating-disorder related inpatient treatments were consecutively admitted to an adapted inpatient DBT program. Assessment points were at pre-treatment, post-treatment, and 15-month follow-up. At follow-up, the remission rate was 54% for BN, and 33% for AN. Yet 44% of women with AN crossed over to BN and one woman additionally met the criteria of AN. For women with AN, the mean weight was not significantly increased at post-treatment, but had improved at follow-up. For women with BN, the frequency of binge-eating episodes was reduced at post-treatment as well as at follow-up. Self-rated eating-related complaints and general psychopathology, as well as ratings on global psychosocial functioning, were significantly improved at post-treatment and at follow-up. Although these findings support the assumption that the adapted DBT inpatient program is a potentially efficacious treatment for those who failed to respond to previous eating-disorder related inpatient treatments, remission rates and maintained eating-related psychopathology also suggest that this treatment needs further improvement.

Mindfulness mediates the relation between disordered eating-related cognitions and psychological distress

The present study investigated whether mindfulness mediates the relation between disordered eating-related cognitions and negative psychological outcomes within a non-clinical college sample. Disordered eating-related cognitions were positively associated with general psychological ill-health and emotional distress in interpersonal contexts and inversely related to mindfulness. Mindfulness, which was also inversely related to general psychological ill-health and emotional distress, was found to partially mediate the relations between disordered eating-related cognitions and the two predicted variables.

Treatment of emotional dysregulation in full syndrome and subthreshold binge eating disorder

The link between negative affect and binge eating in those with binge eating disorder (BED) has been well established. The present study examined the efficacy of a treatment for BED designed to increase recognition and regulation of negative emotion, replicating and extending a previous investigation (Clyne, C., & Blampied, N.M. [2004]. Training in emotion regulation as a treatment for binge eating: A preliminary study. Behaviour Change, 21, 269-281) by including a control group, a larger number of participants, and formal diagnoses rather than classifying binge eating symptomatology from self-report questionnaires. Twenty-three women diagnosed with subthreshold or full syndrome BED (using the Eating Disorders Examination) participated in a treatment program that focused on increasing emotional regulation skills. Each participant completed the Eating Disorders Examination Questionnaire, the Binge Eating Scale, the Emotional Eating Scale, and completed self-monitoring records of binge episodes. Binge abstinence rates following treatment (post-treatment and 1 year follow-up were 78% and 87% respectively) were comparable to other empirically supported treatments for BED. Other positive changes in eating and general pathology were observed. These effects were well-maintained up to 1 year later.

The dialectical behavior therapy ways of coping checklist: development and psychometric properties

Skills training is a crucial mode of treatment in dialectical behavioral therapy (DBT; Linehan, 1993b), yet a psychometrically sound measure of DBT skills use does not exist. We adapted the Revised Ways of Coping Checklist (RWCCL; Vitaliano, Russo, Carr, Maiuro, & Becker, 1985) to create the DBT Ways of Coping Checklist (DBT-WCCL). Using factor analysis procedures, two subscales emerged: one assessing coping via DBT skills, the DBT Skills Subscale (DSS), and one assessing coping via dysfunctional means, the Dysfunctional Coping Subscale (DCS). Principal component, internal consistency, test-retest reliability, and content validity analyses suggested that the scale has good to excellent psychometric properties. In addition, the DSS successfully discriminated patients who received skills training during 4 months of treatment from patients who did not. Moderators of skills use are also discussed. The DBT-WCCL appears to be a promising new measure of DBT skills use.

The functional assessment of maladaptive behaviors: a preliminary evaluation of binge eating and purging among women

This study applied a functional approach to the study of bingeing and purging behaviors. Based on a four-function theoretical model of bingeing and purging, it was hypothesized that these behaviors are performed because of their intrapersonally reinforcing (e.g., emotion regulation) and/or interpersonally reinforcing (e.g., help-seeking, attention-getting behavior) properties. Participants were 298 adult females who had engaged in bingeing or purging in the last 3 months and who provided data via an online survey of these behaviors. Confirmatory factor analyses revealed support for a four-function model of bingeing and purging in which people use these behaviors for intrapersonal reinforcement functions and also for interpersonal reinforcement. Understanding the functions of binge eating and purging has direct implications for assessment and treatment of these behaviors.

Die Skala zur Erfassung der Impulsivität der Borderline-Persönlichkeitsstörung (IS-27)

Zusammenfassung. Um im Bereich von Psychotherapie eingesetzt zu werden, sollte die Skala zur Erfassung der Impulsivität (IS-27) bei der Borderline-Persönlichkeitsstörung (BPS) veränderungssensitiv sein und Personen mit BPS identifizieren können. Das Instrument wurde mit anderen Selbstbeurteilungsinstrumenten einer ambulanten Stichprobe (n = 147), einer gesunden Kontrollgruppe (n = 43) sowie einer Stichprobe von stationären Patienten mit BPS vor und nach einer dreimonatigen dialektisch behavioralen Behandlung (n = 62) vorgelegt. Das reliable und valide Instrument diskriminierte Patienten mit BPS von anderen Diagnosegruppen und konnte die Symptomreduktion infolge der Behandlung abbilden. Die „Receiver-Operating-Characteristic” (ROC)-Kurve zeigte eine hohe diskriminatorische Fähigkeit. Unterschiedliche Cut-Off-Werte wurden hinsichtlich ihrer diagnostischen Effizienz bewertet. Aufgrund der Kosten, die die BPD verursacht, wird ein Cut-off-Wert von ≥ 27 bei fast optimalem Youden-Index und hoher Sensitivität favorisiert. Mit der IS-27 liegt ein Verfahren mit guten teststatischen Kennwerten vor, das einen Beitrag zu einer störungsspezifischen Qualitätssicherung leisten kann.

Meta-analysis of the effectiveness of psychological and pharmacological treatments for binge eating disorder

OBJECTIVE

The aim of this study was to compute and compare mean effects of various treatments for binge eating disorder.

METHOD

A total of 38 studies with 1973 participants fulfilled the defined inclusion criteria. Effect sizes, odds ratios, and simple rates were integrated in fixed and random (mixed) effects categorical models.

RESULTS

From randomized controlled trials, psychotherapy and structured self-help, both based on cognitive behavioral interventions, were found to have large effects on the reduction of binge eating. Regarding pharmacotherapy, mainly comprising antidepressants, randomized controlled trials revealed medium effects for the reduction of binge eating. Uncontrolled studies on weight-loss treatments demonstrated moderate reductions of binge eating. Combination treatments did not result in higher effects compared with single-treatment regimens. Except for weight-loss treatment, none of the interventions resulted in a considerable weight reduction.

DISCUSSION

Psychotherapy and structured self-help, both based on cognitive-behavioral interventions, should be recommended as the first-line treatments.

[Subjective evaluation of DBT treatment by adolescent patients with eating disorders and the correlation with evaluations by their parents and psychotherapists]

OBJECTIVE

The subjective evaluation of a psychotherapeutic treatment may be an essential aspect of the recovery from an eating disorder. Our study investigates the subjective treatment evaluation by patients with eating disorders and the accordance with their parents' and psychotherapist's evaluation.

METHOD

In a sample of 41 eating-disorder patients (M(Age) = 16.3; SD = 1.26), their parents and psychotherapists, we used a questionnaire (FBB) to assess satisfaction with Dialectical Behavioral Therapy treatment.

RESULTS

Our results show good ratings, as well as good correlations between patients and parents.

CONCLUSIONS

The findings implicate the importance of assessing a subjective therapy rating in addition to objective parameters.

Outcome from a randomized controlled trial of group therapy for binge eating disorder: comparing dialectical behavior therapy adapted for binge eating to an active comparison group therapy

Dialectical Behavior Therapy for Binge Eating Disorder (DBT-BED) aims to reduce binge eating by improving adaptive emotion-regulation skills. Preliminary findings have been promising but have only compared DBT-BED to a wait-list. To control for the hypothesized specific effects of DBT-BED, the present study compared DBT-BED to an active comparison group therapy (ACGT). Men and women (n=101) meeting DSM-IV BED research criteria were randomly assigned to 20 group sessions of DBT-BED (n=50) or ACGT (n=51). DBT-BED had a significantly lower dropout rate (4%) than ACGT (33.3%). Linear Mixed Models revealed that posttreatment binge abstinence and reductions in binge frequency were achieved more quickly for DBT-BED than for ACGT (posttreatment abstinence rate=64% for DBT-BED vs. 36% for ACGT) though differences did not persist over the 3-, 6-, and 12-month follow-up assessments (e.g., 12-month follow-up abstinence rate=64% for DBT-BED vs. 56% for ACGT). Secondary outcome measures revealed no sustained impact on emotion regulation. Although both DBT-BED and ACGT reduced binge eating, DBT-BED showed significantly fewer dropouts and greater initial efficacy (e.g., at posttreatment) than ACGT. The lack of differential findings over follow-up suggests that the hypothesized specific effects of DBT-BED do not show long-term impact beyond those attributable to nonspecific common therapeutic factors.