Emotion Regulation Difficulties During and After Partial Hospitalization Treatment Across Eating Disorders

Impulsivity and reward and punishment sensitivity among patients admitted to a specialized inpatient eating disorder treatment program

Introduction

Eating disorders (EDs) are conceptualized as disorders of under- and over-control, with impulsivity reflecting under-control. Extant research indicates that impulsivity and related factors such as reward sensitivity and punishment sensitivity may serve as trait-level transdiagnostic risk and/or maintenance factors in EDs. Findings on impulsivity and reward and punishment sensitivity by diagnosis are mixed and research on the relationship between these factors and ED symptoms, hospital course, and treatment outcomes is limited.

Methods

Participants (N = 228) were patients admitted to a specialized inpatient behavioral treatment program for EDs who agreed to participate in a longitudinal study and completed self-report measures of impulsivity, reward sensitivity, and punishment sensitivity at admission. Weight and ED symptomatology were measured at admission and discharge. Hospital course variables included length of stay and premature treatment dropout.

Results

Impulsivity was lower in individuals with anorexia nervosa (AN) restricting type compared to those with AN binge/purge type or bulimia nervosa; no other group differences were observed. Higher impulsivity was associated with greater bulimic symptoms on the Eating Disorder Inventory 2 (EDI-2) at admission. Impulsivity was not related to ED symptoms, weight outcomes, length of hospital stay, or treatment dropout at program discharge.

Conclusion

Impulsivity may help distinguish restrictive versus binge/purge EDs, but does not necessarily relate to discharge outcomes in an intensive inpatient ED program. Findings from this study provide novel contributions to the literature on personality traits in EDs and have important clinical implications. Results suggest that patients with higher levels of impulsivity or reward and punishment sensitivity can be expected to respond to inpatient treatment. Suggestions for future research are discussed.

A systematic review and meta-analysis of intensive treatment options for adults with eating disorders

Eating disorders (EDs) are complex conditions with one of the highest mortality rates among psychiatric illnesses. While outpatient evidence-based treatments for EDs in adults exist, there is often utilisation of more intensive interventions as part of treatment. However, a comprehensive analysis of the impacts of intensive treatment (inpatient, residential and day program) on physical and psychosocial outcomes is lacking. Thus, the current systematic review and meta-analysis aimed to investigate the effectiveness of intensive treatments in adults with EDs for the outcomes of body mass index (BMI), disordered eating, depression, and quality of life, as well as a moderation analysis investigating a range of clinical characteristics. Overall, 62 studies were included in the meta-analysis. The results revealed that intensive treatment in adults yielded significant improvements in BMI (for underweight patients), disordered eating, depression, and quality of life. Treatment setting, length of stay and geographical region of the study all served as moderators for disordered eating and depression. Nevertheless, given the high heterogeneity in the meta- and moderation analyses, these results should be interpreted with caution. Future high-quality research is needed to determine the most beneficial elements of intensive treatment (compared to outpatient) in adults with EDs.

Reconceptualizing emotion regulation and coping strategy usage in eating disorders research: The utility of a regulatory flexibility framework

Emotion regulation and coping strategies are often conceptualized in eating disorder (ED) research as inherently adaptive or maladaptive, and successful regulation is often defined as greater overall use of adaptive strategies. However, recent empirical work outside of the field of EDs challenges this categorical conceptualization of strategies, demonstrating that adaptiveness is determined by the ability to flexibly implement and adjust strategies based on contextual demands (i.e., regulatory flexibility). Despite evidence that emotion regulation and coping strategies are best conceptualized in terms of flexibility in the broader literature, few ED studies have adopted this model. We review the current conceptual framework of emotion regulation and coping strategies used in ED research and present regulatory flexibility as an alternative approach to conceptualizing these strategies. The lack of research on regulatory flexibility among individuals with EDs limits our understanding of the role of emotion regulation and coping difficulties in ED risk and maintenance. Adopting a regulatory flexibility model of strategies in EDs may extend knowledge of the role of emotion regulation difficulties in the development and maintenance of EDs. We highlight the potential utility of investigating regulatory flexibility and present recommendations for future research on regulatory flexibility in EDs. PUBLIC SIGNIFICANCE STATEMENT: Research on emotion regulation and coping strategy usage in eating disorders often view regulatory strategies as inherently adaptive or maladaptive. However, recent studies support defining strategies in terms of flexibility. Adopting a regulatory flexibility model of strategies in eating disorders research may advance knowledge of the role of emotion regulation difficulties in the development and maintenance of eating disorders, ultimately enhancing prevention and treatment efforts.

A randomized 3-month, parallel-group, controlled trial of CALMA m-health app as an adjunct to therapy to reduce suicidal and non-suicidal self-injurious behaviors in adolescents: study protocol

Background

Suicidal and non-suicidal self-injurious behaviors are among the leading causes of death and injury in adolescents and youth worldwide. Mobile app development could help people at risk and provide resources to deliver evidence-based interventions. There is no specific application for adolescents and young people available in Spanish. Our group developed CALMA, the first interactive mobile application with the user in Spanish, which provides tools based on Dialectical Behavioral Therapy to manage a crisis of suicidal or non-suicidal self-directed violence with the aim of preventing suicide in adolescents and youth.

Methods

To test the effectiveness, safety and level of engagement of the CALMA app in people aged 10 to 19 who are treated in mental health services of two public hospitals, we will conduct a parallel-group, two-arm randomized controlled trial. Participants will be assessed face-to-face and via video call at four timepoints: day-0 (baseline), day-30, day-60, and day-90. A total of 29 participants per group will be included. Change in the frequency of suicidal and non-suicidal self-injurious behaviors will be compared between groups, as well as the level of emotional dysregulation, level of app engagement and time of psychiatric admission during the follow-up period.

Discussion

This study is particularly relevant to young people given their widespread use of mobile technology, while there are currently no available smartphone app-based self-guided psychological strategies in Spanish that attempt to reduce suicidal behavior in adolescents who are assisted in the public health sector from low and middle-income countries in Latin America.

Clinical trial registration

https://clinicaltrials.gov/, NCT05453370.

Trauma Experiences Are Common in Anorexia Nervosa and Related to Eating Disorder Pathology but Do Not Influence Weight-Gain during the Start of Treatment

OBJECTIVE

The main characteristics of Anorexia Nervosa (AN) in adults are restriction of energy intake relative to requirements leading to significant weight loss, disturbed body image, and intense fear of becoming fat. Traumatic experiences (TE) have been reported as common, although less is known about the relationship with other symptoms in severe AN. We investigated the presence of TE, PTSD, and the relation between TE, eating disorder (ED) symptoms, and other symptoms in moderate to severe AN (n = 97) at admission to inpatient weight-restoration treatment. All patients were enrolled in the Prospective Longitudinal all-comer inclusion study on Eating Disorders (PROLED).

METHODS

TE were assessed using the Post-traumatic stress disorder checklist, Civilian version (PCL-C), and ED symptoms using the Eating Disorder Examination Questionnaire (EDE-Q); depressive symptoms were assessed using the Major Depression Inventory (MDI), and the presence of Post-traumatic Stress Disorder (PTSD) was diagnosed according to ICD-10 criteria.

RESULTS

The mean score on PCL-C was high (mean 44.6 SD 14.7), with 51% having a PCL-C score at or above 44 (n = 49, suggested cut-off for PTSD), although only one individual was clinically diagnosed with PTSD. There was a positive correlation between baseline scores of PCL-C and EDE-Q-global score (r = 0.43; p < 0.01) as well as of PCL-C and all EDE-Q subscores. None of the included patients were admitted for treatment of TE/PTSD during the first 8 weeks of treatment.

CONCLUSIONS

In a group of patients with moderate to severe AN, TE were common, and scores were high, although only one had a diagnosis of PTSD. TE were related to ED symptoms at baseline, but this association diminished during the weight restoration treatment.

Associations of suicide risk with emotional reactivity, dysregulation, and eating disorder treatment outcomes

INTRODUCTION

Emotional processes play a role in both suicide risk and eating disorders (EDs), which are often comorbid. However, limited research has explored how emotional processes relate to suicide risk in EDs and the prognostic value of suicide risk for ED treatment. Thus, the current study examined associations between emotion dysregulation and reactivity with suicide risk in patients with EDs, and determined if suicide risk predicts ED treatment outcomes.

METHODS

Participants (n = 201) were adults in an ED partial hospitalization program who completed measures at admission, 1-month post-admission, and discharge.

RESULTS

When controlling for depressive symptoms, limited access to adaptive emotion regulation strategies, difficulties engaging in goal-oriented behaviors, and engaging in impulsive behavior when experiencing negative emotions (i.e., emotion dysregulation) were associated with suicide attempt frequency. Depressive symptoms were associated with suicide risk severity, while emotion dysregulation and reactivity were not. Importantly, patients with elevated suicide risk at admission improved comparably to other risk categories across treatment, despite presenting with greater ED symptoms at admission.

CONCLUSION

Emotion dysregulation and depression are salient factors when examining suicide risk in patients with EDs. Suicide risk and attempt history may not negatively impact ED treatment outcomes when using emotion-focused treatment.

Associations between emotion reactivity and eating disorder symptoms in a transdiagnostic treatment-seeking sample

OBJECTIVE

Individuals with eating disorders (EDs) demonstrate difficulties with emotion regulation, and these difficulties have been associated with severity and maintenance of ED symptoms. Although emotion reactivity (i.e., the strength and duration of emotional experiences) is distinct from emotion regulation, few studies have examined emotion reactivity in the context of EDs. The purpose of the current study was to examine longitudinal associations between emotion reactivity and ED symptoms and impairment in individuals with EDs.

METHOD

Individuals seeking outpatient ED treatment (N = 265) completed questionnaires assessing ED symptoms and severity, emotion reactivity, and emotion regulation difficulties at treatment intake and bi-monthly during treatment.

RESULTS

Individuals with anorexia nervosa or binge eating or purging presentations had higher emotion reactivity scores than a non-ED comparison group. Controlling for age, diagnosis, and emotion regulation difficulties, emotion reactivity was positively associated with ED severity, ED-related impairment, and loss of control eating severity. Moreover, emotion reactivity, but not emotion regulation difficulties, was associated with change in ED symptoms during treatment.

DISCUSSION

Findings support that emotion reactivity may differ based on ED presentations and may be an important correlate of ED symptom severity.

PUBLIC SIGNIFICANCE

Emotion reactivity refers to the strength and duration of an emotional experience. This study found that higher emotion reactivity was related to greater eating disorder symptom severity and eating disorder-related impairment. It may be beneficial to consider the role of emotion reactivity in conceptualizations of eating disorders, particularly those characterized by binge eating or purging.

Application of Dialectical Behaviour Therapy in treating common psychiatric disorders: study protocol for a scoping review

INTRODUCTION

Dialectical behaviour therapy (DBT) is a well-known intervention for treating borderline personality disorder, and has been increasingly adapted for other disorders. Standard DBT consists of four treatment modes, delivered over a year. Adaptations to DBT include changes to modes of delivery, treatment length, and skills modules taught to clients, or incorporating interventions from other evidence-based therapies. There is a need to synthesise existing evidence on DBT so that stakeholders-clinicians, researchers and policymakers-can understand how it has been provided for various psychiatric conditions, and whether it has been effective.

METHODS AND ANALYSIS

This study proposes a scoping review conducted according to Arksey and O'Malley's (2005) procedures, to map and summarise the literature on DBT interventions for treating a range of psychiatric concerns. Electronic databases (ie, the Cochrane Central Register of Controlled Trials, PubMed, PsycINFO, SCOPUS, EBSCOhost and ProQuest Dissertations and Theses), conference proceedings and the US National Institutes of Health Ongoing Trial Register will be searched for intervention studies that involve a control or comparison group, and that report quantitative data on pre/post-measures for psychiatric symptom severity. The initial search was conducted on 18 September 2020, and data charting has not commenced. An update will be performed in September 2022, pending this protocol's publication. Data charting will collect individual studies' characteristics, methodology and reported findings. Outcomes will be reported by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for Scoping Reviews.

ETHICS AND DISSEMINATION

No ethical approval is required for this study. The goal of dissemination is to keep DBT stakeholders abreast on latest updates in clinical applications of DBT. Findings from this research are intended to inform a more specific topic of study (eg, a meta-analysis), to further aid in the development of DBT interventions for psychiatric populations.

REGISTRATION DETAILS

The study protocol was pre-registered with the Open Science Framework on 24 August 2021 (https://osf.io/vx6gw).

Which dimensions of emotion dysregulation predict the onset and persistence of eating disorder behaviours? A prospective study

BACKGROUND

Theoretical models highlight the importance of emotion dysregulation as a key risk and maintaining factor for eating disorders. However, most studies testing these theories are cross-sectional. It remains unclear which dimensions of emotion dysregulation account for the onset and persistence of eating disorder behaviours over time.

METHODS

To address these gaps, data were analyzed from 1321 adult women who completed study measures at baseline and eight-month follow-up. The dimensions of emotion dysregulation assessed were five subscales from the abbreviated 16-item Difficulties in Emotion Regulation Scale. Outcomes included the onset (versus asymptomatic) and persistence (versus remission) of binge eating and compensatory behaviours.

RESULTS

Univariate logistic regressions showed that, among initially asymptomatic women, higher baseline levels of each emotion dysregulation dimension (except the "goals" subscale) predicted the onset of binge eating and compensatory behaviours at follow-up. Each dimension also predicted the persistence of compensatory behaviours at follow-up among women endorsing these behaviours at baseline, while the "impulse", "strategies", and "non-acceptance" dimensions predicted the persistence of binge eating. In multivariate analyses, only the "strategies" dimension predicted the onset and persistence of binge eating, while the "non-acceptance" dimension predicted the onset and persistence of compensatory behaviours.

LIMITATIONS

Only a limited number of emotion dysregulation dimensions were tested.

CONCLUSION

Findings demonstrate the importance of emotion dysregulation dimensions in accounting for the onset and maintenance of eating disorder behaviours. The delivery of specific intervention strategies designed to address emotion dysregulation may depend on the risk and symptom profile of an individual.

Self-regulation deficits moderate treatment outcomes in a clinical trial evaluating just-in-time adaptive interventions as an augmentation to cognitive-behavioral therapy for bulimia-spectrum eating disorders

Objective:

Just-in-time adaptive interventions (JITAIs), momentary interventions delivered at identified times of risk, may improve skill utilization during cognitive-behavioral therapy (CBT-E) for bulimia-spectrum eating disorders (BN-EDs). JITAIs may be especially helpful for individuals with self-regulation deficits, including emotion regulation deficits and elevated impulsivity.

Method:

Participants (N = 55 with BN-EDs) received 16 sessions of CBT-E with electronic self-monitoring and were randomized to receive JITAIs (JITAIs-On) or not receive JITAIs (JITAIs-Off). Baseline Difficulties in Emotion Regulation Scale (DERS) and UPPS-P Impulsive Behavior Scale (UPPS-P) total scores were examined as moderators of baseline to post-treatment change in binge episodes, compensatory behaviors, and Eating Disorder Examination (EDE) global score using repeated measures ANOVAs.

Results:

Emotion regulation difficulties significantly moderated compensatory behavior change (F [1, 51] = 4.31, p = .04, ηp2 = 0.08) such that individuals with emotion regulation deficits demonstrated greater improvements in the JITAIs-On condition. Impulsivity moderated change in binge episodes (F [1, 51] = 8.94, p = .004, ηp2 = 0.15) and compensatory behaviors (F [1, 51] = 7.83, p = .007, ηp2 = 0.13), such that individuals with high impulsivity showed greater improvement in the JITAIs-On condition. Neither DERS nor UPPS-P scores moderated EDE global score change.

Discussion:

JITAIs appear particularly beneficial for facilitating skill use during treatment for BN-EDs for individuals with self-regulation deficits, yielding improved treatment outcomes.

Public Significance Statement:

Reminders to use therapy skills that are delivered via smartphone as an individual goes about their daily life may improve treatment response among individuals with bulimia nervosa who have difficulty coping with emotions or who tend to act impulsively. Results from this study indicate that individuals with these difficulties benefitted more from cognitive-behavioral therapy when it was accompanied by in-the-moment reminders to use therapeutic skills, which may facilitate long-term recovery.

Clinical Trials.gov Registration Number:

NCT03673540 .

Exploring changes in alexithymia throughout intensive dialectical behavior therapy for eating disorders

OBJECTIVE

Alexithymia is proposed as a prominent clinical feature of eating disorders (EDs). However, despite theoretical reason to believe that alexithymia could interfere with the success of treatments, few studies have tested whether alexithymia changes over the course of treatment. The goals of the current study were to evaluate (a) changes in alexithymia over the course of intensive Dialectical Behaviour Therapy (DBT) for EDs, and (b) associations between alexithymia and ED symptoms over time.

METHOD

A mixed-diagnostic group of patients with EDs (N = 894) completed the Eating Disorders Examination-Questionnaire (EDE-Q) and the Toronto Alexithymia Scale (TAS-20) throughout intensive treatment and at various lengths of follow-up (6, 12, 24 months).

RESULTS

Results suggested that even after controlling for relevant covariates, there were significant decreases in alexithymia from intake to discharge and discharge to follow-up. Models exploring changes in self-reported ED symptoms indicated that TAS-20 scores significantly related to ED symptoms across timepoints, such that greater alexithymia was associated with greater severity of symptoms.

CONCLUSIONS

Altogether, findings support an association between alexithymia and ED symptoms over treatment and suggest that emotion-focussed therapies like DBT may result in decreases in alexithymia. Future research should explore whether this effect is consistent across therapies without an emotional focus.

Intact neural and behavioral correlates of emotion processing and regulation in weight-recovered anorexia nervosa: a combined fMRI and EMA study

Altered emotion processing and regulation mechanisms play a key role in eating disorders. We recently reported increased fMRI responses in brain regions involved in emotion processing (amygdala, dorsolateral prefrontal cortex) in acutely underweight anorexia nervosa (AN) patients while passively viewing negatively valenced images. We also showed that patients' ability to downregulate activity elicited by positively valenced pictures in a brain region involved in reward processing (ventral striatum) was predictive of worse outcomes (increased rumination and negative affect). The current study tries to answer the question of whether these alterations are only state effects associated with undernutrition or whether they constitute a trait characteristic of the disorder that persists after recovery. Forty-one individuals that were weight-recovered from AN (recAN) and 41 age-matched healthy controls (HC) completed an established emotion regulation paradigm using negatively and positively valenced visual stimuli. We assessed behavioral (arousal) and fMRI measures (activity in the amygdala, ventral striatum, and dorsolateral prefrontal cortex) during emotion processing and regulation. Additionally, measures of disorder-relevant rumination and affect were collected several times daily for 2 weeks after scanning via ecological momentary assessment. In contrast to our previous findings in acute AN patients, recAN showed no significant alterations either on a behavioral or neural level. Further, there were no associations between fMRI responses and post-scan momentary measures of rumination and affect. Together, these results suggest that neural responses to emotionally valenced stimuli as well as relationships with everyday rumination and affect likely reflect state-related alterations in AN that improve following successful weight-recovery.

A review of sex differences in the mechanisms and drivers of overeating

Disordered eating is often associated with marked psychological and emotional distress, and severe adverse impact on quality of life. Several factors can influence eating behavior and drive food consumption in excess of energy requirements for homeostasis. It is well established that stress and negative affect contribute to the aetiology of eating disorders and weight gain, and there is substantial evidence suggesting sex differences in sub-clinical and clinical types of overeating. This review will examine how negative affect and stress shape eating behaviors, and how the relationship between the physiological, endocrine, and neural responses to stress and eating behaviors differs between men and women. We will examine several drivers of overeating and explore possible mechanisms underlying sex differences in eating behavior.

Differences in the use of emotion regulation strategies between anorexia and bulimia nervosa: A systematic review and meta-analysis

OBJECTIVE

Research has identified abnormal emotion regulation (ER) as an underlying mechanism in the onset and maintenance of eating disorders. Yet, it still remains unclear whether different forms of ER, adaptive and maladaptive strategies, are similar across categories of eating disorders.

METHOD

A systematic review and meta-analysis were carried out to look at ER differences between anorexia nervosa (AN) and bulimia nervosa (BN), two common eating disorder pathologies with different eating patterns.

RESULTS

41 studies were included in the meta-analysis. The results revealed no differences in the use of maladaptive ER strategies between individuals with AN and BN, however patients with AN tend to use less adaptive ER strategies as compared to patients with BN.

CONCLUSIONS

Making less use of adaptive strategies in AN might be due to low body weight and high levels of alexithymia which define AN. In order to improve treatment outcome in individuals suffering from AN, these findings suggest to focus more on improving the use of adaptive ER strategies.

Applying adherent DBT Principles to treatment in a partial hospital setting: An analysis over 5-years of outcomes from intake to discharge

OBJECTIVES

A small number of studies to date have examined Partial Hospital (PH) that utilize a Dialectical Behavior Therapy (DBT) model. Preliminary findings suggest DBT PH programs can be effective in various symptom reduction.

METHODS

This study examined clinically relevant outcomes and included a heterogeneous clinical sample over a five-year period. Specifically, the present study assessed pre-post data to examine changes in symptoms of depression, anxiety, hopelessness, and overall degree of suffering from intake to discharge in a DBT PH.

RESULTS

Findings showed symptom reduction from intake to discharge for depression, anxiety, hopelessness, and suffering for all 5 years. This DBT PH program was successful at reducing various symptoms in a sample of psychiatric patients.

CONCLUSION

Clinicians might consider the advantages of placing patients in PH programs versus an inpatient stay or consider utilizing DBT-informed PH programs after an inpatient hospitalization as a form of step-down care.

Rehospitalization and "Revolving Door" in Anorexia Nervosa: Are There Any Predictors of Time to Readmission?

Objective: Anorexia nervosa (AN) is a severe psychiatric illness with multifactorial etiology and unsatisfactory treatment outcomes. Hospitalization is required for a substantial number of patients, and readmission (RA) commonly occurs. Some individuals need multiple hospitalizations sometimes over a short amount of time, thus, delineating the "revolving door" (RD) phenomenon. However, very little is known about readmissions and their frequency in AN. Therefore, we aimed to longitudinally investigate readmissions in AN in order to: (a) characterize patients with AN who need readmission (i.e., RA-AN), sometimes rapidly (RD-AN); (b) ascertain differences between RA-AN and non-RA-AN groups during baseline hospitalization; (c) investigate as to whether clinical or psychometric parameters worsened on RA; and (d) analyze predictors of time-to-readmission in AN. Methods: A total of 170 inpatients with AN were enrolled at their baseline hospitalization; all their subsequent rehospitalizations were recorded with a longitudinal design by which each patient has been observed for 3 years. Patients were classified as RD-AN if requiring a readmission <12 months since last discharge. Clinical characteristics were measured upon admission and discharge for each hospitalization, and at all time points, patients completed questionnaires assessing eating and general psychopathology, and body shape concerns. Results: Sixty-seven patients (39.4%) needed at least one readmission and 62 (92.5% of RA-AN) reported RD. Compared with non-RA-AN, those with RA-AN were younger, reported a shorter duration of illness, and were more frequently diagnosed with AN-BP. Also, greater severity of anxious and depressive symptoms and body shape concerns emerged in the RA-AN group. The outcome of baseline hospitalization did not differ between groups, and only depressive symptoms worsened at readmission. Shorter duration of AN and low weight gain during baseline hospitalization predicted early readmission but did not survive statistical control. In contrast, high scores on drive for thinness upon baseline hospital entry robustly predicted a shorter time to readmission even after statistical control. Discussion: Individuals with AN who require readmission do so over a short period notwithstanding a positive treatment outcome during their baseline hospitalization. Shorter time-to-readmission can be predicted mostly in case of marked drive for thinness and poor weight gain at baseline hospital admission.

Dialectical behavioral therapy: an update and review of the existing treatment models adapted for adults with eating disorders

Despite the effectiveness of CBT in reducing shape/weight concerns and dietary restraint, research suggests that patients considered recovered may still exhibit emotional difficulties related to eating disorders (EDs). Dialectical behavior therapy (DBT) has been adapted for a variety of mental disorders characterized by emotion dysregulation and, more recently, for EDs specifically. The current review found that the majority of the research studies employed one of the following three adaptations of DBT for EDs: The Stanford Model, Radically Open-DBT (RO-DBT), or Multidiagnostic ED-DBT (MED-DBT). Therefore, this review sought to review and update the empirical research on each adaptation and (2) offer preliminary recommendations for when and which adaptation of DBT to use when treating adults with EDs. Findings from the empirical literature on DBT and EDs indicate that the Stanford Model has the most rigorous and numerous studies demonstrating efficacy and effectiveness in those diagnosed with binge eating disorder. Fewer studies have been conducted using the Stanford Model with bulimia nervosa; therefore, less strong assertions can be made about DBT with those diagnosed with bulimia. The MED-DBT model has been evaluated in several open trials within higher levels of care with promising results, but the lack of randomized clinically-controlled trials prevents a definitive statement about its efficacy. Finally, research on applying the RO-DBT model to anorexia-nervosa, restricting subtype is in its infancy, prohibiting solid conclusions or recommendations regarding its efficacy or effectiveness.