Dialectical Behavior Therapy in the Treatment of Bulimia and Binge

Eating Disorder: Research & Practical Applications

Debra L. Safer, MDDepartment of Psychiatry and Behavioral Sciences

Stanford University School of Medicine

Outline

• Introduction and overview for Bulimia Nervosa and BED– DSM-IV criteria for binge episode, BN, & BED

• Why develop a new treatment for eating disorders?

• What IS DBT?

• How is DBT adapted for the treatment of eating disorders?

Outline: (con’t)

• Research findings from randomized control trials adapting DBT for Bulimia Nervosa & Binge Eating Disorder

• Predictors of Relapse After Successful Treatment with DBT for BED

• Discussion/Questions

DSM-IV Criteria: Binge Episode

• Eating “definitely larger” amounts of food over a discrete time period (e.g. within 2 hrs) than “most people would eat in a similar period under similar circumstances”

• Sense of lack of control during episode (e.g. cannot stop or control what or how much one eats)

• Source: DSM-IV (l994)

DSM-IV Criteria: Bulimia Nervosa• Recurrent episodes of binge eating• Recurrent compensatory behavior to prevent

weight gain (e.g. self-induced vomiting, laxatives, diuretics, enemas, or other medications; fasting, or excessive exercise)

• Occur at least 2x/wk for 3 months• Self evaluation is unduly influenced by body

shape and weight • Source: DSM-IV (l994)

DSM-IV Criteria: Binge Eating Disorder

• Recurrent episodes of binge eating (at least 2x/wk for 6 months)

• Causes marked distress

• Not accompanied by compensatory behaviors such as in bulimia (e.g. purging, fasting, excessive exercising)

• Source: DSM-IV (l994) Appendix for Further Study

BED Criteria (continued)

• Binge episodes associated with ≥ 3 of following:– Eating much more rapidly than normal– Eating until feeling uncomfortably full– Eating large amounts of food when not physically

hungry– Eating alone because of being embarrassed by how

much one is eating– Feeling disgusted with oneself, depressed, or very

guilty after overeating

BED Versus Non-BED Overweight

• Greater psychopathology (e.g. depression, anxiety, substance abuse, personality disorders)

• Higher rates of self-loathing, disgust over body size, interpersonal sensitivity

• Greater risk for attrition during weight loss treatment

• More rapid regain of lost weight • Sources: Marcus et al, l990; Yanovski et al, l993

CBT Model

Low self-esteem

Overvaluation of weight and shape

Strict dieting

Binge eating

Treatment Targets Given Core Assumptions of CBT

• REGARDING ROLE OF DIETING– Treatment includes behavioral focus on 3 meals/day + 2 snacks

• REGARDING OVERVALUATION OF WEIGHT AND SHAPE– Cognitive techniques aim to modify these dysfunctional thoughts about

weight /shape

• OUTCOME AFTER TREATMENT WITH CBT?– ON AVERAGE 50% OF PATIENTS REMAIN SYMPTOMATIC

Affect Regulation ModelBinge Eating temporary relief from negative affect

• Linehan’s Dialectical Behavior Therapy (DBT) – Emotional dysregulation seen as core problem in borderline

personality disorder (BPD)

Binge Eating relief from negative affect

IN THE SAME WAY AS

Impulsive Behaviors (e.g. self-mutilation)

relief in BPD

Support for Affect Regulation Model in Binge Eating

– Negative mood is most frequently cited precipitant of binge eating (Polivy & Herman, l993)

– Inducing a negative mood compared to a neutral mood in the laboratory significantly increased loss of control over eating and the occurrence of self-defined binges in women with BED (Telch & Agras, l996; Agras & Telch, l998)

– Negative mood in bulimics treated with CBT predicted a lower success rate (by more than 50%) than bulimics who were purely restrictive (Stice & Agras, l999)

Orientation to DBT Model for Maladaptive Emotion Regulation

Event (Internal or External)

Negative emotion/need for emotion regulation

Deficitsin adaptiveemotionregulationskills

Lowexpectancyfor moodregulation

Increasedanxiety,fear, & sense ofoverwhelm

Urgency to stop emotion escalation

Overlearned, impulsive,maladaptive, mood regulationbehavior: BINGE EATING & PURGING

Avoidance of adaptive mood regulation

Temporary decreasein distress

Decreased self-esteem, negself-view. Increased guiltand shame.

Goals of Treatment, Goals of Skills Training, and Treatment Targets

Treatment Goals: Stop Binge Eating and Purging

Treatment Targets: Path to Mindful Eating1. Stop any behavior that interferes with treatment2. Stop Binge Eating and Purging3. Eliminate mindless eating4. Decrease cravings, urges, and preoccupation with food5. Decrease “capitulating” (deciding it’s too late to change from binge eating and purging)6. Decrease “Apparently Irrelevant Behaviors” (AIBs) (setting oneself up for binge eating by pretending “It doesn’t matter” (e.g. buying candy for “someone else”)

DBT Brief Overview

DBT Brief Overview

DBT core theories Dialectical Philosophy

Behavioral Zen practice

Science

DBT core theories Dialectical Philosophy

Behavioral Zen practice

Science

DBT Skills: Wise MindStates of Mind

Reasonable Wise Emotional

Mind Mind Mind

DBT Skills-Mindfulness• Diaphragmatic Breathing (attention to the breath)

• Mindful eating

— Observe and describe the sensory experience

— Observe and describe thoughts and feelings• Non-judgmentally

• One-mindfully

• Effectively

Modification of DBT concepts/skills from DBT for Substance Abuse

• Dialectical Abstinence

• Alternate Rebellion

• Urge Surfing

Increase Skillful Emotion Regulation Behaviors

MINDFULNESS SKILLS (WEEKS 1-5) to increase awareness and experience of the current moment without self-consciousness or judgment

EMOTION REGULATION SKILLS (WEEKS 6-13) to help the participant identify her emotions, understand their function, and reduce her vulnerability to negative emotions

DISTRESS TOLERANCE SKILLS (WEEKS 14-18) distraction, self-soothing, or acceptance -- meant to help participants more effectively tolerate painful emotional states that cannot, in that moment, be changed.

REVIEW & RELAPSE STRATEGIES (WEEKS 19-20)

DIARY CARDDay Urge to

Binge(1-6)

#Episodes

Anger Fear Sad Pride

MonTues

Wed

Thur

Fri

Sat

Sun

Behavioral chain analysisBehavioral chain analysis

• Describe the problem behavior – e.g. binge eating and/or purging, mindless eating,

cravings etc.

• What prompted the behavior?

• What made me vulnerable?

• What were the consequences of the behavior?

Randomized Trial of DBT for BED:Changes in Objective Binge Eating

0102030405060708090

100

Pre Post 3-mthfollow-up

6-mthfollow-up

DBTWaitlist

Telch, Agras, & Linehan: Dialectical behavior therapy for binge eating disorder. J of Consult Clin Psychol 2001; 69:1061-1065

% Abstinent

DBT for Bulimia Nervosa

• OBJECTIVES– To develop and standardize a 20 session manual-based

therapy applying the emotion regulation skills of DBT to the treatment of bulimia nervosa

– To pilot a randomized clinical trial to test the efficacy of this treatment in reducing rates of binge eating and purging

Demographics

• Age– Mean= 34.19 years old, range=18-54

• BMI– Mean= 23.67, range (21.65 - 42.09)

• Ethnicity– 87%= white, 10%=Asian, 3%=Latino, 0%= black

• Marital Status– 39%=single, 39%=married, 19%=divorced,

3%=widowed

Severity of Bulimic Symptoms• Number of years with bulimic symptoms

– 12 years (range 6 months-30 years)

• Age when began bulimic behaviors– 22 y.o. (range 14 1/2 - 41 1/2 y.o.)

• Average # binge episodes in past 4 weeks– 28 (range 0-75)

• Average # purge episodes in past 4 weeks– 56 (range 4-330)

• Percentage meeting DSM-IV criteria for bulimia nervosa (= or > 24 binge episodes and purge episodes/3mo)

– 81% (25 of 31 subjects)

OUTCOME MEASURES

• Eating Disorders Examination (EDE)

• Negative Mood Regulation (NMR)

• Beck Depression Inventory (BDI)

• Emotion Eating Scale (EES)

• Minnesota Impulsivity Scale (MPQ)

• Positive and Negative Affect Schedule (PANAS)

• Rosenberg Self-Esteem Scale (RSE)

Changes in Median # Binge Episodes: DBT versus Wait-list (p < 0.001)

and 3 month post-tx follow-up

0

5

10

15

20

25

30

Pre Post 3 month

DBTWait- list

Median # binge episodes (Over Prior 4 weeks)

Assessment period

Changes in Median # Purge Episodes: DBT versus Wait-list (p < 0.002)

and 3 month post-tx follow-up

0

5

10

15

20

25

30

35

40

Pre Post 3 month

DBT

Wait-list

Assessment period

Median # purge episodes (Over Prior 4 weeks)

Negative Mood Regulation (p = 0.022)

81.3

96.1 98.1 97.7

40.0

50.0

60.0

70.0

80.0

90.0

100.0

DBT-Pre DBT-Post Wait-list Pre Wait-list Post

NMR Score

Emotional Eating Scale (EES):

Anger/Frustration, Anxiety, Depression, subscale(p < 0.006) ( p <0.006) ( p < 0.008)

2.7

2.1

2.9

1.8

1.3

2.1

2.7

2.1

2.7 2.6

2.0

2.6

0.0

0.5

1.0

1.5

2.0

2.5

3.0

DBT-Pre DBT-Post Wait-list Pre Wait-list Post

EES Score

Impulsivity (MPQ) (p < 0.170)

15.416.4 16.0

15.6

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

DBT-Pre DBT-Post Wait-list Pre Wait-list Post

MPQ Score

Rosenberg Self-Esteem (p < 0.107)

23.5

26.4 25.6 25.4

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

DBT-Pre DBT-Post Wait-list Pre

Wait-list Post

RSE Score

Comparison of CBT, IPT, & DBT for BN

% abstinentIntent to treat

% abstinentCompleters

% Drop-out N =

CBT 29 45 28 110

IPT 6 8 24 110

DBT 28.5 28.5 0 16

Agras WS, Fairburn CG, Walsh T, Wilson GT, & Kraemer HC. A multicenter comparison of cognitive-behavioral therapy and interpersonal therapy for bulimia nervosa. Arch Gen Psychiatry, 2000: 57: 4590466

Conclusions of Study

• A pilot study of a 20 week manualized treatment adapting DBT for bulimic symptoms shows promising results with significant decreases in binge/purge behavior compared to wait-list controls. Safer DL, Telch CF, Agras WS. Dialectical

Behavior Therapy for Bulimia Nervosa. American Journal

of Psychiatry. 2001; 158:632-634

• Remaining issues: Compare DBT with CBT, medications, or as an add-on for CBT nonresponders? How to improve maintenance?

Predictors of Relapse Following SuccessfulDialectical Behavior Therapy for

Binge Eating Disorder

Binge Eating Disorder

A pattern of recurrent episodes of consuming large amounts of food in which an individual experiences loss of control

Without the compensatory behaviors seen in Bulimia Nervosa

PARTICIPANTS32 women from the three different treatment

groups: 8 women from the uncontrolled study (Telch et al.

2000)

16 women from the randomized study who had initially been assigned to 20 weeks of DBT (Telch et al. 2001)

8 who had been randomized to wait-list but who were later offered and accepted DBT treatment. (Telch et al. 2001)

Inclusion Criteria for Participation in Study

Achievement of abstinence at the end of 20 weeks of DBT treatment Abstinence was defined as no binge episodes reported in the 1 month prior to assessment.

Availability of 6-month follow-up data.

PARTICIPANT CHARACTERISTICS Age= 49.2 (range: 29 - 64 y.o.; SD = 9.9) Educational status (75% completed >4 years of

college) Married (59.4%) Caucasian (90.6%) BMI at baseline= 37.4 (SD = 6.9) Age of onset of binge eating = 20.6 (SD=12.4) Duration of binge eating problems=29.7 (6.9)

Predictors of Relapse in Eating Disorders Bulimia Nervosa:

dissatisfaction with body imageself-esteemdegree of overvalued ideas regarding weight and shapegreater severity of eating disorder pathology restraint length of continuous abstinence response during txyounger agemotivation for change

Binge Eating Disorder: None to date But earlier age of binge eating onset predicted poor outcome at end

of treatment

Hypothesized Predictors of Relapse in BED

• Higher dietary restraint scores

• Higher levels of shape and weight concerns

• Higher levels of emotional eating

• Lower levels of self-esteem• Higher body mass index (kg/m2) • Earlier age of onset for binge eating (at or before age 16)

Measures

• Eating Disorder Examination (Fairburn & Cooper, 1993)

Restraint subscale score Average of the Weight and Shape Concerns subscales

• Emotional Eating Scale (Arnow, Kenardy, & Agras, 1995)

• Rosenberg Self Esteem Scale (RSE; Rosenberg, 1979)  

• Questionnaire on Eating and Weight Patterns (Spitzer et al, 1992)

TWO PREDICTORS OF RELAPSE AT 6 MONTH FOLLOW-UP

1) Early onset of binge eating (beginning binge eating at or before age 16) 77.8% who relapsed had an early onset versus 28.6%

of those who maintained abstinence had an early onset (ES= 2.17)

2) Higher EDE Restraint subscale scores Higher post-treatment EDE Restraint subscale

scores (1.8 versus 1.0, ES = 0.86)

Independent variables not predicting relapse versus maintenance

Predictor Relapsedat 6 mo

MaintainedAbstinence

EDE averageWeight/ShapeConcerns

2.2 2.3

EES post-tx 2.0 1.7

RosenbergSelf-Esteem

32.9 31.3

BMI post-tx 36.5 36.7

Comparison between participants with early versus late binge eating onset

GROUP EARLYBINGEONSET

LATEBINGEONSET

P value

Age at first dietwhen lost 10 lb

14.3 25.9 0.002

Age first overwtby 10 lb as childor 15 lb as adult 12.9 18.8 0.104Relapsed at 6months

53.8% (7/13) 11.8% (2/17) 0.037

Importance of Early Age of Onset in Relation to Treatment Outcome

Extends a study by Agras and colleagues (1995)

Onset of binge eating before the age of 16 years was a prognostic indicator of poor treatment outcome in BED

Present report extends this finding to individuals with BED who have an early onset of binge eating, recover by the end of treatment, and then relapse

Role of dietary restraint in BED is unclear

The effects of dietary restraint and acute caloric deprivation leading to binge eating is well documented in both longitudinal and experimental studies

BUTIndividuals with BED tend to have lower EDE Restraint subscale scores (e.g. 1.9) than those with BN (e.g. 3.1) but higher than normal-weight controls (e.g. 0.9)

A significant subset of patients with BED report onset of binge eating that precedes dieting

Comparison 5 individual items of EDE Restraint subscale

Variable Relapsedat 6 mo

Maintainat 6 mo

Effect Size

FoodAvoidance

3.78 1.52 0.88

DietaryRules

1.11 0.17 0.70

Avoidanceof eating

0.22 0.04 0.60

EmptyStomach

0.11 0.39 .18

Restraintovereating

3.67 3.44 0.09

Two Aspects of Restraint

Cognitive restraint the conscious attempt to restrict one’s intake for

the purpose of weight loss, irrespective of actual eating practices

  Overt behavioral restraint

the successful limitation of caloric intake

BED: Unsuccessful Dieters?

Binge eating in BED may more often be precipitated by violations of cognitive restraint than physiological pressures to eat resulting from severe behavioral restriction

Individuals with BED, who are frequently overweight, do not appear to consistently behaviorally restrict between binge eating episodes as do individuals with BN

How does restraint decrease by the end of treatment if rules regarding food are not

addressed specifically?

DBT advocates a focus on tolerating the underlying negative emotions that participants attempt to avoid through binge eating

Through teaching nonjudgmental acceptance of emotions, emotionally charged food rules may decrease

Practice of Mindful Eating may help reduce chronic dieters’ restrictive mindset

Limitations of Study

Small sample size and subsequent limited power preclude definitive statements regarding predictors of relapse

Other potential predictors may have been missed

Wider applicability is limited by sample Women only Exceptionally well educated sample

The 6 month follow-up period is brief considering the chronic nature of binge eating disorder

Future Directions for Research on Predictors of Relapse in BED •Alter frequency of sessions

–Allow 2 weeks between meetings to allow more time to “practice” relapse

•Refine and/or add skills to target mindful eating, nonjudgmental acceptance of body, etc

•Chart restraint scores every week and during follow-up.

– Target those with higher scores

WEIGHT CHANGES Mean weight loss over the initial 20 week course of treatment

was 1.9 kg, or 4.2 pounds (SD=12.13) for all participants

At 6 month follow-up, the 23 (71.9%) participants who maintained abstinence had lost an additional 3.3 kg or 7.2 pounds (SD = 8.6)

The 9 (28.1%) who relapsed lost an additional 0.7 kg, or 1.5 pounds (SD = 3.0)

Predictors of Relapse Following Successful Dialectical Behavior

Therapy for Binge Eating Disorder

Safer DL, Lively TJ, Telch CF, Agras WS. International Journal of Eating Disorders.

2002; 32: 155-163

SUMMARY• CBT, most studied treatment for BN and BED,

leaves some patients symptomatic after treatment

• DBT, based on the Affect Regulation Model for disordered eating is a promising manual-based therapy for BN and BED

• Earlier age of onset (< 16 y.o.) and higher post-treatment restraint scores predicted relapse at 6 months in those treated with DBT for BED

• Further research is needed to compare DBT with other therapies and to improve maintenance