DBT and Eating Disorders

DBT Therapy for Eating DisodersEating Disorders' Prevalence and Consequences

According to the National Eating Disorder Association
(2013), 20 million women and 10 million men suffer from a clinically
significant eating disorder including anorexia nervosa, bulimia nervosa, binge
eating disorder or eating disorder not otherwise specified (EDNOS) at a point
in their lifetime. Eating disorders can result in a wide range of physical and
psychological health problems. For women, eating disorders are among the top 10 causes of disability (Striegel-Moore & Bulik, 2007) and anorexia has the
highest lethality rate of any mental disorder (Crow et al., 2009). Individuals
with eating disorders also tend to experience strained interpersonal
relationships (Ringer & Crittenden, 2007), difficulty regulating emotions
(Whiteside et al, 2007), more frequent anxiety and depression (Doyle, le
Grange, Goldschmidt, & Wilfley, 2007) and lower levels of occupational
functioning (McElroy et al., 2011). The more frequently an individual engages
in disordered eating behaviors (restriction, bingeing/purging, or both), the
more health consequences they may to face. Some examples are bone density loss,
gastrointestinal complications, chronic pain, inflammation, tooth decay, high
blood pressure, cardiovascular impairment, heart disease, gallbladder disease,
high cholesterol, etc. (NEDA, 2014). Due to the chronic and often long-lasting
course of eating disorders, clients are also more prone to developing
co-occurring psychiatric disorders including anxiety disorders, obsessive
compulsive disorder (OCD), and depression. Depression is highly associated with
suicidal gestures and attempts (O’Brien & Vincent, 2003), therefore
reducing depression symptoms (and the potential for self-injurious and suicidal
behaviors) is important for successful treatment (Walsh et al., 2006).

DBT Model of Eating
Disorders

DBT was originally developed by Marsha Linehan for the
treatment of borderline personality disorder but has been adopted to treat
various other disorders including eating disorders since then. The DBT model of
eating disorders conceptualizes eating disorder episodes as attempts by the
client to neutralize intense negative emotions as a result of feeling
emotionally vulnerable due to severely restricted food intake or bingeing
(Bankoff et al., 2012). When disordered eating fails to decrease the intensity
of negative emotional experiences, the client intensifies the behavior to try
to achieve a sense of balance, control and belonging. According to Linehan (1987)
an individual keeps using disordered eating and self-harming strategies because
they lack skills such as distress tolerance, inadequate coping resources, and
believe that the behavior is an effective problem-solving strategy. DBT aims to
help clients through developing a strong working alliance with the therapist,
accepting the client’s current level of functioning and desire for change while
learning more adaptive coping skills to increase well-being and healthy
functioning (Salsman & Linehan, 2006).

DBT Program for
Eating Disorders

A comprehensive Dialectical Behavior Therapy (DBT) program
for eating disorders includes four main targets: a) reducing life-threatening
behaviors (self-injury, suicide, severe food restriction), b) reducing
therapy-interfering behaviors (missing appointments, early termination), c)
reducing behaviors that interfere with the client’s quality of life
(unemployment, divorce, financial issues), and d) increasing behavioral skill
use (Linehan et al., 1991). Clients are expected to commit to a one-year
program that includes a weekly individual therapy session and a weekly DBT
skills group. DBT skills groups are a fundamental element of DBT and are
created to teach clients healthier ways to cope with painful emotions and difficult
life circumstances. Groups are 2.5 hours long and include four areas of skill
development – mindfulness, distress tolerance, interpersonal skills, and
emotion regulation (Bankoff et al., 2012).

A fundamental aspect of DBT is the concept of dialectics –
the understanding that multiple truths can exist in a given moment and one idea
or belief is not more true or right than another. DBT aims to decrease tension
by searching for a synthesis between two opposite points of view instead of
allowing one party to override another (Linehan, 1993a). This idea, however, is
not a feature of traditional eating disorder treatment. In general, DBT
advocates an approach that offers greater choice, collaboration, and autonomy
for clients than traditional treatment modalities (Geller, Brown, Zaitsoff,
Goodrich, & Hastings, 2003). Therapists and clients in DBT treatment
continually strive to balance acceptance and change, flexibility and stability,
nurturance and challenge, and focus on deficits while developing capabilities
(Linehan, 1993a). For example, if the client wants to stay underweight and the
treatment team wants her to gain 2lbs a week, the therapist would work to find
a synthesis by validating the client’s position and looking for common ground
such as gaining only 1lb a week instead of 2lbs.

Another dominant feature of DBT is its emphasis on enabling
clients to act as their own agents. DBT therapists do not solve problems for
clients but teach them to take responsibility for their own lives including
coordinating treatment with other providers, improving communication with
others, and problem-solving (Linehan, 1993a).

Eating Disorders Conclusion

Eating disorders are complex, often long-lasting, and
sometimes life-threatening illnesses. While some traditional treatment
approaches (CBT, Interpersonal Psychotherapy) have been shown to be effective,
DBT can certainly offer many additional benefits in this field and can be a
part of a well-rounded treatment program.

If you or someone you know suffers from an eating disorder
or disordered eating, please contact New York Behavioral Health or a qualified
treatment provider for help. 

DBT and Eating Disorders References

Lenz, S.A., Taylor, R., Fleming, M., & Serman, N.
(2014). Effectiveness of dialectical behavior therapy for treating eating
disorders. Journal of Counseling &
Development
, 92, 26-35.

Federici, A., Wisniewski, L., & Ben-Porath, D. (2012).
Description of an intensive dialectical behavior therapy program for
multidiagnostic clients with eating disorders. Journal of Counseling & Development, 90, 330-338.

Striegel-Moore, R., & Bulik, C. (2007). Risk factors for
eating disorders. American Psychologist,
62, 181–198.

Crow, S., Peterson, C., Swanson, S., Raymond, N., Specker,
S., Eckert, E. D., & Mitchell, J. (2009). Increased mortality in bulimia nervosa
and other eating disorders. American
Journal of Psychiatry,
166, 1342–1346.

Ringer, F., & Crittenden, P. M. (2007). Eating disorders
and attachment: The effects of hidden family processes on eating disorders. European Eating Disorders Review, 15, 119–130.
doi:10.1002/erv.761

Whiteside, U., Chen, E., Neighbors, C., Hunter, D., Lo, T.,
& Larimer, M. (2007). Difficulties regulating emotions: Do binge eaters
have fewer strategies to modulate and tolerate negative affect? Eating Behaviors, 8, 162–169. doi:10.1016/j.eatbeh.2006.04.001

Doyle, A. C., le Grange, D., Goldschmidt, A., & Wilfley,
D. E. (2007). Psychosocial and physical impairment in overweight adolescents at
high risk for eating disorders. Obesity,
15, 145–154.

McElroy, S. L., Frye, M. A., Hellemann, G., Altshuler, L.,
Leverich, G. S., Suppes, T., & Post, R. (2011). Prevalence and correlates of
eating disorders in 875 patients with bipolar disorder. Journal of Affective Disorders, 128, 191–198.

O’Brien, K. M. O., & Vincent, N. K. (2003). Psychiatric
comorbidity in anorexia and bulimia nervosa: Nature, prevalence, and causal relationships.
Clinical Psychology Review, 23,
57–74.

Walsh, B. T., Kaplan, A. S., Attia, E., Olmsted, M.,
Parides, M., Carter, J. C., Rockert, W. (2006). Fluoxetine after weight restoration
in anorexia nervosa: A randomized controlled trial. Journal of the American Medical Association, 295, 2605–2612.

Bankoff, S., Karpel, M., Forbes, H., & Pantalone, D.
(2012). A systematic review of dialectical behavioral therapy for eating disorders.
Eating Disorders, 20, 196–215.

Linehan, M. M. (1993a). Cognitive behavioral treatment of
borderline personality disorder. New York, NY: Guilford Press.

Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D.,
& Heard, H. L. (1991). Cognitive-behavioral treatment of chronically
parasuicidal borderline patients. Archives
of General Psychiatry
, 48, 1060–1064.

Geller, J., Brown, K. E., Zaitsoff, S. L., Goodrich, S.,
& Hastings, F. (2003). Collaborative versus directive interventions in the treatment
of eating disorders: Implications for care providers. Professional Psychology: Research and Practice, 34, 406–413.doi:10.1037/0735-7028.34.4.406