Treating Co-Occurring Eating Disorders and Substance Use Disorders with DBT

Girl with eating disorder

Co-Occurrence of ED and SUD

Eating disorders (ED) and substance use disorders (SUD) are often concurrent conditions and, compared to patients with ED alone, those with both ED and SUD experience “more severe social and psychosocial impairment, greater psychiatric co-morbidity, increased impulsivity, higher number of suicidal attempts and promiscuous acts, higher rates of concurrent borderline personality disorder (BPD), previous sexual abuse, and a poorer prognosis” (Courbasson, Nishikawa, & Yasunori, 2012, p. 435). Linehan’s model of therapy, Dialectical Behavior Therapy (DBT), is the standard treatment for BPD but has also been adapted for and used separately with patients diagnosed with ED and SUD. However, no study exists that examines the efficacy of DBT in the treatment of patients with co-occurring ED and SUD (ED-SUD).  Historical logic dictated that exclusive focus on one problem at a time may best serve individuals with competing co-morbidities. However, Courbasson et al. (2012) argue that this approach may leave individuals “vulnerable to replacing one maladaptive behavior with another” (Courbasson et al., 2012, p. 435). 


Treating ED-SUD with DBT

The researchers, therefore, opted to assess the capabilities of a DBT program in the treatment of symptoms of co-occurring ED and SUD. DBT focuses on “awareness of problems and impulsive behaviors, emotion regulation strategies and increasing coping skills, which are all consistent with many of the needs of individuals with both ED and SUD” (Courbasson et al., 2012, p. 435). The twenty-five women who participated in the study had been referred by various mental health professionals and primary care physicians for assessment and treatment of concurrent ED and SUD. Participants were administered several tests to establish baseline levels and then were randomly allocated to either treatment via DBT or treatment as usual (TAU). The participants were administered the same testing measures again at three, six, nine, and twelve month intervals, as well as one year post treatment at three month intervals.


Improvements in Attitude and Behavior 

Preliminary support for the “usefulness of DBT in the treatment of concurrent ED and SUD” was found by the study (Courbasson et al., 2012, p. 444). At post-treatment, there were notable and sustained improvements in behavioral and attitudinal characteristics associated with disordered eating, including reductions in binge eating episodes. From a cognitive perspective, participants were also able to identify, post-treatment, emotions and sensations connected with hunger and satiation, as well as general feelings of low self-worth. Considerable reductions were also found in the severity and use of substances over a sustained period post treatment. The researchers further note that participants reported greater coping skills and negative emotion regulation (Courbasson et al., 2012). The DBT group retained its members at a higher rate than the TAU group, with 87% remaining in post-treatment (p. 444). Interestingly, in anecdotal feedback given by participants in the DBT group, it was noted that mindfulness skills were most beneficial – in conjunction with a strong therapeutic alliance and validation. The researchers encourage additional research be conducted to support these preliminary findings and bolster treatment knowledge for a demographic that can face significant challenges during the treatment process.



DBT Skills Groups

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Courbasson, C., Nishikawa, Y., & Dixon, L. (2012). Outcome of dialectical behavior therapy for concurrent eating and substance use disorders. Clinical Psychology and Psychotherapy, 19(5), 434-449.