DBT for Eating Disorders: An Overview
DBT for Eating Disorders: An Overview
Caitlin Martin-Wa­
Kelly Bhatnagar , gar
, and Lucene Wisniewski
The Oxford Handbook of Dialectical Behaviour Therapy
Edited by Michaela A. Swales
Print Publication Date: Nov 2018 Subject: Psychology, Clinical Psychology
Online Publication Date: Sep 2017 DOI: 10.1093/oxfordhb/9780198758723.013.15
Abstract and Keywords
Eating disorders (EDs) are severe and life-threatening illnesses that impact psychological
and physical health. Because ED behaviours can result in premature mortality and/or lead
to significant impairment, finding effective treatment for EDs is essential. There are ED
treatment models for adults and adolescents that have garnered empirical support; how­
ever, not all individuals experience full recovery from these approaches. Furthermore, in­
dividuals with certain clinical presentations (e.g. affect and emotion regulation deficits)
may be even less likely to reach remission using existing models. Due to its affect regula­
tion focus and unique blend of behavioural and Zen principles, DBT may help address as­
pects of the ED that tend to result in poorer outcomes in traditional treatment models.
This chapter provides an overview of the DBT for ED treatment model. It presents ratio­
nale for the model, specific components of the model, and a review of preliminary re­
search supporting the use of the model.
Keywords: Eating disorders, DBT, treatment, outcomes, adults, adolescents
An Overview of Eating Disorders
EATING disorders (ED) such as anorexia nervosa (AN), bulimia nervosa (BN), and bingeeating disorder (BED) are serious conditions characterized by a persistent disturbance of
eating behaviours that results in the altered consumption or absorption of food (American
Psychiatric Association [APA], 2013). Maladaptive eating disorder behaviours may include
extreme attempts to limit food intake and/or other weight management behaviours such
as self-induced vomiting, excessive/compulsive exercise, and laxative or diuretic abuse.
Eating disorder behaviours can be life-threatening and have dire medical consequences.
For example, excessive dietary restriction causes cardiac abnormalities, endocrine and
metabolic irregularities, renal complications, decreased bone density, abdominal bloating,
delayed gastric emptying, and dry and thin skin (Pomeroy, Mitchell, Roerig, & Crow,
2002). Recurrent compensatory behaviours such as self-induced vomiting and laxative
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DBT for Eating Disorders: An Overview
abuse can lead to oesophageal tears, sodium and potassium deficiencies, cardiac hypoten­
sion, and permanent erosion of dental enamel (Kaplan & Noble, 2007; Pomeroy et al.,
2002). The combined medical and psychosocial impairments lead to substantially higher
morbidity and mortality rates when compared to the general population and to other psy­
chiatric conditions (Arcelus, Mitchell, Wales, & Nelson, 2011; Fichter & Quadflieg, 2016;
Klump, Bulik, Kaye, Treasure, & Tyson, 2009). These statistics make identification of effi­
cacious treatment models for ED vastly important.
Traditional Eating Disorder Treatment
Models
(p. 574)
Cognitive-behavioural therapy (CBT) and interpersonal psychotherapy (IPT) have the
strongest evidence-base for the treatment of adult BN and BED (Hay, 2013; Wilson, Grilo,
& Vitousek, 2007). Therefore, CBT and IPT are recommended as first-line treatments for
those illnesses (National Institute for Health and Care Excellence [NICE], 2004). CBT
challenges distorted thoughts and maladaptive behaviours that maintain ED symptoms,
while IPT addresses interpersonal difficulties that maintain ED symptoms (Kass, Kolko, &
Wilfley, 2013). CBT is also the most commonly tested treatment for adult AN, although re­
search has yet to identify an approach that demonstrates its superiority over others for
AN (Kass et al., 2013).
For adolescents, results of a comprehensive review highlighted the efficacy of familybased interventions for the treatment of ED (Downs & Blow, 2013). Family-Based Treat­
ment (FBT) or the “Maudsley Model” (Lock, le Grange, Agras, & Dare, 2001; Lock & le
Grange, 2012) is considered particularly efficacious in treating adolescents with AN and
BN. Studies have reported approximately two-thirds of adolescent patients to be recov­
ered at the end of FBT with 75%–90% maintaining full weight restoration at five-year fol­
low-up (Downs & Blow, 2013; Eisler et al., 1997).
Despite the empirical support for CBT, IPT, and FBT, there continues to be a substantial
number of individuals that do not fully recover using these approaches, especially adults
with AN (Anderson & Maloney, 2001; Ball & Mitchell, 2004; Carter et al., 2011; Lundgren,
Danoff-Burg, & Anderson, 2004; McIntosh et al., 2005). Additionally, a 2010 study by Lock
and colleagues found as many as 50% of adolescent patients do not achieve full ED remis­
sion using FBT alone, and consequently, require alternative or supplementary treatment
(Lock et al., 2010). These data, along with clinical experiences, have prompted clinicians
and researchers alike to look to other empirically validated treatments for guidance man­
aging patients with EDs (e.g. Fairburn, Cooper, & Shafran, 2003; Wonderlich, Mitchell,
Peterson, & Crow, 2001). If research can identify predictors of treatment response, then
novel or adapted approaches can be developed in the hope of ameliorating outcome. Al­
though still early in the scientific study process, certain variables have been found to be
related to successful or poorer outcomes in standard models of ED treatment. Adults with
multidiagnostic, complex clinical pictures (e.g. dual diagnosis of Borderline Personality
Disorder (BPD), Substance Abuse (SA)/Dependency, recurrent suicidality or self-harm be­
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DBT for Eating Disorders: An Overview
haviours, and/or deficits in emotion regulation abilities) may not benefit as greatly from
CBT (e.g., Chen, Matthews, Allen, Kuo, & Linehan, 2008; Johnson, Tobin, & Enright, 1989;
Wilfley et al., 2000). For youth, there are data to suggest patients with moderate to se­
vere ED symptoms, slow rate of weight gain, comorbid psychiatric disorders, parent his­
tory of psychiatric illness, greater emotion dysregulation (e.g. suicidal/self-injurious be­
haviours, anger management problems), and/or personality disorder features (e.g. emerg­
ing BPD traits) may not do as (p. 575) well in FBT and are considered “difficult to treat”
using FBT alone (Doyle, le Grange, Leob, Doyle, & Crosby, 2010; Le Grange, Crosby, &
Lock, 2008). Families scoring high in expressed criticism and expressed emotion may also
decrease the effectiveness of the FBT model (Eisler, Simic, Russell, & Dare, 2007; Trea­
sure et al., 2008).
Why Dialectical Behaviour Therapy for the
Treatment of Eating Disorders?
The rationale for applying Dialectical Behaviour Therapy (DBT; Linehan, 1993) to the
treatment of ED has been described comprehensively in the literature (Bankoff, Karpel,
Forbes, & Pantalone, 2012; Ben-Porath, Wisniewski, & Warren, 2009; Lenz, Taylor, Flem­
ing, & Sherman, 2014; McCabe, LaVia, & Marcus, 2004; Ritschel, Lim, & Steward, 2015;
Wiser & Telch, 1999; Wisniewski, Bhatnagar, & Warren, 2013; Wisniewski & Kelly, 2003;
Wisniewski, Safer, & Chen, 2007). While the etiology of ED is complex and not yet entire­
ly understood, there is evidence that affect and emotion regulation deficits have a role
transdiagnostically in the development and maintenance of the illnesses (Harrison, Sulli­
van, Tchanturia, & Treasure, 2009; Haynos & Fruzzetti, 2011; Svaldi, Griepenstroh,
Tuschen-Caffier, & Ehring, 2012). It has been suggested that eating pathology (e.g. di­
etary restraint and restriction, self-induced vomiting, binge-eating, etc.) may function as a
mechanism to cope with emotion sensitivity and vulnerability (Fairburn, 2008; Telch,
Agras, & Linehan, 2000). DBT is proposed as a logical, alternative choice to traditional
models, therefore, because it is based on an affect regulation model of treating symptoms
(Telch et al., 2000).
In addition to its focus on affect regulation, other components of DBT may make it a vi­
able option for ED treatment. The unique blend of behavioural principles, dialectical phi­
losophy, and Zen influence may be useful in helping ED patients who struggle with moti­
vation and commitment to treatment. AN, in particular, differs from other mental illnesses
(such as depression and anxiety) in that patients often hold a considerable degree of am­
bivalence regarding symptom reduction/elimination and recovery as a whole (Williams &
Reid, 2010). Treatment of such “ego syntonic” symptoms requires use of motivational
strategies that delicately balance the need to change while simultaneously accepting a
patient’s present state and condition. DBT acknowledges the presence of dialectics and
holds a firm stance on the necessity of both change-based and acceptance-based thera­
peutic strategies to bring about symptom relief (Linehan, 1993). Acceptance-based strate­
gies may be particularly useful in ED treatment because patients are challenged to ac­
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DBT for Eating Disorders: An Overview
cept their current progress (including history of relapses), fluctuating weight and shape,
and other difficult-to-change aspects of treatment. The focus on acceptance is also helpful
for clinicians and family members in that it offers a framework for meeting a patient
where he/she is and allows (p. 576) for a more flexible time course for which lasting
change can be expected to occur (Wisniewski et al., 2013).
The DBT model may also be useful in addressing premature termination rates that are un­
fortunately common in ED treatment population. Drop-out rates in traditional treatment
models range from 20.2 to 70% (e.g., Swan-Kremeier, Mitchell, Twardowski, Lancaster, &
Crosby, 2005; Wallier et al., 2009). DBT has specific strategies to target treatment dropout that might help ameliorate this problem. A small number of studies have indeed re­
ported fewer drop-outs than typically seen in ED treatment, although this has been pri­
marily observed to date in the BN and BED populations (Hill, Craighead, & Safer, 2011;
Safer, Telch, & Agras, 2001b; Safer, Robinson, & Jo, 2010; Telch et al., 2000). While the
number of studies examining DBT drop-out with AN is more limited, there are at least two
studies to date that have promising preliminary results. One case series found a prema­
ture drop-out rate of 13.3% and another study focusing on Radically Open-DBT (RO-DBT)
found a drop-out rate of 27.7% (Chen et al., 2015; Lynch et al., 2013). More research is
needed to better understand DBT’s impact on treatment compliance and completion, par­
ticularly for AN.
Other aspects of the DBT model, such as therapist and patient case-management strate­
gies, also make DBT a feasible treatment option. ED patients and their symptoms (partic­
ularly those that can be a risk to life) have been noted to evoke strong emotions in their
treatment providers (Warren, Schafer, Crowley, & Olivardia, 2012). Similar to symptoms
related to BPD, ED symptoms are often conceptualized as conniving, dishonest, and su­
perficial by mental health providers, family, and friends (Golan, Yaroslavski, & Stein,
2009). Such negative attributions can create significant challenges in the client’s life and
treatment, particularly if these beliefs are held by the therapist. DBT’s solution is to em­
phasize the importance of maintaining a “non-judgmental stance” (Linehan, 1993) by pos­
ing that all behaviours, including those that appear dangerous and unhealthy, should be
viewed without judgment. Therapists may be challenged to understand how any behav­
iour might be useful to the patient, and DBT reminds clinicians that the behaviour is like­
ly indicative of a reinforced response that falls within a patient’s current skill repertoire.
Reframing a behaviour as “effective” or “ineffective” allows a patient to explore alterna­
tive behaviours for more adaptive environmental responses throughout the therapeutic
process. Therapists treating ED patients can greatly benefit from the “therapy for the
therapists” that a DBT consultation team meeting offers in order to receive support in
managing strong feelings towards patients and upholding fidelity to DBT principles and
interventions, even when treatment appears slow and frustrating for all. The authors be­
lieve this support to be fundamental to the successful treatment of chronic ED.
Case-management strategies encourage patients to deal with his/her own problems in the
environments in which they occur, with the appropriate help and support of the therapist.
Patient case-management strategies such as aiding (but not directly managing oneself) a
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DBT for Eating Disorders: An Overview
patient in the management of an often-extensive health provider network (i.e. medical
team, psychiatric team, nutrition team, hospitalizations, etc.) may help develop (p. 577) an
ED patient’s sense of mastery, control, and self-efficacy. This DBT strategy of consulta­
tion-to-the-patient promotes a therapeutic partnership that encourages patients to learn
new behaviours that result in the achievement of developmental and interpersonal goals;
this likely reinforces the collegial nature of the therapeutic alliance. A strong alliance can
assist with a client’s commitment to the therapist, and ultimately, to treatment in general.
Finally, it is important to consider the high frequency in which ED co-occur with other
mental health issues, such as BPD and SA (Holderness, Brooks-Gunn, & Warren, 1994;
Linehan et al., 2006). This is particularly important because rates of comorbid BPD and
ED range from 3% of AN patients, to 21% of BN patients, making it likely for those that
treat ED frequently to encounter these patients (Cassin & von Ranson, 2005). It is diffi­
cult to successfully treat eating pathology without addressing the symptoms of other di­
agnoses that may interfere with treatment or exacerbate ED symptoms. Also, both BPD
and ED symptoms can be highly life-threatening, making priority in addressing harmful
behaviours complicated. DBT for EDs provides a structure to address the co-occurring
maladaptive behaviours (e.g., purging, self-harm, suicide attempts) that individuals with
EDs often experience, which may make DBT especially useful for individuals with com­
plex diagnostic presentations (Chen et al., 2008; Federici & Wisniewski, 2013; Harned et
al., 2008; Kröger et al., 2010; Palmer et al., 2003).
The DBT for ED Treatment Model
DBT was first adapted for use with ED patients meeting criteria for a primary diagnosis of
BN or BED (Wiser & Telch, 1999). This DBT for ED adaptation consists of providing six
months of DBT skills training either in a group format for BED patients (Telch et al.,
2000; Wiser & Telch, 1999) or individually for BN (Safer et al., 2001b). As part of this
treatment model, all skills except the Interpersonal Effectiveness skills are taught and the
adaptation does not include the provision of individual DBT therapy or telephone skills
coaching. This adaptation, which has accumulating evidence supporting its effectiveness,
has been developed into an easy-to-use and widely available clinician’s manual (Safer,
Telch, & Chen, 2009) for use with primary, uncomplicated ED patients. However, DBT has
a reputation for providing an evidenced-based model for patients considered “difficult to
treat”. There are likely clinicians who are interested in using DBT with ED patients who
have more complex and comorbid presentations. While the literature on this is evolving,
the authors have recommended elsewhere that complex and comorbid individuals be
treated with comprehensive and standard DBT, as opposed to the adapted version of DBT
(Wisniewski et al., 2007). The next section presents eligibility criteria for the use of DBT
with ED patients and guidance to clinicians for deciding when to use the full DBT model
versus the adapted version. (p. 578)
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DBT for Eating Disorders: An Overview
Eligibility Criteria
When determining course of treatment for individuals with ED, it is important to consider
both the level of medical compromise and the state of nutritional insufficiency. Psycholog­
ical interventions such as DBT may have limited effectiveness if a patient’s physical
health and cognitive processes are ill-functioning due to extreme starvation or other EDrelated symptoms. The APA published guidelines can assist with decision-making sur­
rounding the appropriateness of various treatment settings and levels of care during
times of medical compromise (American Psychiatric Association, 2006). It is recommend­
ed that these guidelines be consulted prior to initiating DBT (or any other outpatient psy­
chological treatment approach) with ED patients.
Given the success of CBT and FBT respectively for adult and adolescent ED patients, the
authors view DBT as a treatment that can be offered if those treatments are not success­
ful. Complex or comorbid patients can be identified as eligible for comprehensive DBT if a
course of CBT, IPT, or FBT has not resulted in adequate symptom reduction. Additionally,
if the patient describes ED symptoms being used for emotion regulation, engages in self
harm, experiences chronic suicidality, or has a history of engaging in behaviours that in­
terfere with treatment, DBT can be a viable treatment option (Federici & Wisniewski,
2013; Federici, Wisniewski, & Ben-Porath, 2013). The authors recommend that therapists
consult the literature to guide the determination of whether or not a patient has respond­
ed to first-line ED treatment models. Table 26.1 shows specific admissions criteria devel­
oped and being tested at the authors’ clinic to determine whether or not a patient may be
an ideal candidate for DBT for ED.
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Table 26.1 Dialectical behaviour therapy for eating disorders eligibili­
ty criteria
Eligibility Criteria
(A)
Meets diagnostic criteria for eating disorders and is medically
stable for outpatient treatment.
(B)
Presents with an established and documented history of emo­
tion regulation difficulties, supported by a clinically significant
Difficulties in Emotion Regulation Scale (DERS; Gratz & Roe­
mer, 2004).
(C)
Exhibits two or more symptoms that DBT has evidence in man­
aging (e.g. recurrent self-harm, suicidality, impulsivity with the
potential for danger, substance abuse/dependence, pattern of
affective instability, disturbance in interpersonal relation­
ships).
For Patients Already Participating in Standard Treatment (CBT or
FBT)
(D)
Presents with comorbid diagnoses that are complicating stan­
dard ED treatment.
(E)
There is evidence that the patient is not being fully helped by
standard CBT or FBT alone, as evidenced by slow treatment
response or inability to meet treatment goals.
(F)
There is evidence of Therapy-Interfering Behaviours that make
it difficult to follow the manualized CBT or FBT agenda and
contribute to ineffectiveness of the standard models.
Orientation and Commitment to Treat­
ment: Target Hierarchy Adaptations to Reflect
ED Symptoms
(p. 579)
Once it has been determined that a particular patient may benefit from standard, compre­
hensive DBT, the commitment process in DBT for complex, comorbid ED is not unlike the
commitment for DBT in general. However, a clinician will need to understand how ED be­
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DBT for Eating Disorders: An Overview
haviours are evaluated in the hierarchy of treatment targets and adapt the target hierar­
chy accordingly for each ED patient.
It is typical that during orientation and commitment sessions, patients are advised of the
treatment targets and how they will be addressed both in and across sessions (Linehan,
1993). In addition to the Life-Threatening Behaviours (Target I), such as self-harm and
suicidal behaviour, that are traditionally addressed in standard DBT, each of these occur
with some frequency in the ED client (Paul, Schroeter, Dahme, & Nutzinger, 2002; Stein,
Lilenfeld, Wildman, & Marcus, 2004) and therefore, clinicians and patients alike need to
understand that ED behaviours can also be lethal. During periods of medical instability,
ED behaviours may be considered life-threatening (Wisniewski et al., 2007), as imminent
risk of death is increased during these periods (see e.g., Sachs, Harnke, Mehler, &
Krantz, 2016). Furthermore, if an individual meets criteria for medical conditions such as
bradycardia, arrhythmia, or electrolyte abnormalities, then any ED behaviour would be
considered life-threatening. Examples of behaviours that would be considered life-threat­
ening include engaging in self-induced vomiting while hypokalaemic, exercising or re­
stricting while bradycardic, and excessive drinking of water when hyponatraemic.
In addition to the general Therapy-Interfering Behaviours (TIB; Target II) of failure to
complete diary cards or being late for a session, patients with ED may engage in TIB that
are unique and directly related to their illness. For example, when a patient exhibits nonattentive behaviours such as being unable to focus in session or to remember what was
discussed between sessions, the non-attentive behaviour is considered a TIB. The thera­
pist may hypothesize, given the relationship between food deprivation and cognitive func­
tioning (Keys, Brozek, & Henscheo, 1950), that restriction is a significant link on the
chain leading to the non-attention. Another TIB related specifically to EDs includes noncollaborative behaviours such as drinking water before being weighed to give the illusion
of weight gain (i.e. “water-loading”).
ED behaviours that occur outside of periods of medical instability or that do not interfere
with treatment, are considered Quality-Of-Life-Interfering-Behaviours (Target III). It may
not always be clear where an ED symptom lies on the treatment hierarchy. Some behav­
iours will straddle the border between two categories and the therapist must carefully
consider where such behaviours will be targeted. Consultation with the treatment team
as well as a collaborative conversation with the patient is often necessary to determine
where more complicated behaviours fall on the treatment hierarchy.
(p. 580)
Treatment Components
Individual Therapy & Diary Cards
The role of the individual therapist (IT) in DBT for ED is no different to their role in stan­
dard DBT. The IT must review diary cards, conduct behaviour chain analyses, work to set
the session agenda collaboratively, and support the patient staying in treatment and gen­
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DBT for Eating Disorders: An Overview
eralizing skills. The authors recommend that the diary card for ED patients receiving DBT
should monitor food and beverage consumption, as well as the time of day and location
where the food or beverage was consumed. Some typical urges and behaviours to moni­
tor on the diary card include restriction, binge-eating, vomiting, laxative, diuretic or diet
pill use, and over-exercise. Having this information on the diary card will aid the patient
and therapist in understanding how food- and exercise-related issues might trigger be­
haviours and how they might make an individual vulnerable to emotions, as in the
PLEASE Master skills. PLEASE Master is a DBT technique used to reduce emotional vul­
nerability. This includes treating physical illness, balanced eating, avoid mood altering
drugs, balanced sleep, get exercise, and achieve mastery (Linehan, 2015). Figure 26.1
provides an example of how the diary card has been adapted for ED treatment.
Although the role of the therapist is not different, the knowledge base of the DBT thera­
pist that works with ED patients should ideally be skilled in ED-related issues and treat­
ments. In working with complex and comorbid ED patients and using DBT, the authors
have found it to be important to enhance standard DBT with some specific strategies for
directly addressing ED behaviours. There is a robust treatment literature employing CBT
strategies in the treatment of disordered eating (e.g., Fairburn, 2008). The authors have
recommended some additions to the DBT model from CBT model that directly address ED
issues (e.g., incorporating ED behaviours in the target hierarchy; weight, food and med­
ical monitoring; food exposures and meal planning). In conclusion, the DBT therapist
working with an ED patient needs to have a solid knowledge base of nutrition, exercise
physiology, and traditional ED-treatment approaches.
Skills Training
In comprehensive DBT for EDs skills training, all four skills modules are taught without
editing or alteration from how they are written in the published manuals (Linehan, 1993,
2015; Rathus & Miller, 2015). There are, however, some special considerations for clini­
cians working with ED patients. First, due to the medical issues related to ED behaviours,
some DBT skills may not be physically safe. For example, given the impact that changes
in temperature have on the heart, ED patients, especially those with a history of brady­
cardia, should not use the TIP skills (i.e., distress tolerance skills that encourage (p. 581)
(p. 582) clients to engage in temperature change, intense exercise, and progressive relax­
ation) unless cleared by a medical professional (Linehan, 2015). This may also be true for
exercise in the PLEASE skills. Second, given the nature of ED, there are some skills con­
sidered over-used or used to the exclusion of others, such as patients who self-soothe with
taste or who exclusively use exercise to change body chemistry (TIP skill). A clinician may
use a dialectical and non-judgmental framework when discussing these issues with pa­
tients. It can be helpful to acknowledge with patients that they may have been using
these skills regularly to regulate emotion and that it is the therapist’s job to teach them
quite a few more skills with which to manage that do not reinforce the ED. Using the
strategies of irreverence, a clinician faced with patients who had engaged in binge eating
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after becoming emotionally dysregulated might state “you already have mastered using
taste to self-soothe! We want to help you develop a range of skills to manage emotions”.
Figure 26.1 Example of a diary card used in adult
eating disorder treatment.
With respect to mindfulness skills and EDs, the authors are often asked about the use of
mindful eating in DBT for eating disorders. In order to effectively answer this question,
one of the authors conducted a study evaluating the impact of Mindfulness versus Dis­
traction during a snack with AN and BN patients in a day treatment programme (Marek,
Ben-Porath, Federici, & Wisniewski, 2013). The study found that using mindfulness de­
creased negative affect after meals for normal controls only and that negative affect actu­
ally increased after the mindfulness intervention compared to the distraction intervention
for the ED group. Other research has shown that post-meal use of distracting activities
(e.g., playing a computer game) leads to decreases in negative affect and intrusive
thoughts and increases in positive affect in hospitalized, underweight ED patients (Grif­
fiths, Hawkes, Gilbert, & Serpell, 2016). Taken together, these data suggest that distrac­
tion may be an effective skill to use for restricting and purging patients experiencing a
high level of behavioural dyscontrol (e.g., when individuals are meeting criteria for hospi­
talization or day treatment). However, for individuals with BED, disconnection from inter­
nal cues and over-focus on external, hedonic cues can encourage mindless overeating and
binge-eating. For BED patients, mindful eating approaches have been found to be helpful
in decreasing binge and overeating episodes and for increasing internal awareness (Allen
& Craighead, 1999; Kristeller, Wolever, & Sheets, 2014). Further, one study showed that
improvements in eating disorder symptomology were related to the degree to which indi­
viduals practiced mindfulness (Kristeller et al., 2014). Additional research is needed to
determine if mindful eating may be taught to individuals with AN or BN later in recovery,
or with patients whose illness is mild to moderate.
Telephone Skills Coaching (TSC)
With ED patients, the TSC protocol for non-suicidal self-injurious (NSSI) and suicidal be­
haviour shares the same elements (e.g. 24-hour rule) as Linehan’s original guidelines. As
in standard DBT’s telephone coaching, ED patients are instructed to call if they need help
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DBT for Eating Disorders: An Overview
managing urges for suicidal or NSSI behaviours. However, there are (p. 583) some modifi­
cations recommended when working with an ED population (Wisniewski & Ben-Porath,
2005). First, ED patients are instructed to call for coaching prior to engaging in any eat­
ing disorder behaviours (e.g., restricting, binging, purging). This adaptation was adopted
due to the high morbidity and mortality associated with ED behaviours. A second and re­
lated modification of standard TSC was an adjustment to DBT’s 24-hour rule that ac­
counted for eating behaviour. Because eating disordered patients are likely to be exposed
to food repeatedly over the course of a day, the Next Meal/Snack Rule was implemented.
The Next Meal/Snack Rule states that if a patient engages in an ED behaviour, she is not
permitted to call her therapist for TSC until the next scheduled meal or snack. However,
if the patient has engaged in an ED behaviour and elects to call at the next scheduled
meal or snack to receive coaching, the previous ED behaviour(s) is not addressed on the
call and must wait until the next scheduled therapy appointment to do so. This adaptation
was developed because a 24-hour waiting period for a behaviour that must occur at a
minimum of three times per day might have the unintended consequence of preventing an
individual from ever being able to call for coaching or get back on track. Additionally, be­
cause ED patients can exhibit avoidant ED behaviours, patients often report that calling
for “accountability” is helpful. When calling for accountability, the patient schedules a
coaching call with her therapist before eating a particular meal (Limbrunner, Ben-Porath,
& Wisniewski, 2011).
Consultation Team
There are no specific adaptations for the DBT consultation team when working with ED
patients. It will be important that all members of the team have expertise in the treat­
ment of EDs. If members of a team do not have ED expertise, the consultation team could
be the place to work on increasing competency via web trainings or expert consultation.
For a list of topics suggested for a DBT therapist to learn in order to increase competence
when treating EDs, see Wisniewski et al., 2007.
Child and Adolescent Adaptations and Consid­
erations
In 2007, Miller and colleagues published a DBT treatment manual designed specifically
for adolescents. The adolescent DBT treatment model closely resembles the adult model
in that it shares the same theoretical framework, targeting structure, treatment modes,
and strategies (Klein & Miller, 2011); however, seven key adaptations were proposed to
make DBT more developmentally suitable for youth and their families (Chapter 25, this
volume; Miller, Rathus, & Linehan, 2007). In summary, the adaptations include: 1) family
members attend skills training groups and are offered telephone skills coaching (p. 584)
by the multi-family skills group leader; 2) family therapy sessions are held on an as-need­
ed basis to address familial conflict and crises that arise; 3) dialectical dilemmas specific
to adolescents and families are introduced and are considered secondary behavioural tar­
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DBT for Eating Disorders: An Overview
gets; 4) treatment length was decreased from 12 months to six months; 5) a second phase
of treatment, a 16-week optional graduate group, is offered to youth who continue to ex­
perience symptom-related challenges after the first phase of treatment; 6) the number of
skills taught within each module decreased and a fifth adolescent-inspired skills module,
“Walking the Middle Path”, was added; and 7) group handouts were modified to be more
appealing and use language understandable to most adolescents (please see Miller et al.,
2007 for a detailed description and rationale for the changes).
When working with youth with EDs, most of the adaptations proposed by Miller et al.
(2007) apply strikingly well. For example, not only can family participation in skills train­
ing be helpful with enhancing an adolescent’s potential for skills generalization and rein­
forcement outside of the treatment (Miller et al., 2007), but if an adolescent’s cognitive
functioning is impaired due to the effects of malnutrition, as is commonly seen in AN
(Chui et al., 2008), it can be helpful to have an adult with a “healthy brain” present to
help re-teach and interpret information that is not being completely understood. The
modified handouts and condensed worksheets can also be helpful when assisting a pa­
tient with cognitive difficulties secondary to starvation. Furthermore, additional interven­
tion in the form of a DBT graduate group may improve long-term successful outcomes for
an illness where relapse is common (Berkman, Lohr, & Bulik, 2007). Symptom interrup­
tion and health/weight restoration in a severely ill adolescent can sometimes take much
longer than six months to occur. An option for peer-led, ongoing support after the first
treatment phase can help the recovering adolescent to improve motivation, improve ef­
fective behaviour, and promote skills generalization (MacPherson, Cheavens, & Fristad,
2013), which could theoretically serve as a protective factor against a relapse.
Despite the fact that most of the adaptations do have relevance to adolescent ED treat­
ment as well, the authors do suggest one significant variation specific to ED treatment.
As opposed to offering family therapy “as needed”, as suggested in the original model, it
is proposed that family therapy in the form of FBT be offered regularly and in conjunction
with standard DBT to create a blended FBT/DBT ED treatment model for youth. A blend­
ed model is recommended for two reasons. First, there is a significant amount of research
data to support the effectiveness of the FBT treatment model (Downs & Blow, 2013) and
because of this, it has emerged as the “gold standard” treatment for youth with ED. The
level of empirical support FBT has obtained suggests adding to (as opposed to replacing)
the model may make more sense. Second, parent/caregiver accountability and support
are considered well-established key factors in successful ED treatment for children and
adolescents (Le Grange, Lock, Loeb, & Nicholls, 2010). FBT empowers parents to take
charge of eating and weight management behaviours until an ill adolescent becomes less
behaviourally and psychologically involved with the ED and can make healthy decisions
on his/her own. This is accomplished in (p. 585) therapy by staying “laser-focused” on ED
symptoms until they are in remission and/or the child is weight restored (Lock & le
Grange, 2012). Maintaining a “laser-focus” on ED symptoms can be quite difficult to do,
particularly when adolescents present with other life-threatening or safety-compromising
behaviours (e.g. NSSI, suicidality, etc.). When working with children and adolescents with
EDs, however, there is a narrow window of opportunity (i.e. approximately three years) to
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DBT for Eating Disorders: An Overview
intervene so that symptoms do not progress into a more chronic and even more difficultto-treat form of illness (Eisler et al., 1997; Russell, Szmukler, Dare, & Eisler, 1987), so an
ideal treatment approach would be one that continues to rapidly and aggressively target
ED symptoms and other dangerous comorbidities simultaneously. In the proposed blend­
ed FBT/DBT blended treatment model, each adolescent would be assigned a specially
trained DBT individual therapist (one well-versed in FBT principles) to target life-threat­
ening, therapy- and quality-of-life-interfering symptoms along with a specially trained FBT
family therapist (one well-versed in DBT principles) who will remain hyper-focused on em­
powering parents to manage ED symptoms. For a detailed theoretical overview of the
FBT/DBT treatment model, please see Bhatnagar & Wisniewski, 2015.
Data Supporting DBT for Eating Disorders
Since the first DBT with EDs study in 2000, additional modifications and various types of
trials have been published, such as single case presentations, case series, uncontrolled
trials, and randomized clinical trials. DBT treatment has been examined within AN, BN,
BED, and multidiagnostic populations. Early results have found overall support for low
drop-out rates, reduced therapist burnout, and reduced ED pathology and general symp­
tomology. A primary goal of studies examining DBT with ED is to determine whether DBT
is effective in reducing ED behaviours and conducive to reaching remission. To the au­
thors’ knowledge, there have been no randomized trials of DBT compared directly to an­
other evidence-based ED treatment to date. However, evidence has been accumulating
from case studies and wait-list control/treatment as usual (TAU) trials that DBT can be ef­
fective in facilitating the reduction of BED symptoms (Masson, von Ranson, Wallace, &
Safer, 2013; Safer et al., 2010; Telch et al., 2000; Telch, Agras, & Linehan, 2001) and BN
symptoms (Hill et al., 2011; Safer, Telch, & Agras, 2001a; Safer et al., 2001b). While re­
search on DBT with AN patients is scarce, preliminary findings have found increases in
BMI and reductions in ED psychopathology (Chen et al., 2015; Lynch et al., 2013). Some
studies have examined DBT with a mixed sample of patients with AN, BN, or an eating
disorder not otherwise specified (EDNOS) to increase knowledge of how DBT functions
transdiagnostically. Transdiagnostic and multidiagnostic studies have also found signifi­
cant support for the utility of DBT as an ED treatment (Chen et al., 2008; Courbasson,
Nishikawa, & Dixon, 2012; Federici & Wisniewski, 2013; (p. 586) Kröger et al., 2010; Lenz
et al., 2014; Palmer et al., 2003). These findings are especially important because comor­
bity is very high among those who have ED (Hudson, Hiripi, Pope, & Kessler, 2007).
Follow-up study results provide additional support for DBT as a viable ED treatment op­
tion. ED behaviour abstinence rates and eating pathology reductions are observed at
three and six months post-treatment, although at somewhat reduced levels in some stud­
ies (Chen et al., 2008; Safer et al., 2010; Telch et al., 2001). For individuals who needed to
gain weight as part of their treatment, BMI increases were also reasonably retained, al­
though more studies are needed to more thoroughly examine how DBT impacts BMI
(Chen et al., 2015). Interestingly, while DBT may help achieve symptom improvements
more quickly than active comparison group therapy (ACGT), long-term remission rates
Page 13 of 24
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DBT for Eating Disorders: An Overview
are comparable to ACGTs (e.g., Safer et al., 2010). Due to the complexity of some ED pre­
sentations, extended versions of DBT or follow-up skills groups may be helpful in further­
ing skills generalization and ED symptom reductions (Chen et al., 2008; Hill et al., 2011).
Continued booster sessions may also support sustained rates of ED symptom reductions
in the long term.
While reducing ED symptoms and behaviours is vital for the treatment of an ED, other
factors may also impact the success of ED treatment. For instance, it is important to pre­
vent the premature treatment termination that is common for individuals with EDs
(Swan-Kremeier et al., 2005; Wallier et al., 2009). A crucial strength of DBT for EDs is the
low rate of premature drop-out, which has been found to range from 0% to 28% (Chen et
al., 2008; Chen et al., 2015; Courbasson et al., 2012; Federici & Wisniewski, 2013; Hill et
al., 2011; Lynch et al., 2013; Palmer et al., 2003; Safer et al., 2001b; Safer et al., 2010;
Telch et al., 2000) or similar to rates found in control groups (Masson et al., 2013; Telch
et al., 2001). These low rates of premature drop-out may be because DBT targets TIB that
obstruct patients from receiving their full dose of treatment. While many of these studies
have very few participants, early results are promising. Finally, in line with traditional
DBT goals, DBT with EDs has also been found to improve emotion regulation (Courbasson
et al., 2012; Hill et al., 2011; Telch et al., 2000).
Adolescent Data
Over the last decade, DBT has been examined in adolescent ED populations as well. While
only a handful of studies have looked at adapting DBT to adolescents with EDs, early re­
sults suggest DBT can aid in the reduction of eating disorder symptoms, depression symp­
toms, and general psychopathology (Johnston, O’Gara, Koman, Baker, & Anderson, 2015;
Safer, Couturier, & Lock, 2007; Salbach, Klinkowski, Pfeiffer, Lehmkuhl, & Korte, 2007;
Salbach-Andrae, Bohnekamp, Pfeiffer, Lehmkuhl, & Miller, 2008). Increases in BMI for
AN patients have also been found in DBT-ED treatment (Salbach et al., 2007; Johnston et
al., 2015). Further research examining DBT in adolescent ED populations, especially
those with complicated presentations, comorbidity, and/or treatment-resistant EDs, is
needed.
Taken together, the results thus far are promising and exciting, but more is need­
ed to solidify DBT as an evidence-based treatment, particularly for AN. Direct compar­
isons of DBT to other, more heavily researched standard treatments are needed to inform
clinical interventions. It may also be helpful in understanding which types of patients ben­
efit best from established treatments, such as CBT and IPT, and which may need DBT to
reach recovery.
(p. 587)
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DBT for Eating Disorders: An Overview
Conclusions and Future Directions
Given that ED can be resistant to traditional treatments, and that ED symptoms can be
life-threatening, as well as severely impact the lives of both patients and their families,
understanding additional viable treatment options is essential. This is especially true for
when other evidence-based treatments have not been successful for an individual with an
ED or who exhibits complex comorbidity. As this chapter shows, adapting traditional DBT
to the needs of EDs is achievable and useful. The research evaluating the use of compre­
hensive DBT with ED patients is small but growing (e.g., Ben-Porath et al., 2009; Chen et
al., 2008; Chen et al., 2015; Federici & Wisniewski, 2013; Groves, Backer, van den Bosch,
& Miller, 2011; Kröger et al., 2010; Palmer et al., 2003), with the research consistently
finding a reduction in ED behaviours and/or ED cognitions. However, DBT has not been
examined at the same level and with the same rigour as other established ED treatments.
More research is needed to aid in the understanding of DBT for the treatment of EDs.
There are numerous areas in which future research might focus. First, it is important that
research directly compare DBT to standard, well-established ED treatments in RCTs.
Larger sample sizes and increased control within future studies may be helpful in provid­
ing additional support (or contradiction) to the use of DBT with ED patients. Studies com­
paring adapted versions of DBT to the more comprehensive, original version of DBT may
also be helpful in guiding clinicians in their treatment decision-making process. While
DBT was originally adapted for use with BED and BN patients, much less is known about
the effectiveness of DBT for patients with AN, thus, leaving an important gap in the litera­
ture.
Finally, DBT has been studied primarily in white women, making knowledge on how effec­
tive DBT is with men and minority populations difficult to discern. Prevalence rates of ED
indicate men and minority populations experience a substantial number of ED symptoms,
although much less is known about the factors that influence treatment seeking, barriers
to recovery, and unique needs. For example, specific barriers present with low socio-eco­
nomic status individuals, such as lack of insurance or the reduced ability to take time
away from work due to limited financial resources, may impact DBT for ED treatment be­
cause the course of treatment is lengthy and intensive. Understanding more about the
barriers present within various populations can help find ways for all individuals diag­
nosed with ED to access and maintain treatment. Hopefully, through the information pro­
vided in this chapter, clinicians can feel better equipped to use DBT with relevant ED pa­
tients and researchers can find additional areas of inquiry. (p. 588)
Key Points for Clinicians
• Because eating pathology can function as a strategy to cope with emotion sensi­
tivity and vulnerability, dialectical behaviour therapy (DBT) can fill a needed gap
for individuals who have not responded to standard treatment approaches.
Page 15 of 24
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DBT for Eating Disorders: An Overview
• The following characteristics in individuals with eating disorders (ED) may indi­
cate the utility of a DBT approach:
a. Failed treatment attempts with evidence-based treatment approaches.
b. Affect or emotion regulation deficits.
c. Multidiagnostic, complex clinical presentations, especially:
i. Recurrent suicidality or self-harm behaviours
ii. Borderline Personality Disorder or Substance Use Disorders.
d. Slow rate of weight gain (for adolescents who need to gain weight as
part of their treatment recommendations).
• The “non-judgmental stance” in DBT can be a powerful tool for clinicians to
help reduce their burnout and prevent judgments related to behaviours that are
often considered as dangerous, shallow, or deceitful. Participating in “therapy for
the therapists” in DBT consultation teams is vital in order to receive support from
other DBT clinicians and to uphold treatment fidelity.
• ED behaviours can fit into the target hierarchy by assessing the level of threat
the behaviour poses. The ED behaviours may move targets over time depending
on medical instability and implications of the behaviour.
• While the standard DBT protocol utilizes a 24-hour rule for phone coaching, for
ED behaviours, this rule should be adapted to the “Next Meal/Snack Rule” due to
the frequency of exposure to food and expected meals/snacks in one 24-hour peri­
od.
References
Allen, H., & Craighead, L. (1999). Appetite monitoring in the treatment of binge eating
disorder. Behavior Therapy, 30(2), 253–272.
American Psychiatric Association. (2006). Practice guideline for the treatment of patients
with eating disorders, 3rd Edition. Arlington, VA: American Psychiatric Publications.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental dis­
orders, 5th Edition. Arlington, VA: American Psychiatric Publishing.
Anderson, D. A., & Maloney, K. C. (2001). The efficacy of cognitive-behavioral therapy on
the core symptoms of bulimia nervosa. Clinical Psychology Review, 21(7), 971–988.
Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with
anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. Archives of
General Psychiatry, 68(7), 724–731.
Page 16 of 24
PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). © Oxford University Press, 2022. All Rights
Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in
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Subscriber: University of Pennsylvania; date: 25 January 2022
DBT for Eating Disorders: An Overview
Ball, J., & Mitchell, P. (2004). A randomized controlled study of cognitive behavior therapy
and behavioral family therapy for anorexia nervosa patients. Eating Disorders, 12(4), 303–
314.
Bankoff, S. M., Karpel, M. G., Forbes, H. E., & Pantalone, D. W. (2012). A system­
atic review of dialectical behavior therapy for the treatment of eating disorders. Eating
Disorders, 20(3), 196–215.
(p. 589)
Ben-Porath, D. D., Wisniewski, L., & Warren, M. (2009). Differential treatment response
for eating disordered patients with and without a comorbid borderline personality diagno­
sis using a dialectical behavior therapy (DBT)-informed approach. Eating Disorders,
17(3), 225–241.
Berkman, N. D., Lohr, K. N., & Bulik, C. M. (2007). Outcomes of eating disorders: A sys­
tematic review of the literature. International Journal of Eating Disorders, 40(4), 293–309.
Bhatnagar, K., & Wisniewski, L. (2015). Integrating dialectical behavior therapy with fam­
ily therapy for adolescents with affect dysregulation. In K. L. Loab, D. Le Grange, & J.
Lock (Eds.), Family therapy for adolescent eating and weight disorders (pp. 305–327).
New York: Taylor & Francis.
Carter, F. A., Jordan, J., McIntosh, V. V., Luty, S. E., McKenzie, J. M., Frampton, C., …
Joyce, P. R. (2011). The long‐term efficacy of three psychotherapies for anorexia nervosa:
A randomized, controlled trial. International Journal of Eating Disorders, 44(7), 647–654.
Cassin, S. E., & von Ranson, K. M. (2005). Personality and eating disorders: A decade in
review. Clinical Psychology Review, 25(7), 895–916.
Chen, E. Y., Matthews, L., Allen, C., Kuo, J. R., & Linehan, M. M. (2008). Dialectical behav­
ior therapy for clients with binge‐eating disorder or bulimia nervosa and borderline per­
sonality disorder. International Journal of Eating Disorders, 41(6), 505–512.
Chen, E. Y., Segal, K., Weissman, J., Zeffiro, T. A., Gallop, R., Linehan, M. M., … Lynch, T.
R. (2015). Adapting dialectical behavior therapy for outpatient adult anorexia nervosa—A
pilot study. International Journal of Eating Disorders, 48(1), 123–132.
Chui, H. T., Christensen, B. K., Zipursky, R. B., Richards, B. A., Hanratty, M. K., Kabani, N.
J., … Katzman, D. K. (2008). Cognitive function and brain structure in females with a his­
tory of adolescent-onset anorexia nervosa. Pediatrics, 122(2), e426–e437.
Courbasson, C., Nishikawa, Y., & Dixon, L. (2012). Outcome of dialectical behaviour ther­
apy for concurrent eating and substance use disorders. Clinical Psychology & Psychother­
apy, 19(5), 434–449.
Downs, K. J., & Blow, A. J. (2013). A substantive and methodological review of familybased treatment for eating disorders: The last 25 years of research. Journal of Family
Therapy, 35(S1), 3–28.
Page 17 of 24
PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). © Oxford University Press, 2022. All Rights
Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in
Oxford Handbooks Online for personal use (for details see Privacy Policy and Legal Notice).
Subscriber: University of Pennsylvania; date: 25 January 2022
DBT for Eating Disorders: An Overview
Doyle, P., Le Grange, D., Loeb, K., Doyle, A. C., & Crosby, R. (2010). Early response to
family-based treatment for adolescent anorexia nervosa. International Journal of Eating
Disorders, 43(7), 659–662.
Eisler, I., Dare, C., Russell, G. F. M., Szmukler, G. I., Le Grange, D., & Dodge, E. (1997).
Family and individual therapy in anorexia nervosa: A five-year follow-up. Archives of Gen­
eral Psychiatry, 54(11), 1025–1030.
Eisler, I., Simic, M., Russell, G. F. M., & Dare, C. (2007). A randomised controlled treat­
ment trial of two forms of family therapy in adolescent anorexia nervosa: A five-year fol­
low-up. Journal of Child Psychology and Psychiatry, 48(6), 552–560.
Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. New York: Guil­
ford Press.
Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating
disorders: A “transdiagnostic” theory and treatment. Behaviour Research and Therapy,
41(5), 509–528.
(p. 590)
Federici, A., & Wisniewski, L. (2013). An intensive DBT program for patients with
multidiagnostic eating disorder presentations: A case series analysis. International Jour­
nal of Eating Disorders, 46(4), 322–331.
Federici, A., Wisniewski, L., & Ben-Porath, D. (2013). Description of an intensive dialecti­
cal behavior therapy program for multidiagnostic clients with eating disorders. Journal of
Counseling & Development, 90(3), 330–338.
Fichter, M. M., & Quadflieg, N. (2016). Mortality in eating disorders—results of a large
prospective clinical longitudinal study. International Journal of Eating Disorders, 49(4),
391–401.
Golan, M., Yaroslavski, A., & Stein, D. (2009). Managing eating disorders: Countertrans­
ference processes in the therapeutic milieu. International Journal of Child and Adolescent
Health, 2(2), 213–227.
Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and
dysregulation: Development, factor structure, and initial validation of the difficulties in
emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1),
41–54.
Griffiths, E., Hawkes, N., Gilbert, S., & Serpell, L. (2016). Improving the post-meal experi­
ence of hospitalised patients with eating disorders using visuospatial, verbal and somatic
activities. Journal of Eating Disorders, 4(9), 1–5.
Groves, S., Backer, H. S., van den Bosch, W., & Miller, A. (2011). Dialectical behaviour
therapy with adolescents. Child and Adolescent Mental Health, 17(2), 65–75.
Page 18 of 24
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Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in
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Subscriber: University of Pennsylvania; date: 25 January 2022
DBT for Eating Disorders: An Overview
Harned, M. S., Chapman, A. L., Dexter-Mazza, E. T., Murray, A., Comtois, K. A., & Line­
han, M. M. (2008). Treating co-occurring Axis I disorders in recurrently suicidal women
with borderline personality disorder: A 2-year randomized trial of dialectical behavior
therapy versus community treatment by experts. Journal of Consulting and Clinical Psy­
chology, 76(6), 1068–1075.
Harrison, A., Sullivan, S., Tchanturia, K., & Treasure, J. (2009). Emotion recognition and
regulation in anorexia nervosa. Clinical Psychology & Psychotherapy, 16(4), 348–356.
Hay, P. (2013). A systematic review of evidence for psychological treatments in eating dis­
orders: 2005–2012. International Journal of Eating Disorders, 46(5), 462–469.
Haynos, A. F., & Fruzzetti, A. E. (2011). Anorexia nervosa as a disorder of emotion dys­
regulation: Evidence and treatment implications. Clinical Psychology: Science and Prac­
tice, 18(3), 183–202.
Hill, D. M., Craighead, L. W., & Safer, D. L. (2011). Appetite‐focused dialectical behavior
therapy for the treatment of binge eating with purging: A preliminary trial. International
Journal of Eating Disorders, 44(3), 249–261.
Holderness, C. C., Brooks-Gunn, J., & Warren, M. P. (1994). Co‐morbidity of eating disor­
ders and substance abuse review of the literature. International Journal of Eating Disor­
ders, 16(1), 1–34.
Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007). The prevalence and corre­
lates of eating disorders in the National Comorbidity Survey Replication. Biological Psy­
chiatry, 61(3), 348–358.
Johnson, C., Tobin, D., & Enright, A. (1989). Prevalence and clinical characteristics of bor­
derline patients in an eating-disordered population. Journal of Clinical Psychiatry, 50(1),
9–15.
Johnston, J. A., O’Gara, J. S., Koman, S. L., Baker, C. W., & Anderson, D. A. (2015). A pilot
study of Maudsley family therapy with group dialectical behavior therapy skills training in
an intensive outpatient program for adolescent eating disorders. Journal of Clinical Psy­
chology, 71(6), 527–543.
Kaplan, A. S., & Noble, S. (2007). Medical complications of eating disorders. In S.
Wonderlich, J. E. Mitchell, M. de Zwaan, & H. Steiger (Eds.), Annual review of eating dis­
orders (Part 1, pp. 101–111). Oxford: Radcliffe.
(p. 591)
Kass, A. E., Kolko, R. P., & Wilfley, D. E. (2013). Psychological treatments for eating disor­
ders. Current Opinions in Psychiatry, 26(6), 549–555.
Keys, A., Brozek, J., & Henscheo, A. (1950). The biology of human starvation. Minneapolis:
University of Minnesota Press.
Page 19 of 24
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DBT for Eating Disorders: An Overview
Klein, D. A., & Miller, A. L. (2011). Dialectical behavior therapy for suicidal adolescents
with bordeline personality disorder. Child and Adolescent Psychiatric Clinics of North
America, 20(2), 205–216.
Klump, K. L., Bulik, C. M., Kaye, W. H., Treasure, J., & Tyson, E. (2009). Academy for eat­
ing disorders position paper: Eating disorders are serious mental illnesses. International
Journal of Eating Disorders, 42(2), 97–103.
Kristeller, J., Wolever, R. Q., & Sheets, V. (2014). Mindfulness-based eating awareness
training (MB-EAT) for binge eating: A randomized clinical trial. Mindfulness, 5(3), 282–
297.
Kröger, C., Schweiger, U., Sipos, V., Kliem, S., Arnold, R., Schunert, T., & Reinecker, H.
(2010). Dialectical behaviour therapy and an added cognitive behavioural treatment mod­
ule for eating disorders in women with borderline personality disorder and anorexia ner­
vosa or bulimia nervosa who failed to respond to previous treatments. An open trial with
a 15-month follow-up. Journal of Behavior Therapy and Experimental Psychiatry, 41(4),
381–388.
Le Grange, D., Crosby, R. D., & Lock, J. (2008). Predictors and moderators of outcome in
family-based treatment for adolescent bulimia nervosa. Journal of the American Academy
of Child and Adolescent Psychiatry, 47(4), 464–470.
Le Grange, D., Lock, J., Loeb, K., and Nicholls, D. (2010). Academy for Eating Disorders
position paper: The role of the family in eating disorders. International Journal of Eating
Disorders, 43(1), 1–5.
Lenz, A. S., Taylor, R., Fleming, M., & Serman, N. (2014). Effectiveness of dialectical be­
havior therapy for treating eating disorders. Journal of Counseling & Development, 92(1),
26–35.
Limbrunner, H. M., Ben-Porath, D. D., & Wisniewski, L. (2011). DBT telephone skills
coaching with eating disordered clients: Who calls, for what reasons, and for how long?
Cognitive and Behavioral Practice, 18(2), 186–195.
Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., …
Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical
behavior therapy vs therapy by experts for suicidal behaviors and borderline personality
disorder. Archives of General Psychiatry, 63(7), 757–766.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder.
New York: Guilford Press.
Linehan, M. M. (2015). DBT skills training manual, 2nd edition. New York: Guilford Press.
Lock, J., & Le Grange, D. (2012). Treatment manual for anorexia nervosa: A family-based
approach, 2nd Edition. New York: Guilford Press.
Page 20 of 24
PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). © Oxford University Press, 2022. All Rights
Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in
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Subscriber: University of Pennsylvania; date: 25 January 2022
DBT for Eating Disorders: An Overview
Lock, J., Le Grange, D., Agras, W. S., & Dare, C. (2001). Treatment manual for anorexia
nervosa: A family-based approach. New York: Guilford Press.
Lock, J., Le Grange, D., Agras, W. S., Moye, A., Bryson, S. W., & Jo, B. (2010). Randomized
clinical trial comparing family-based treatment with adolescent-focused individual thera­
py for adolescents with anorexia nervosa. Archives of General Psychiatry, 67(10), 1025–
1032.
Lundgren, J. D., Danoff-Burg, S., and Anderson, D. A. (2004). Cognitive-behavioral
therapy for bulimia nervosa: An empirical analysis of clinical significance. International
Journal of Eating Disorders, 35(3), 262–274.
(p. 592)
Lynch, T. R., Gray, K. L., Hempel, R. J., Titley, M., Chen, E. Y., & O’Mahen, H. A. (2013).
Radically open-dialectical behavior therapy for adult anorexia nervosa: feasibility and out­
comes from an inpatient program. BMC Psychiatry, 13, 293–309.
MacPherson, H. A., Cheavens, J. S., & Fristad, M. A. (2013). Dialectical behavior therapy
for adolescents: Theory, treatment adaptations, and empirical outcomes. Clinical Child
and Family Psychology Review, 16(1), 59–80.
Marek, R. J., Ben‐Porath, D. D., Federici, A., Wisniewski, L., & Warren, M. (2013). Target­
ing premeal anxiety in eating disordered clients and normal controls: A preliminary inves­
tigation into the use of mindful eating vs. distraction during food exposure. International
Journal of Eating Disorders, 46(6), 582–585.
Masson, P. C., von Ranson, K. M., Wallace, L. M., & Safer, D. L. (2013). A randomized
wait-list controlled pilot study of dialectical behaviour therapy guided self-help for binge
eating disorder. Behaviour Research and Therapy, 51(11), 723–728.
McCabe, E., LaVia, M., & Marcus, M. (2004). The use of dialectical behavior therapy in
the treatment of eating disorders. In J. K. Thompson (Ed.), Handbook of eating disorders
and obesity (pp. 232–244). Hoboken, NJ: John Wiley and Sons.
McIntosh, V. V., Jordan, J., Carter, F. A., Luty, S. E., McKenzie, J. M., Bulik, C. M., … Joyce,
P. R. (2005). Three psychotherapies for anorexia nervosa: A randomized, controlled trial.
American Journal of Psychiatry, 162(4), 741–747.
Miller, A. L., Rathus, J. H., & Linehan, M. M. (2007). Dialectical behavior therapy with sui­
cidal adolescents. New York: Guilford Press.
National Institute for Clinical Excellence. (2004). Core interventions in the treatment and
management of anorexia nervosa, bulimia nervosa, and binge eating disorder (National
Clinical Practice Guideline CG9). Retrieved from www.nice.org.uk/nicemedia/pdf/
CG9FullGuideline.pdf
Palmer, R. L., Birchall, H., Damani, S., Gatward, N., McGrain, L., & Parker, L. (2003). A di­
alectical behavior therapy program for people with an eating disorder and borderline per­
Page 21 of 24
PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). © Oxford University Press, 2022. All Rights
Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in
Oxford Handbooks Online for personal use (for details see Privacy Policy and Legal Notice).
Subscriber: University of Pennsylvania; date: 25 January 2022
DBT for Eating Disorders: An Overview
sonality disorder—description and outcome. International Journal of Eating Disorders,
33(3), 281–286.
Paul, T., Schroeter, K., Dahme, B., & Nutzinger, D. O. (2002). Self-injurious behavior in
women with eating disorders. American Journal of Psychiatry, 159(3), 408–411.
Pomeroy, C., Mitchell, J. E., Roerig, J., & Crow, S. (2002). Medical complications of psychi­
atric illness. Washington, DC: American Psychiatric Press.
Rathus, J. H., & Miller, A. L. (2015). DBT® Skills Manual for Adolescents. New York: Guil­
ford Press.
Ritschel, L. A., Lim, N. E., & Stewart, L. M. (2015). Transdiagnostic applications of DBT
for adolescents and adults. Americal Journal of Psychotherapy, 69(2), 111–128.
Russell, G. F., Szmukler, G. I., Dare, C., & Eisler, I. (1987). An evaluation of family therapy
in anorexia nervosa and bulimia nervosa. Archives of General Psychiatry, 44(12), 1047–
1056.
Sachs, K. V., Harnke, B., Mehler, P. S., & Krantz, M. J. (2016). Cardiovascular complica­
tions of anorexia nervosa: A systematic review. International Journal of Eating Disorders,
49, 238–248.
Safer, D. L., Couturier, J. L., & Lock, J. (2007). Dialectical behavior therapy modified for
adolescent binge eating disorder: A case report. Cognitive and Behavioral Practice, 14(2),
157–167.
Safer, D. L., Robinson, A. H., & Jo, B. (2010). Outcome from a randomized con­
trolled trial of group therapy for binge eating disorder: comparing dialectical behavior
(p. 593)
therapy adapted for binge eating to an active comparison group therapy. Behavior Thera­
py, 41(1), 106–120.
Safer, D. L., Telch, C. F., & Agras, W. S. (2001a). Dialectical behavior therapy adapted for
bulimia: A case report. International Journal of Eating Disorders, 30(1), 101–106.
Safer, D. L., Telch, C. F., & Agras, W. S. (2001b). Dialectical behavior therapy for bulimia
nervosa. American Journal of Psychiatry, 158(4), 632–634.
Safer, D. L., Telch, C. F., & Chen, E. Y. (2009). Dialectical behavior therapy for binge eat­
ing and bulimia. New York: Guilford Press.
Salbach, H., Klinkowski, N., Pfeiffer, E., Lehmkuhl, U., & Korte, A. (2007). Dialectical be­
havior therapy for adolescents with anorexia and bulimia nervosa (DBT-AN/BN): A pilot
study. der Kinderpsychologie und Kinderpsychiatrie, 56, 91–108.
Salbach-Andrae, H., Bohnekamp, I., Pfeiffer, E., Lehmkuhl, U., & Miller, A. L. (2008). Di­
alectical behavior therapy of anorexia and bulimia nervosa among adolescents: A case se­
ries. Cognitive and Behavioral Practice, 15(4), 415–425.
Page 22 of 24
PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). © Oxford University Press, 2022. All Rights
Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in
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Subscriber: University of Pennsylvania; date: 25 January 2022
DBT for Eating Disorders: An Overview
Stein, D., Lilenfeld, L. R., Wildman, P. C., & Marcus, M. D. (2004). Attempted suicide and
self-injury in patients diagnosed with eating disorders. Comprehensive Psychiatry, 45,
447–451.
Svaldi, J., Griepenstroh, J., Tuschen-Caffier, B., & Ehring, T. (2012). Emotion regulation
deficits in eating disorders: A marker of eating pathology or general psychopathology?
Psychiatry Research, 197(1), 103–111.
Swan-Kremeier, L. A., Mitchell, J. E., Twardowski, T., Lancaster, K., & Crosby, R. D.
(2005). Travel distance and attrition in outpatient eating disorders treatment. Internation­
al Journal of Eating Disorders, 38(4), 367–370.
Telch, C. F., Agras, W. S., & Linehan, M. M. (2000). Group dialectical behavior therapy for
binge-eating disorder: A preliminary, uncontrolled trial. Behavior Therapy, 31(3), 569–
582.
Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavior therapy for binge
eating disorder. Journal of Consulting and Clinical Psychology, 69(6), 1061.
Treasure, J., Sepulveda, A. R., MacDonald, P., Whitaker, W., Lopez, C., Zabala, M., … Todd,
G. (2008). The assessment of the family of people with eating disorders. European Eating
Disorders Review, 16(4), 247–255.
Wallier, J., Vibert, S., Berthoz, S., Huas, C., Hubert, T., & Godart, N. (2009). Dropout from
inpatient treatment for anorexia nervosa: critical review of the literature. International
Journal of Eating Disorders, 42(7), 636–647.
Warren, C. S., Schafer, K. J., Crowley, M., & Olivardia, R. (2012). A qualitative analysis of
job burnout in eating disorder treatment providers. Eating Disorders: The Journal of
Treatment & Prevention, 20(3), 175–195.
Wilfley, D. E., Friedman, M. A., Dounchis, J. Z., Stein, R. I., Welch, R. R., & Ball, S. A.
(2000). Comorbid psychopathology in binge eating disorder: Relation to eating disorder
severity at baseline and following treatment. Journal of Consulting and Clinical Psycholo­
gy, 68, 641–649.
Williams, S., & Reid, M. (2010). Understanding the experience of ambivalence in anorexia
nervosa: The maintainer’s perspective. Psychology & Health, 25(5), 551–567.
Wilson, G. T., Grilo, C. M., & Vitousek, K. M. (2007). Psychological treatment of eating dis­
orders. American Psychologist, 62, 199–216.
Wiser, S., & Telch, C. F. (1999). Dialectical behavior therapy for binge‐eating disorder.
Journal of Clinical Psychology, 55(6), 755–768.
Wisniewski, L., & Ben‐Porath, D. D. (2005). Telephone skill‐coaching with eating‐
disordered clients: clinical guidelines using a DBT framework. European Eating Disorders
Review, 13(5), 344–350.
(p. 594)
Page 23 of 24
PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). © Oxford University Press, 2022. All Rights
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DBT for Eating Disorders: An Overview
Wisniewski, L., Bhatnagar, K., & Warren, M. (2013). Using dialectical behavior therapy
for the treatment of eating disorders: A model for DBT enhanced CBT. In I. Dancyger & V.
Fornari (Eds.), Evidence-based treatments for eating disorders: Children, adolescents and
adults (pp. 275–290). New York: Nova Science Publishers.
Wisniewski, L., & Kelly, E. (2003). The application of dialectical behavior therapy to the
treatment of eating disorders. Cognitive and Behavioral Practice, 10(2), 131–138.
Wisniewski, L., Safer, D., and Chen, E. (2007). Dialectical Behavior Therapy and Eating
Disorders. In L. Dimeff & K. Koerner (Eds.), Dialectical behavior therapy in clinical prac­
tice (pp. 174–221). New York: Guilford Press.
Wonderlich, S. A., Mitchell, J. E., Peterson, C. B., and Crow, S. (2001). Integrative cogni­
tive therapy for bulimic behavior. In R. Striegel-Moore & L. Smolak (Eds.), Eating disor­
ders: Innovative directions in research and practice (pp. 173–195). Washington, DC:
American Psychological Association.
Kelly Bhatnagar
Kelly A. C. Bhatnagar, The Emily Program, Department of Psychological Sciences,
Case Western Reserve University, USA
Caitlin Martin-Wagar
Caitlin Martin-Wagar, The Emily Program, Department of Psychology, University of
Akron, USA
Lucene Wisniewski
Lucene Wisniewski, LLC, Department of Psychological Sciences, Case Western Re­
serve University, USA
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