Dialectical Behavior Therapy in the Treatment of Bulimia and Binge Eating Disorder: Research

1
Dialectical Behavior Therapy in the Treatment of
Bulimia and Binge Eating Disorder Research
Practical Applications

• Debra L. Safer, MD
• Department of Psychiatry and Behavioral Sciences
• Stanford University School of Medicine

2
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?

3
Outline (cont)

• 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

4
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)

5
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)

6
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

7
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

8
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

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CBT Model

• Low self-esteem
• Overvaluation of weight and shape
• Strict dieting
• Binge eating

10
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

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Affect Regulation ModelBinge Eating
temporary relief from negative affect

• Linehans 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

12
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)

13
Orientation to DBT Model for Maladaptive Emotion
Regulation
Event (Internal or External)
Increased anxiety, fear, sense of overwhelm
Deficits in adaptive emotion regulation skills
Low expectancy for mood regulation
Negative emotion/ need for emotion regulation
Urgency to stop emotion escalation
Overlearned, impulsive, maladaptive, mood
regulation behavior BINGE EATING PURGING
Decreased self-esteem, neg self-view. Increased
guilt and shame.
Avoidance of adaptive mood regulation
Temporary decrease in distress
14
Goals of Treatment, Goals of Skills Training, and
Treatment Targets
Treatment Goals Stop Binge Eating and Purging
Treatment Targets Path to
Mindful Eating 1. Stop any behavior that
interferes with treatment 2. Stop Binge Eating
and Purging 3. Eliminate mindless eating 4.
Decrease cravings, urges, and preoccupation with
food 5. Decrease capitulating (deciding its
too late to change from binge eating and
purging) 6. Decrease Apparently Irrelevant
Behaviors (AIBs) (setting oneself up for binge
eating by pretending It doesnt matter (e.g.
buying candy for someone else)
15
DBT Brief Overview

• DBT core theories
• Dialectical Philosophy
• Behavioral Zen
  practice
• Science

16
DBT Skills Wise Mind

• States of Mind
• Reasonable Wise
  Emotional
• Mind Mind
  Mind

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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

18
Modification of DBT concepts/skills from DBT for
Substance Abuse

• Dialectical Abstinence
• Alternate Rebellion
• Urge Surfing

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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)

20
DIARY CARD
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Behavioral 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?

22
Randomized Trial of DBT for BEDChanges in
Objective Binge Eating
Abstinent
Telch, Agras, Linehan Dialectical
behavior therapy for binge eating disorder. J of
Consult Clin Psychol 2001 691061-1065
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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

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Demographics

• Age
• Mean 34.19 years old, range18-54
• BMI
• Mean 23.67, range (21.65 - 42.09)
• Ethnicity
• 87 white, 10Asian, 3Latino, 0 black
• Marital Status
• 39single, 39married, 19divorced, 3widowed

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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 gt 24 binge episodes and purge
  episodes/3mo)
• 81 (25 of 31 subjects)

26
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)

27
Changes in Median Binge Episodes DBT versus
Wait-list (p lt 0.001) and 3 month post-tx
follow-up
30
25
Median binge episodes (Over Prior 4 weeks)
20
15
DBT
Wait- list
10
5
0
Pre
Post
3 month
Assessment period
28
Changes in Median Purge Episodes DBT versus
Wait-list (p lt 0.002) and 3 month post-tx
follow-up
Median purge episodes (Over Prior 4 weeks)
Assessment period
29
Negative Mood Regulation (p 0.022)
100.0
98.1
97.7
96.1
90.0
80.0
81.3
NMR Score
70.0
60.0
50.0
40.0
DBT-Pre
DBT-Post
Wait-list Pre
Wait-list Post
30
Emotional Eating Scale (EES)
Anger/Frustration, Anxiety,
Depression, subscale(p lt 0.006) (
p lt0.006) ( p lt 0.008)
EES Score
DBT-Pre
DBT-Post
Wait-list Pre
Wait-list Post
31
Impulsivity (MPQ) (p lt 0.170)
18.0
16.0
16.4
16.0
15.4
15.6
MPQ Score
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0
DBT-Pre
DBT-Post
Wait-list Pre
Wait-list Post
32
Rosenberg Self-Esteem (p lt 0.107)
40.0
35.0
RSE Score
30.0
26.4
25.0
25.4
25.6
23.5
20.0
15.0
10.0
5.0
0.0
DBT-Pre
DBT-Post
Wait-list Pre
Wait-list Post
33
Comparison of CBT, IPT, DBT for BN
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
34
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 158632-634
• Remaining issues Compare DBT with CBT,
  medications, or as an add-on for CBT
  nonresponders? How to improve maintenance?

35
Predictors of Relapse Following
SuccessfulDialectical Behavior Therapy for
Binge Eating Disorder
36
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

37
PARTICIPANTS

• 32 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)

38
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.

39
PARTICIPANT CHARACTERISTICS

• Age 49.2 (range 29 - 64 y.o. SD 9.9)
• Educational status (75 completed gt4 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 (SD12.4)
• Duration of binge eating problems29.7 (6.9)

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Predictors of Relapse in Eating Disorders

• Bulimia Nervosa
• dissatisfaction with body image
• self-esteem
• degree of overvalued ideas regarding weight and
  shape
• greater severity of eating disorder pathology
• restraint
• length of continuous abstinence response during
  tx
• younger age
• motivation for change
• Binge Eating Disorder None to date
• But earlier age of binge eating onset predicted
  poor outcome at end of treatment

41
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)

42
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)

43
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)

44
Independent variables not predicting relapse
versus maintenance
45
Comparison between participants with early versus
late binge eating onset
46
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

47
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
• BUT
• Individuals 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

48
Comparison 5 individual items of EDE Restraint
subscale
49
Two Aspects of Restraint

• Cognitive restraint
• the conscious attempt to restrict ones intake
  for the purpose of weight loss, irrespective of
  actual eating practices
•  
• Overt behavioral restraint
• the successful limitation of caloric intake

50
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

51
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

52
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

53
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

54
WEIGHT CHANGES

• Mean weight loss over the initial 20 week course
  of treatment was 1.9 kg, or 4.2 pounds (SD12.13)
  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)

55
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

56
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 (lt 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