Transcript No Slide Title

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
Outline
• Introduction and overview for Bulimia Nervosa and BED
– DSM-IV criteria for binge episode, BN, & BED
• Why develop a new treatment for eating disorders?
• What IS DBT?
• How is DBT adapted for the treatment of eating
disorders?
Outline: (con’t)
• Research findings from randomized control trials
adapting DBT for Bulimia Nervosa & Binge
Eating Disorder
• Predictors of Relapse After Successful Treatment
with DBT for BED
• Discussion/Questions
DSM-IV Criteria: Binge Episode
• Eating “definitely larger” amounts of food over a
discrete time period (e.g. within 2 hrs) than “most
people would eat in a similar period under similar
circumstances”
• Sense of lack of control during episode (e.g.
cannot stop or control what or how much one
eats)
• Source: DSM-IV (l994)
DSM-IV Criteria: Bulimia Nervosa
• Recurrent episodes of binge eating
• Recurrent compensatory behavior to prevent
weight gain (e.g. self-induced vomiting,
laxatives, diuretics, enemas, or other
medications; fasting, or excessive exercise)
• Occur at least 2x/wk for 3 months
• Self evaluation is unduly influenced by body
shape and weight
• Source: DSM-IV (l994)
DSM-IV Criteria: Binge Eating Disorder
• Recurrent episodes of binge eating (at least 2x/wk
for 6 months)
• Causes marked distress
• Not accompanied by compensatory behaviors
such as in bulimia (e.g. purging, fasting, excessive
exercising)
• Source: DSM-IV (l994) Appendix for Further Study
BED Criteria
(continued)
• Binge episodes associated with ≥ 3 of following:
– Eating much more rapidly than normal
– Eating until feeling uncomfortably full
– Eating large amounts of food when not physically
hungry
– Eating alone because of being embarrassed by how
much one is eating
– Feeling disgusted with oneself, depressed, or very
guilty after overeating
BED Versus Non-BED Overweight
• Greater psychopathology (e.g. depression,
anxiety, substance abuse, personality disorders)
• Higher rates of self-loathing, disgust over body
size, interpersonal sensitivity
• Greater risk for attrition during weight loss
treatment
• More rapid regain of lost weight
• Sources: Marcus et al, l990; Yanovski et al, l993
CBT Model
Low self-esteem
Overvaluation of weight and shape
Strict dieting
Binge eating
Treatment Targets Given Core
Assumptions of CBT
• REGARDING ROLE OF DIETING
– Treatment includes behavioral focus on 3 meals/day + 2 snacks
• REGARDING OVERVALUATION OF WEIGHT AND
SHAPE
– Cognitive techniques aim to modify these dysfunctional thoughts
about weight /shape
• OUTCOME AFTER TREATMENT WITH CBT?
– ON AVERAGE 50% OF PATIENTS REMAIN SYMPTOMATIC
Affect Regulation Model
Binge Eating
temporary relief from negative affect
• Linehan’s Dialectical Behavior Therapy (DBT)
– Emotional dysregulation seen as core problem in borderline
personality disorder (BPD)
Binge Eating
relief from negative affect
IN THE SAME WAY AS
Impulsive Behaviors (e.g. self-mutilation)
relief in BPD
Support for Affect Regulation
Model in Binge Eating
– Negative mood is most frequently cited precipitant of
binge eating (Polivy & Herman, l993)
– Inducing a negative mood compared to a neutral mood
in the laboratory significantly increased loss of control
over eating and the occurrence of self-defined binges
in women with BED (Telch & Agras, l996; Agras &
Telch, l998)
– Negative mood in bulimics treated with CBT predicted
a lower success rate (by more than 50%) than bulimics
who were purely restrictive (Stice & Agras, l999)
Orientation to DBT Model for Maladaptive
Emotion Regulation
Event
(Internal or External)
Negative
emotion/
need for
emotion
regulation
Deficits
in
adaptive
emotion
regulation
skills
Low
expectancy
for mood
regulation
Increased
anxiety,
fear, &
sense of
overwhelm
Urgency
to stop
emotion
escalation
Overlearned, impulsive,
maladaptive, mood regulation
behavior: BINGE EATING
& PURGING
Decreased self-esteem, neg
self-view. Increased guilt
and shame.
Temporary decrease
in distress
Avoidance of adaptive mood
regulation
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 it’s too late to
change from binge eating and purging)
6. Decrease “Apparently Irrelevant Behaviors” (AIBs)
(setting oneself up for binge eating by pretending “It
doesn’t matter” (e.g. buying candy for “someone else”)
DBT
Brief Overview
DBT core theories
Dialectical Philosophy
Behavioral
Science
Zen practice
DBT Skills: Wise Mind
States of Mind
Reasonable
Mind
Wise
Mind
Emotional
Mind
DBT Skills-Mindfulness
• Diaphragmatic Breathing (attention to the
breath)
• Mindful eating
— Observe and describe the sensory experience
— Observe and describe thoughts and feelings
• Non-judgmentally
• One-mindfully
• Effectively
Modification of DBT concepts/skills
from DBT for Substance Abuse
• Dialectical Abstinence
• Alternate Rebellion
• Urge Surfing
Increase Skillful Emotion Regulation
Behaviors
MINDFULNESS SKILLS (WEEKS 1-5) to increase
awareness and experience of the current moment without selfconsciousness 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)
Day
Mon
Tues
Wed
Thur
Fri
Sat
Sun
Urge to
Binge
(1-6)
DIARY
CARD
#
Anger Fear Sad Pride
Episodes
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?
Randomized Trial of DBT for BED:
Changes in Objective Binge Eating
100
90
80
70
%
60
Abstinent
50
40
30
20
10
0
DBT
Waitlist
Pre
Post
3-mth
follow-up
6-mth
follow-up
Telch, Agras, & Linehan: Dialectical behavior therapy for binge eating disorder. J of Consult Clin Psychol 2001; 69:1061-1065
DBT for Bulimia Nervosa
• OBJECTIVES
– To develop and standardize a 20 session manual-based
therapy applying the emotion regulation skills of DBT
to the treatment of bulimia nervosa
– To pilot a randomized clinical trial to test the efficacy
of this treatment in reducing rates of binge eating and
purging
Demographics
• Age
– Mean= 34.19 years old, range=18-54
• BMI
– Mean= 23.67, range (21.65 - 42.09)
• Ethnicity
– 87%= white, 10%=Asian, 3%=Latino, 0%= black
• Marital Status
– 39%=single, 39%=married, 19%=divorced,
3%=widowed
Severity of Bulimic Symptoms
• Number of years with bulimic symptoms
– 12 years (range 6 months-30 years)
• Age when began bulimic behaviors
– 22 y.o. (range 14 1/2 - 41 1/2 y.o.)
• Average # binge episodes in past 4 weeks
– 28 (range 0-75)
• Average # purge episodes in past 4 weeks
– 56 (range 4-330)
• Percentage meeting DSM-IV criteria for bulimia nervosa
(= or > 24 binge episodes and purge episodes/3mo)
– 81% (25 of 31 subjects)
OUTCOME MEASURES
•
•
•
•
•
•
•
Eating Disorders Examination (EDE)
Negative Mood Regulation (NMR)
Beck Depression Inventory (BDI)
Emotion Eating Scale (EES)
Minnesota Impulsivity Scale (MPQ)
Positive and Negative Affect Schedule (PANAS)
Rosenberg Self-Esteem Scale (RSE)
Changes in Median # Binge Episodes:
DBT versus Wait-list (p < 0.001)
and 3 month post-tx follow-up
30
25
Median # 20
binge
episodes
15
(Over
Prior 4
10
weeks)
DBT
Waitlist
5
0
Pre
Post
3 month
Assessment period
Changes in Median # Purge Episodes:
DBT versus Wait-list (p < 0.002)
and 3 month post-tx follow-up
40
35
Median
# purge
episodes
(Over
Prior 4
weeks)
30
25
20
DBT
15
Waitlist
10
5
0
Pre
Post
3 month
Assessment period
Negative Mood Regulation
(p = 0.022)
100.0
98.1
96.1
90.0
80.0
NMR
Score
97.7
81.3
70.0
60.0
50.0
40.0
DBT-Pre
DBT-Post
Wait-list Pre
Wait-list Post
Emotional Eating Scale (EES):
Anger/Frustration,
Anxiety,
(p < 0.006)
Depression, subscale
( p <0.006)
( p < 0.008)
3.0
2.9
2.5
EES
Score
2.0
2.7
2.7
2.7
2.1
2.1
2.1
2.6
2.6
2.0
1.8
1.5
1.3
1.0
0.5
0.0
DBT-Pre
DBT-Post
Wait-list Pre
Wait-list Post
Impulsivity (MPQ)
(p < 0.170)
18.0
16.0
16.4
16.0
15.4
15.6
MPQ 14.0
Score 12.0
10.0
8.0
6.0
4.0
2.0
0.0
DBT-Pre
DBT-Post
Wait-list Pre
Wait-list Post
Rosenberg Self-Esteem
(p < 0.107)
40.0
RSE
Score
35.0
30.0
26.4
25.0
25.6
25.4
23.5
20.0
15.0
10.0
5.0
0.0
DBT-Pre
DBT-Post
Wait-list Pre
Wait-list Post
Comparison of CBT, IPT, & DBT
for BN
% abstinent
Intent to treat
% abstinent
Completers
% Drop-out N =
CBT
29
45
28
110
IPT
6
8
24
110
DBT
28.5
28.5
0
16
Agras WS, Fairburn CG, Walsh T, Wilson GT, & Kraemer HC. A multicenter comparison of cognitive-behavioral therapy and
interpersonal therapy for bulimia nervosa. Arch Gen Psychiatry, 2000: 57: 4590466
Conclusions of Study
• A pilot study of a 20 week manualized treatment
adapting DBT for bulimic symptoms shows
promising results with significant decreases in
binge/purge behavior compared to wait-list
controls. Safer DL, Telch CF, Agras WS. Dialectical
Behavior Therapy for Bulimia Nervosa. American Journal
of Psychiatry. 2001; 158:632-634
• Remaining issues: Compare DBT with CBT,
medications, or as an add-on for CBT
nonresponders? How to improve maintenance?
Predictors of Relapse Following Successful
Dialectical Behavior Therapy for
Binge Eating Disorder
Binge Eating Disorder
 A pattern of recurrent episodes of consuming large
amounts of food in which an individual experiences
loss of control
 Without the compensatory behaviors seen in
Bulimia Nervosa
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)
Inclusion Criteria for Participation
in Study
 Achievement of abstinence at the end of 20 weeks
of DBT treatment Abstinence was defined as no
binge episodes reported in the 1 month prior to
assessment.
 Availability of 6-month follow-up data.
PARTICIPANT CHARACTERISTICS
 Age= 49.2 (range: 29 - 64 y.o.; SD = 9.9)
 Educational status (75% completed >4 years of
college)
 Married (59.4%)
 Caucasian (90.6%)
 BMI at baseline= 37.4 (SD = 6.9)
 Age of onset of binge eating = 20.6 (SD=12.4)
 Duration of binge eating problems=29.7 (6.9)
Predictors of Relapse in Eating Disorders
 Bulimia Nervosa:
 dissatisfaction with body 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
Hypothesized Predictors of
Relapse in BED
• Higher dietary restraint scores
• Higher levels of shape and weight concerns
• Higher levels of emotional eating
• Lower levels of self-esteem
• Higher body mass index (kg/m2)
• Earlier age of onset for binge eating (at or before age
16)
Measures
• Eating Disorder Examination (Fairburn & Cooper, 1993)
 Restraint subscale score
 Average of the Weight and Shape Concerns subscales
• Emotional Eating Scale (Arnow, Kenardy, & Agras, 1995)
• Rosenberg Self Esteem Scale (RSE; Rosenberg, 1979)
• Questionnaire on Eating and Weight Patterns
(Spitzer et al, 1992)
TWO PREDICTORS OF RELAPSE
AT 6 MONTH FOLLOW-UP
1) Early onset of binge eating (beginning
binge eating at or before age 16)
 77.8% who relapsed had an early onset versus 28.6%
of those who maintained abstinence had an early
onset (ES= 2.17)
2) Higher EDE Restraint subscale scores
 Higher post-treatment EDE Restraint subscale
scores (1.8 versus 1.0, ES = 0.86)
Independent variables not predicting
relapse versus maintenance
Predictor
EDE average
Weight/Shape
Concerns
Relapsed Maintained
at 6 mo Abstinence
2.2
2.3
EES post-tx
2.0
1.7
Rosenberg
Self-Esteem
BMI post-tx
32.9
31.3
36.5
36.7
Comparison between participants with
early versus late binge eating onset
GROUP
Age at first diet
when lost 10 lb
Age first overwt
by 10 lb as child
or 15 lb as adult
Relapsed at 6
months
EARLY
BINGE
ONSET
14.3
LATE
BINGE
ONSET
25.9
P value
0.002
12.9
18.8
0.104
53.8% (7/13) 11.8% (2/17) 0.037
Importance of Early Age of Onset in Relation to
Treatment Outcome
Extends a study by Agras and colleagues (1995)
 Onset of binge eating before the age of 16 years was
a prognostic indicator of poor treatment outcome in
BED
 Present report extends this finding to individuals with
BED who have an early onset of binge eating, recover
by the end of treatment, and then relapse
Role of dietary restraint in BED is unclear
 The effects of dietary restraint and acute caloric deprivation
leading to binge eating is well documented in both longitudinal and
experimental studies

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
Comparison 5 individual items of EDE
Restraint subscale
Variable
Maintain
at 6 mo
Effect Size
Food
3.78
Avoidance
1.52
0.88
1.11
0.17
0.70
Avoidance 0.22
of eating
0.04
0.60
Empty
Stomach
0.11
0.39
.18
Restraint
over
eating
3.67
3.44
0.09
Dietary
Rules
Relaps ed
at 6 mo
Two Aspects of Restraint
 Cognitive restraint
the conscious attempt to restrict one’s intake for
the purpose of weight loss, irrespective of actual
eating practices

 Overt behavioral restraint
the successful limitation of caloric intake
BED: Unsuccessful Dieters?
Binge eating in BED may more often be precipitated by
violations of cognitive restraint than physiological
pressures to eat resulting from severe behavioral
restriction
Individuals with BED, who are frequently overweight, do
not appear to consistently behaviorally restrict between
binge eating episodes as do individuals with BN
How does restraint decrease by the end of
treatment if rules regarding food are not
addressed specifically?
 DBT advocates a focus on tolerating the
underlying negative emotions that participants
attempt to avoid through binge eating
Through teaching nonjudgmental acceptance of
emotions, emotionally charged food rules may
decrease
Practice of Mindful Eating may help reduce
chronic dieters’ restrictive mindset
Limitations of Study
 Small sample size and subsequent limited power
preclude definitive statements regarding predictors of
relapse
 Other potential predictors may have been missed
 Wider applicability is limited by sample
 Women only
 Exceptionally well educated sample
 The 6 month follow-up period is brief considering the
chronic nature of binge eating disorder
Future Directions for Research on
Predictors of Relapse in BED
•Alter frequency of sessions
–Allow 2 weeks between meetings to allow more
time to “practice” relapse
•Refine and/or add skills to target mindful
eating, nonjudgmental acceptance of body, etc
•Chart restraint scores every week and during
follow-up.
– Target those with higher scores
WEIGHT CHANGES
 Mean weight loss over the initial 20 week course of
treatment was 1.9 kg, or 4.2 pounds (SD=12.13) for all
participants
 At 6 month follow-up, the 23 (71.9%) participants who
maintained abstinence had lost an additional 3.3 kg or
7.2 pounds (SD = 8.6)
 The 9 (28.1%) who relapsed lost an additional 0.7 kg, or
1.5 pounds (SD = 3.0)
Predictors of Relapse Following
Successful Dialectical Behavior
Therapy for Binge Eating Disorder
Safer DL, Lively TJ, Telch CF, Agras WS.
International Journal of Eating Disorders.
2002; 32: 155-163
SUMMARY
• CBT, most studied treatment for BN and BED,
leaves some patients symptomatic after treatment
• DBT, based on the Affect Regulation Model for
disordered eating is a promising manual-based
therapy for BN and BED
• Earlier age of onset (< 16 y.o.) and higher posttreatment 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