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

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

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

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  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: (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

  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

  9. 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

  11. Affect Regulation ModelBinge 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

  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 DBTModel 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 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”)

  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

  17. 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/skillsfrom DBT for Substance Abuse • Dialectical Abstinence • Alternate Rebellion • Urge Surfing

  19. Increase Skillful Emotion Regulation Behaviors MINDFULNESS SKILLS (WEEKS 1-5)toincrease 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

  21. 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 BED:Changes in Objective Binge Eating % Abstinent Telch, Agras, & Linehan: Dialectical behavior therapy for binge eating disorder. J of Consult Clin Psychol 2001; 69:1061-1065

  23. 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

  24. 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

  25. 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)

  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 < 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 < 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. 3.0 2.9 2.7 2.7 2.6 2.6 2.7 2.5 2.1 2.1 2.1 2.0 2.0 1.8 1.5 1.3 1.0 0.5 0.0 Emotional Eating Scale (EES): Anger/Frustration, Anxiety, Depression, subscale(p < 0.006) ( p <0.006) ( p < 0.008) EES Score DBT-Pre DBT-Post Wait-list Pre Wait-list Post

  31. Impulsivity (MPQ) (p < 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 < 0.107) 40.0 35.0 RSE Score 30.0 25.0 26.4 25.4 25.6 23.5 20.0 15.0 10.0 5.0 0.0 DBT-Pre Wait-list Pre Wait-list Post DBT-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; 158:632-634 • 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 >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)

  40. 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 one’s 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

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