Eating Disorders

The Journal of Treatment & Prevention

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Dialectical behavioral therapy: an update and

review of the existing treatment models adapted
for adults with eating disorders

Denise Ben-Porath, Florencia Duthu, Tana Luo, Fragiskos Gonidakis, Emilio J.

Compte & Lucene Wisniewski

To cite this article: Denise Ben-Porath, Florencia Duthu, Tana Luo, Fragiskos Gonidakis, Emilio
J. Compte & Lucene Wisniewski (2020) Dialectical behavioral therapy: an update and review of
the existing treatment models adapted for adults with eating disorders, Eating Disorders, 28:2,
101-121, DOI: 10.1080/10640266.2020.1723371

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EATING DISORDERS
2020, VOL. 28, NO. 2, 101–121
https://doi.org/10.1080/10640266.2020.1723371

Dialectical behavioral therapy: an update and review of

the existing treatment models adapted for adults with
eating disorders
Denise Ben-Poratha, Florencia Duthub, Tana Luoc, Fragiskos Gonidakis d
,
Emilio J. Compte b,e,f, and Lucene Wisniewskig,h
a
Department of Psychology, John Carroll University, University Heights, Ohio, USA; bDBT-Eating
Disorders Team, Fundación Foro, Buenos Aires, Argentina; cEating Disorders Center for Treatment and
Research, University of California, San Diego, California, USA; dDepartment of Psychiatry, National and
Kapodistrian University of Athens, Athens, Greece; eSchool of Human and Behavioral Sciences, Favaloro
University, Buenos Aires, Argentina; fResearch Department, Comenzar De Nuevo Treatment Center,
Monterrey, México; gDepartment of Psychological Sciences, Case Western Reserve University,
Cleveland, Ohio, USA; hCenter for Evidence Based Treatment Ohio, Shaker Heights, Ohio, USA

ABSTRACT
Despite the effectiveness of CBT in reducing shape/weight concerns and
dietary restraint, research suggests that patients considered recovered
may still exhibit emotional difficulties related to eating disorders (EDs).
Dialectical behavior therapy (DBT) has been adapted for a variety of
mental disorders characterized by emotion dysregulation and, more
recently, for EDs specifically. The current review found that the majority
of the research studies employed one of the following three adaptations
of DBT for EDs: The Stanford Model, Radically Open-DBT (RO-DBT), or
Multidiagnostic ED-DBT (MED-DBT). Therefore, this review sought to
review and update the empirical research on each adaptation and (2)
offer preliminary recommendations for when and which adaptation of
DBT to use when treating adults with EDs. Findings from the empirical
literature on DBT and EDs indicate that the Stanford Model has the most
rigorous and numerous studies demonstrating efficacy and effectiveness
in those diagnosed with binge eating disorder. Fewer studies have been
conducted using the Stanford Model with bulimia nervosa; therefore,
less strong assertions can be made about DBT with those diagnosed
with bulimia. The MED-DBT model has been evaluated in several open
trials within higher levels of care with promising results, but the lack of
randomized clinically-controlled trials prevents a definitive statement
about its efficacy. Finally, research on applying the RO-DBT model to
anorexia-nervosa, restricting subtype is in its infancy, prohibiting solid
conclusions or recommendations regarding its efficacy or effectiveness.

Clinical implications
● Evidence for adaptations for Eating Disorders in adults is presented.
● Findings across research designs and treatment settings are discussed.
● Eating Disorder-Dialectical Behavior Therapy adaptations guidelines
suggested.

CONTACT Denise Ben-Porath [email protected] John Carroll University, 1 Carroll Blvd, University
Heights, OH 44118, USA
© 2020 Taylor & Francis
102 D. BEN-PORATH ET AL.

Dialectical behavior therapy (DBT), was originally developed to treat highly

suicidal, self injurious individuals diagnosed with borderline personality disorder
(BPD) (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991). Because of the
success of DBT in addressing deficits in emotion regulation in those with BPD, it
has been applied to comorbidly diagnosed individuals with ED and BPD with
promising results (Ben-Porath, Wisniewski, & Warren, 2009; Chen, Matthews,
Allen, Kuo, & Linehan, 2008; Kröger et al., 2010; Palmer et al., 2003). In fact,
some theorists have argued that ED symptoms represent a maladaptive method
to regulate negative affect (Heatherton & Baumeister, 1991; Safer, Telch, & Agras,
2001; Safer, Telch, & Chen, 2009; Telch, Agras, & Linehan, 2000, 2001), and
several studies have demonstrated that negative mood states are reduced in
women after a binge eating episode (Polivy & Herman, 1993).
Thus, some have suggested that eating disorder (ED) patients present with
issues related to emotional undercontrol, such as those diagnosed with binge
eating disorder (BED) and bulimia nervosa (BN) who use bingeing and/or
purging to regulate emotions (Telch et al., 2000), while other researchers have
posited that some ED patients present with emotional overcontrol, such as those
diagnosed with anorexia nervosa (AN), who may restrict food to regulate affect
(Hempel, Vanderbleek, & Lynch, 2018). While symptom presentation may vary
amongst ED subtypes, difficulties in affect regulation appear to be a core problem
for all who struggle with EDs, and, as such, there has been a growing interest in
applying DBT to individuals diagnosed with EDs.
Bankoff, Karpel, Forbes, and Pantalone (2012) conducted the first systematic
review of the empirical literature on DBT for EDs. Their review consisted of 13
peer- reviewed articles published between the years of 2000 to 2011. Collectively
the reviewed studies indicated that DBT is effective in reducing ED behaviors.
While fewer studies in the review examined abstinence rates (defined as refraining
from binging or purging for one month), those that did found encouraging
findings, with rates ranging from 29% to 89% at post treatment. Data examining
individuals diagnosed with comorbid BPD and ED found similar results, with the
studies demonstrating a reduction in ED symptoms and remission rates ranging
from 33% to 50%. Findings were equivocal with respect to improvement in mood
symptoms and social functioning, suggesting that the role of affect regulation in
maintaining ED symptoms is less well understood. In a meta-analysis of rando-
mized controlled trials of third-wave behavioral therapies, including DBT,
Linardon, Fairburn, Fitzsimmons-Craft, Wilfley, and Brennan (2017) concluded
that DBT was “possibly efficacious” for the treatment of BN and BED. With slightly
broader inclusion criteria, Lenz, Taylor, Fleming, and Serman (2014) evaluated
nine studies utilizing between and within-subjects designs. Both between subjects
design studies (n = 4) and within-subjects design studies (n = 4) indicated a large
effect size with respect to eating disorder symptoms and a medium effect size with
respect to depression symptoms. Likely a result of the small sample size (n = 8), the
 EATING DISORDERS 103

one remaining study (Chen et al., 2008) of the nine yielded a small effect size on
eating disorder symptoms.
In sum, the research for DBT in those with EDs is still in its nascent stages
as no study has yet to conduct a randomized trial comparing DBT to an
established treatment for EDs such as cognitive behavioral therapy (CBT) or
interpersonal therapy (IPT). Despite this, the data reviewed do seem to
indicate that DBT is superior to no treatment, is likely efficacious in treating
some ED diagnoses, and may improve psychosocial functioning and mood
symptoms in some patients.
Interpretation of these findings and the application of DBT to EDs is
complex, in part because the majority of the studies published have utilized
adaptations of DBT for EDs. For example, in the Bankoff et al. (2012) review,
12 of the 13 studies reviewed employed an adaptation of DBT for EDs, which
included either the Stanford Model for outpatient BED and BN (DBT-
BED;DBT-BN) or DBT adapted for EDs treated in higher levels of care called
the Multidiagnostic Complex Eating Disorders for DBT Model (MED-DBT;
Federici, Wisniewski, & Ben-Porath, 2012). Since the Bankoff et al. (2012)
review, an additional model, Radically Open-DBT (RO-DBT), has been
developed for those diagnosed with anorexia nervosa, restricting subtype
(AN-R; Lynch et al., 2013).
Thus, a primary aim of the current review is to provide an update to the Bankoff
et al. (2012) review of the literature on DBT and EDs. In an effort to do this, we
searched the electronic database, PsycInfo, using the same terms (e.g., DBT or
dialectical behavior therapy and eating disorder anorexia, bulimia, or binge eating)
that were used in the Bankoff et al. (2012) review. This resulted in 232 articles. We
further narrowed the search by limiting articles from August 2011 (where the
Bankoff et al. review ended) until the present (December 2019). This search
resulted in 138 articles. From these abstracts, like Bankoff et al. (2012), we selected
for inclusion, English-language, peer-reviewed, journals with empirical data for
which the target population was adults diagnosed with EDs. This left 19 remaining
studies. From these, 6 studies were excluded due to the lack of treatment outcome
data (n = 3), confounding treatment interventions intermingled with DBT (n = 2),
or limited information about the treatment (n = 1). This left 13 studies. By
searching the reference section from selected articles, four additional studies
were found (Brown et al., 2018, 2019a; 2019b; Carter, Kennedy, Singleton, Van
Wijk, & Heath, 2019) bringing the count up to 17. Similar to Bankoff et al. (2012),
with the exception of two studies (Courbasson, Nishikawa, & Dixon, 2012;
Navarro-Haro et al., 2018), all of the remaining 15 articles reviewed used one of
the following adaptations of DBT for EDs: (1) The Stanford Model, (2) RO-DBT,
or (3) DBT-MED.
While these adaptations of DBT to EDs may be necessary to effectively
treat ED symptoms, scientist-practitioners may not know which model to
use, under which circumstances, and for which patients. Therefore, the goal
104 D. BEN-PORATH ET AL.

of this review is to provide a brief overview of each of these three adaptations

and then summarize the empirical research on each since the Bankoff et al.
(2012) review (see Table 1). Given that the studies prior to August 2011 have
already been described in greater depth, they will not be reviewed in detail.
(Interested readers are referred to Bankoff et al., 2012 for a more thorough
review of these previous studies.) A final aim of this review is to offer
preliminary recommendations based upon the current literature for when
and which adaptation of DBT to use when treating adults with EDs.

The stanford model: DBT-BED and DBT-BN

The first and most widely researched DBT adaptation for EDs is what has been
referred to as the Stanford Model for BED and BN or DBT-BED/DBT-BN.
Although CBT has been the treatment of choice for decades with respect to BN
and BED, as many as half the patients treated with CBT do not respond (Haye,
Bacaltchuk, & Stefano, 2009). Several studies indicate that individuals diagnosed
with BED and BN often report engaging in ED behaviors when emotionally
dysregulated (Arnow, Kenardy, & Agras, 1992). Thus, this adaptation, which
proposes that bingeing and/or purging occur as a way to regulate painful affect,
was developed to address emotion regulation deficits found in those with BN
and BED (Linehan & Chen, 2005; Waller, 2003; Wiser & Telch, 1999;
Wisniewski & Kelly, 2003).

Review of the empirical literature on DBT- BED and DBT-BN

Several uncontrolled clinical trials (Chen et al., 2008; Safer, Lively, Telch, &
Agras, 2002; Safer, Telch, Agras, 2001) and randomized clinical trials (RCT;
Safer, Robinson, & Jo, 2010; Safer et al., 2001; Telch et al., 2001) have been
conducted using DBT-BED/BN for adults with EDs. These studies have yielded
promising results, including abstinence from binge eating at rates ranging from
64% to 89% (Safer et al., 2010; Telch et al., 2001), improvements in weight,
shape, and eating concerns (Telch et al., 2001), and quicker response rates in
those assigned to DBT-BED as compared to active comparison group treatment
(ACGT; Safer et al., 2010).
Since the Bankoff et al. (2012) review, five RCTs (Carter, Kennedy, Singleton,
Van Wijk, & Heath, 2019; Chen et al., 2017; Masson, von Ranson, Wallace, &
Safer, 2013; Rahmani, Omidi, Asemi, & Akbari, 2018; Robinson & Safer, 2012),
and three uncontrolled clinical trials (Erb, Farmer, & Mehlenbeck, 2013; Klein,
Skinner, & Hawley, 2012; Mushquash & McMahan, 2015) using DBT with BED
or BN have been conducted. Of these nine studies, eight employed the Stanford
Model for DBT-BED/BN.
Like studies reviewed in Bankoff et al. (2012), findings continue to demon-
strate that DBT is efficacious for those diagnosed with BED. Utilizing DBT-BED,
Table 1. Overview of Studies Examining DBT/BED, MED-DBT, and RO-DBT for ED in Adults since 2011.
Sample
Study Design Size Sample Demographics Treatment/ Setting Outcomes Follow up Results
DBT/BED
Robinson and RCT 101 Mage: 52.2 years; 20 weekly (2h) DBT/BED-group Putative moderators Participants with Avoidant
Safer (2012) 85% female; sessions Vs. Active comparison (demographic variables, Personality Disorder or an
100% BED; group therapy (ACGT). ED & general earlier onset of overweight/
76% Caucasian, 13% Latino, psychopathology). dieting evidenced significantly
5% Asian, 3% African worsened outcome when
American. treated with ACGT versus DBT/
BED.
Klein et al. UCT 5 Mage: 39.6 years; 16-weeks (2-21=2h) DBT/BED- Binge eating and attrition. - Large reductions in the primary
(2012) 100% female; group sessions. outcome of weekly binge
100% with either sub- frequency from pretreatment to
threshold and post-treatment. Attrition was
full-threshold BED or BN; elevated compared with
100% Caucasian. previous efficacy trials.
Erb et al. (2013) Case 3 Mage: 44.3 years; 12-weekly sessions (1 online) of Binge eating frequency 12 months Participants demonstrated
Report 100% female; DBT/BED-based (2h) skills- and eating clinically significant reduction in
100% BED; training group, and addition psychopathology. disordered eating behavior and
33.3% Asian, 33% Caucasian, interpersonal skills. improvements in self-esteem,
33% Hispanic emotion regulation, and quality
of life. Treatment gains were
maintained at follow-up.
Masson et al. Pilot 60 Mage: 42.8 years; DBT guided self-help (DBTgsh) Binge eating episodes 6 months DBTgsh participants reported
(2013) RCT 88.3% female; (orientation session, manual, and and abstinence from significantly fewer binge eating
100% BED; six 20-min support calls over binge eating. episodes and greater rates of
90%-93.1% Caucasian. 13 weeks) Vs. Waiting list. abstinence from binge eating
than controls. At 6-month
follow-up, DBTgsh participants
had improved quality of life and
reduced eating
EATING DISORDERS

psychopathology compared to
baseline.
(Continued )
105
 106

Table 1. (Continued).
Sample
Study Design Size Sample Demographics Treatment/ Setting Outcomes Follow up Results
Mushquash and UCT 11 Mage: 44.6 years; 10 weekly (2h) DBT/BED-group Binge eating severity and - On average participants
McMahan 90.9% female; sessions. eating psychopathology. showed a significant reduction
(2015) 100% patients seeking in binge eating severity from
bariatric services; baseline to post-treatment, but
81.8% Caucasian. not for the remaining variables
on eating psychopathology.
Low dropout rates suggest that
D. BEN-PORATH ET AL.

DBT/BED is acceptable to
patients.
Chen et al. RCT 109 Mage: 38.2 years; 100% Participants received a guided Binge eating frequency 6& Regardless of assigned
(2017) female; 73.4% Caucasian; self-help CBT (cGSH) manual + 4 and attrition 12 months treatment, all participants no
71.6% BED;28.4% BN . sessions (30/min). After session longer met criteria for BED/BN
4, strong responders continued at the end of treatment.
in the cGSH. Weak responders However, early strong
were randomized to either responders treated with cGSH
6 months of DBT or an adapted had faster and greater
CBT treatment (CBT+). reductions in binge episodes as
compared to those in the DBT
or the CBT+ conditions. At a six
and then 12-month follow-up
gains were maintained in all
treatment conditions with no
significant differences among
groups in binge episodes. No
differences were observed in
treatment attrition across
treatment groups
Rahmani et al. RCT 60 Mage: 29.8–31.3 years; 100% 20 DBT/BED-group sessions (2h) Binge eating, weight and - DBT/BED improved BMI, binge
(2018) female; 100% Overweight- twice a week Vs. Waiting list. emotional regulation eating and emotion regulation
BED. ability.
(Continued )
Table 1. (Continued).
Sample
Study Design Size Sample Demographics Treatment/ Setting Outcomes Follow up Results
Carter, Kenny, RCT 71 Mage: 40.2–41 years; 91.7%- 12-week DBT guided self-help Binge eating, ED 3 months There was a significant decrease
Singleton, Van 95.7% female; 100% BED; (DBT-GSH) (30-min/2-week psychopathology, general in binge frequency from pre- to
Wijk, & Heath 91.7%-95.7% Caucasian, initial, 3 biweekly, and final psychological distress, post-treatment that did not
(2019) other 4.3%-8.3%. guided sessions), vs. 12-week and health-related quality differ across groups, which it
active control condition (self- of life. was maintained at follow-up in
esteem and DBT unguided self all three conditions. The pattern
help (SE-USH, DBT-USH). of results for the other outcome
measures was also a significant
improvement in all three
conditions that was maintained
at follow-up, with no
statistically significant across
groups.
RO-DBT
Lynch et al. UCT 47 Mage: 27.1 years; Inpatient Radically Open-DBT Weight, eating - RO-DBT was associated with
(2013) 100% female; (RO-DBT) program (22 weeks psychopathology and significant improvements in
100% AN; average) quality of life weight gain, reductions in ED
94.1% Caucasian. psychopathology and increases
in ED-related quality of life.
Chen et al. Case 6&9 Mage: 32.3–27.6 years; 100% Case Series 1: standard DBT; Case BMI, eating 6 & 12 Case Series 1 and 2 resulted in
(2015). Series female; 100% AN or series 2: DBT augmented with psychopathology. months an increase in BMI and an
subclinical AN; 80% skills addressing over-control. improvement in eating
Caucasian. psychopathology, with larger
effect sizes for Case Series 2.
Adding skills addressing over
controlled emotions and
behaviors may be helpful.
EATING DISORDERS

(Continued )
107
 108

Table 1. (Continued).
Sample
Study Design Size Sample Demographics Treatment/ Setting Outcomes Follow up Results
MED-DBT
Federici and Case 7 Mage: 23.9 years; 6-month Multi-diagnostic ED- ED symptoms, self-harm, - Treatment was associated with
Wisniewski Series 100% female; DBT Outpatient Program (6h/ weight, medical stability, reductions in ED symptoms,
(2013) 100% Multi-diagnostic ED day, 5 days/week) or intensive hospitalizations over the suicidal and self-injurious
Presentations; programming (3h/day, 3–5 days/ course of treatment, behaviors, treatment interfering
100% Caucasian. week). client and clinician behaviors, psychiatric and
D. BEN-PORATH ET AL.

program acceptability. medical hospitalizations, and

clinician burnout.
Ben-Porath et al. UCT 65 Mage: 23.4 years; 5-days per week (6h) CBT-ED Affect regulation, eating - Participants demonstrated
(2014) 100% female; based treatment program, and psychopathology. a significant improvement in
4.6% AN, 29.2% AN with weekly DBT skills-training group their ability to regulate affect.
regular menses, 66.2% BN. (2h). Median length: 20 days. Also, participants showed
a significant increase in weight
gain, reduction in restriction,
bingeing, purging and eating
disordered cognitions.
Brown et al. ND 243 Mage: 26.6 years; 94.7% PHP (up to 6 days/week, 6-10h/ ED behaviors and 3, 6, 12 & Results support the efficacy of
(2018) female; 51.4% AN spectrum, day). Full DBT (2h/week skills- psychopathology, BMI, 24 months PHP across all primary
48.6% BN spectrum; 74.7% group, individual therapy, team depressive symptoms, outcomes variables (BMI, binge/
Caucasian, 5.4% Asian, 1.2% consultation, phone coaching) + and trait anxiety. purge frequency, and ED
African American, 0.4% variety of evidence-based groups psychopathology) from intake
Native American/Alaskan, (applied DBT, RO-DBT, CBT, CBT- to discharge and across follow-
18.3% other (21% identified E). Patients went into IOP before up for AN-R and BN patients. All
as Latino). discharge. Mean length diagnoses demonstrated
89.2 days. significant improvements at
discharge on depression and
anxiety measures, and patients
maintained these
improvements at follow-up
(Continued )
Table 1. (Continued).
Sample
Study Design Size Sample Demographics Treatment/ Setting Outcomes Follow up Results
Brown et al. ND 135 Mage: 25.1 years, 93.3% DBT-based PHP program focused ED psychopathology, - DBT skills use predicted greater
(2019a) female; 29.6% ANR, 11.9% on weight restoration (10h/day, depression symptoms, improvements in ED,
ANBP, 42.9% BN, 3% BED, 6-day/week). Patient went into emotion dysregulation depressive, and emotion
12.6% OSFED; (70.4% mood, IOP before discharge to regular symptoms. dysregulation symptoms from
68.9% anxiety, 3.7% alcohol outpatient care. Mean length treatment admission to
use, & 4.4% SUD); 72.6% 97.1 days. discharge. Notably, early versus
Caucasian, 9.6% Asian, 1.5% later change in skills use was
African American, 16.2% a stronger predictor of
other (17.6% Hispanic). outcome.
Brown et al. ND Mage: 26.63 years; 95% DBT-based PHP program focused Emotion regulation and Mdays until BN patients demonstrated
(2019b) female; 32% ANR, 19% on weight restoration (10h/day, ED symptomology follow up improvements in emotion
ANBP, 49% BN (78.4% mood, 6-day/week). Patients step down assessment regulation from pre to post
75.5% anxiety, 7.5% alcohol to IOP before discharge to post treatment and at follow-up.
use, & 8.7% SUD); 74.9% regular outpatient care. Mean discharge: ANBP and ANR patients
Caucasian, 5.0% Asian, 1.3% length 88.7 days 309.58 demonstrated improvement in
African American, 0.4% emotion regulation from
Native American, other admission to discharge, but did
(18.4%). not maintain improvement at
follow-up; Changes in emotion
regulation were moderately
associated with improvement in
ED pathology at discharge but
not at follow up.
ND = naturalistic design; RCT = randomized control trial; UCT = uncontrolled trial; CBT = cognitive behavioral therapy; CBT-E = Cognitive Behavioral Therapy-Enhanced;
DBT = dialectical behavioral therapy; IOP = intensive outpatient treatment; PHP = partial hospital programs; ED = eating disorder; AN = anorexia nervosa; ANBP = anorexia
nervosa binge/purge subtype; ANR = anorexia nervosa restrictive subtype; BN = bulimia nervosa; BED = binge eating disorders; EDNOS = eating disorders not otherwise specified;
EATING DISORDERS

OSFED = other specified feeding or eating disorder; BPD = borderline personality disorder; MDD = major depressive disorder, PTSD = post-traumatic stress disorder;
SUD = substance use disorder.
109
110 D. BEN-PORATH ET AL.

Rahmani et al. (2018) investigated the efficacy of DBT by randomly assigning 60

individuals diagnosed with BED to either 20 two-hour DBT group sessions twice
a week or to a wait-list control condition. Individuals in the DBT arm of the
study reported significant reductions in binge eating episodes, lower BMIs,
greater improvements in emotion regulation, and better treatment retention as
compared to those in the wait-list condition.
Given the growing body of research on the efficacy of DBT-BED, research-
ers have begun to explore more complex research questions in this popula-
tion such as identifying treatment outcome moderators and differential
treatment response rates to DBT-BED. Toward this end, Robinson and
Safer (2012) sought to explore treatment moderators in a randomized con-
trolled trial in 101 adults diagnosed with BED. Participants were randomly
assigned to 20 group-DBT sessions or an ACGT. Results indicated that
participants with avoidant personality disorder or an earlier onset of diet-
ing/weight issues evidenced significantly worse outcomes when treated with
ACGT vs. DBT-BED.
Investigating the differential treatment effects of DBT and CBT-enhanced
in early-weak responders, Chen et al. (2017) provided four weeks of CBT-
guided self-help (CBTgsh) to women diagnosed with BED or BN. Early-
strong responders continued on in CBTgsh for the remainder of the study.
Those who were identified as early-weak responders (e.g., no appreciable
improvement after 4 sessions of GSH) were randomly assigned to either DBT
or CBT-enhanced. Results indicated that early-strong responders who
received CBTgsh had somewhat quicker and greater reductions in objective
binge days compared to those who were randomized to DBT or CBT-
enhanced, but these differences were small. At the end of treatment, early-
weak responders in both DBT and CBT-enhanced exhibited reductions in
objective binge days, but these improvements were smaller than those found
in early-strong responders who received CBTgsh. While CBTgsh overall was
superior to DBT and CBT-enhanced, these findings may have been due to
selection bias in the CBTgsh group.
Given the success of DBT-BED, many have begun to explore translational
research with DBT-BED by implementing self-help interventions guided by
the Stanford Model. For example, Masson et al. (2013) tested the effective-
ness of a 13-week DBT-guided self-help (DBTgsh) protocol in women
diagnosed with BED. The DBTgsh protocol included one in-person, 45-
minute orientation session to the DBT skills manual, as well as six supportive
phone calls over the course of treatment. Participants in the study were
randomly assigned to DBTgsh vs a wait list condition. Results indicated
fewer binge eating episodes and greater abstinence rates in the DBTgsh
group compared to the control condition at post-treatment and at
a 6-month follow-up.
 EATING DISORDERS 111

Following up on this research, Carter, Kennedy, Singleton, Van Wijk, and

Heath (2019) randomly assigned 71 participants who met criteria for BED to
one of three conditions: (1) DBT-unguided self-help (DBT-USH), where
participants received a copy of DBT Solution for Emotional Eating (Safer,
Adler, & Masson, 2018) to review, (2) DBT-guided self-help (DBT-GSH),
where participants received a copy of DBT Solution for Emotional Eating to
review and attended six 30-minute web-based sessions, or (3) Self-esteem-
unguided self-help (SE-USH), where participants received a copy of Self-
esteem: A Proven Program of Cognitive Techniques for Assessing, Improving,
and Maintaining Your Self-esteem (McKay & Fanning, 2016) to review. After
12 weeks, all participants regardless of condition reported a decrease in binge
eating. Compared to the other two conditions, the DBT-GSH group demon-
strated the greatest reduction in binge frequency and had the fewest people
engaging in binge eating at diagnostic levels at post treatment. Despite these
promising findings, none of the groups differed significantly. This may have
been due to the high attrition across all treatment groups leaving the study
significantly underpowered.
While not as methodologically stringent as randomized trials, several uncon-
trolled clinical trials and case studies have been conducted using DBT-BED since
the Bankoff et al. (2012) review. For example, Klein et al. (2012) examined the
Stanford adaptations for BED and BN in individuals diagnosed with sub- or full-
threshold BED or BN. After 16 weeks of 2-½ hour group DBT sessions (plus
phone coaching), participants demonstrated significant reductions in binge
eating and improvement in secondary cognitive outcomes related to ED beha-
viors. While not diagnosed with BED, 11 individuals undergoing pre-treatment
interventions for bariatric surgery participated in 10-weekly, 2-hour group
DBT-BED sessions. Findings indicated significant improvements in binge eating
from pre- to post-intervention, but not in psychosocial functioning (Mushquash
& McMahan, 2015). Finally, participants from one small case study on DBT for
BED demonstrated reductions in binge eating frequency as well as failure to
meet criteria for BED at the end of treatment (Erb et al., 2013).
Taken in total these studies indicate strong evidence for the use of DBT for
those diagnosed with BED. Several well controlled RCTs have demonstrated
its efficacy with this population. Less well-researched, however, is DBT-BN.
The studies that have utilized DBT for this population have also included
individuals diagnosed with BED, which may artificially inflate the outcomes
given the known success of DBT for BED and the better prognosis for those
with BED compared to BN. A needed next step is RCTs in samples that are
exclusively diagnosed with BN to parse out differential response to DBT
treatment in these two groups.
112 D. BEN-PORATH ET AL.

Radically open-DBT for eating disorders (RO-DBT) model

While the DBT-BED/BN adaptation and standard DBT focus on addressing
deficits related to emotion dysregulation, individuals diagnosed with AN-R
often present as emotionally overcontrolled. Indeed, existing research indicates
that anorexia is associated with low novelty-seeking (Rossier, Bolognini,
Plancherel, & Halfon, 2000), heightened threat sensitivity (Harrison, Sullivan,
Tchanturia, & Treasure, 2010), low sensitivity to reward (Harrison, O’Brien,
Lopez, & Treasure, 2010), cognitive rigidity (Tchanturia et al., 2012), inhibited
emotional expression/recognition (Geller, Cockell, Hewitt, Goldner, and Flett
(2000), and loneliness (Zucker et al., 2007).
RO-DBT theorizes that, over time, temperamental threat sensitivity inter-
acts with feedback from the environment that emphasizes self-control and
minimizing mistakes, which results in impairment in individuals’ ability to
feel safe (Hempel et al., 2018). Thus, RO-DBT presents a unique conceptua-
lization of restrictive eating behaviors as a maladaptive inhibitory control
behavior that allows individuals with AN-R to dampen these negative emo-
tions. While this specific theory of overcontrol as it applies to restrictive ED
behaviors has yet to be empirically tested, the four modules in DBT have
each been adapted to teach skills that address problematic behaviors that are
driven by overcontrol. In addition, a new skills module, radical openness is
considered the core skill set of RO-DBT, and is based on three features:
openness, flexibility, and connectedness. Thus, rather than focusing on
weight restoration, RO-DBT teaches individuals skills that target the issues
of overcontrol that are thought to underlie problematic behaviors, emotions,
and cognitions, (Lynch et al., 2013).

Review of the empirical literature on RO-DBT

At the time of the Bankoff et al. (2012) review, no empirical studies had been
published on RO-DBT. Since this time, two studies have been published with
promising outcomes. Lynch et al. (2013) in an open, uncontrolled clinical trial
treated 47 inpatients diagnosed with AN-R with RO-DBT with an average length
of treatment of 21.7 weeks. The response rate was high with 35% in full
remission and 55% in partial remission at discharge. Treatment completers
also demonstrated significant improvements in eating disorder symptoms and
quality of life, as well as reductions in psychological distress. Interestingly, 72%
who completed the inpatient treatment program demonstrated substantial gains
in BMI despite weight gain not being actively targeted in this treatment. Thus,
this increase in BMI may be due to the inherent structure present in inpatient
settings, including set meal times.
Chen et al. (2015) reported results from two case series of DBT for adult
AN outpatients. The first group (n = 6) of AN or subclinical AN patients was
 EATING DISORDERS 113

treated with standard DBT and the DBT for binge eating manual from 4 to
24 months, with one patient dropping out. At the end of the treatment, the
improvement in BMI yielded a medium effect size. The second group (n = 9)
consisted primarily of EDNOS patients with AN symptoms. This group was
treated with standard DBT augmented with a skills module for over con-
trolled emotions and behaviors. Treatment ranged from 4 to 12 months, with
one dropout. Pre- to post-treatment improvement in BMI yielded a large
effect size that was maintained at both 6- and 12-month follow-ups (Chen
et al., 2015). The results of these two case series showed a similar effect size of
DBT for AN to other treatments specific for outpatient AN.
Adding a skills training module targeting rigidity and increasing openness
and social connectedness could possibly increase the effectiveness of DBT for
AN, particularly for those with AN-R. However, no RCTs have yet been
conducted using RO-DBT. Given the absence of a wait-list condition or
comparison group in the two existing studies of RO-DBT for EDs, it is
impossible to conclude whether these symptomatic improvements are due
to time, maturation, non-specific effects inherent in general inpatient/out-
patient treatment, or the actual intervention of RO-DBT. Thus, these initial
findings, while promising for targeting overcontrolled symptoms in restrict-
ing-type eating disorders, should be interpreted with cautious optimism.

Multidiagnostic complex EDs (MED-DBT) model for higher levels of

care
MED-DBT was developed to address multi-diagnostic, highly complex indivi-
duals diagnosed with an ED who may require a higher level of ED care (e.g.,
9–30 hours of treatment per week) due to the severity of ED symptoms and/or
comorbid diagnoses, including, but not limited to, BPD (see Federici et al., 2012
for a more detailed discussion of the treatment development). Indeed, Johnson,
Tobin, and Dennis (1990) have speculated that the one-third of patients who
typically do not respond to traditional treatments are likely ED individuals who
are also comorbidly diagnosed with BPD. While several studies have found
promising results using standard DBT in individuals with BPD and EDs, these
studies recruited individuals to DBT settings that specialized in BPD and for
which the BPD diagnosis was considered primary and the ED diagnosis second-
ary (Chen et al., 2008; Navarro-Haro et al., 2018; Palmer et al., 2003).
Patients in an ED higher level of care are admitted because the ED diagnosis is
primary and yet these patients may also present with multiple comorbid diag-
noses, such as BPD. The increased level of severity of the ED symptoms
combined with comorbid diagnoses pose significant therapeutic challenges for
clinicians as these patients frequently fail numerous outpatient treatments,
engage in significant TIBs, present with self-harm and suicidality, and exhibit
ED symptoms severe enough to be life-threatening. An added complexity of
114 D. BEN-PORATH ET AL.

these presentations is the potential for additional diagnoses and/or BPD to

thwart the progress of ED treatment or worse, elevate the ED to a life-
threatening crisis.
Thus, MED-DBT combines evidence-based CBT for EDs (Fairburn, 2008)
with the empirically supported treatment of DBT for managing multiple high-
risk behaviors (e.g., suicidality, NSSI, exercising while having cardiac complica-
tions due to the eating disorder, etc.) in the context of significant TIBs and
emotion dysregulation. The MED-DBT program emphasizes patient responsi-
bility and flexibility in defining and achieving their treatment goals, while the
therapist creates a therapeutic environment that is collaborative, yet grounded in
behavioral principles, including contingency management to assist the patient in
reaching those goals (Wisniewski & Ben-Porath, 2015).

Review of the empirical literature on the MED-DBT model

Prior to 2012, the research on using DBT to treat individuals with multi-
diagnostic and complex EDs was limited. Neither the treatment provided nor
the environment within which it was offered could be considered uniform.
Specifically, some studies offered standard DBT to complex/comorbid ED
patients in an outpatient, weekly format (Chen et al., 2008) or standard DBT
with an added skills module directed at EDs (Palmer et al., 2003). Other studies
provided DBT within a partial hospitalization program (Ben-Porath et al., 2009)
or within an adapted inpatient DBT program (Kröger et al., 2010).
The majority of the studies (5/7) since the Bankoff et al. (2012) review have
utilized the DBT-MED model in a higher level of care. The two notable excep-
tions are Courbasson et al. (2012) and Navarro-Haro et al. (2018), both of which
used a non-randomized treatment design comparing DBT to treatment as usual
(TAU) in an outpatient setting. Courbasson et al. (2012), for example, compared
outpatient DBT to treatment as usual (TAU) in individuals comorbidly diag-
nosed with ED and substance use disorder (SUD). Individuals in the DBT
condition showed significant improvement in affect regulation and a decrease
in emotional eating as well an increase in the ability to resist urges to use
substances. Indeed, those in the TAU condition did so poorly (e.g., high drop-
out rates, worsening of symptoms), recruitment in the TAU condition was
terminated prematurely. Navarro-Haro et al. (2018) compared DBT to TAU-
CBT for those comorbidly diagnosed with ED and BPD in an outpatient setting.
Although those in the DBT condition showed a greater decrease in non-suicidal
self-injurious behaviors and depressive symptoms, similar improvements
between groups were seen in suicide attempts, ED symptoms, and hospitaliza-
tions. While those patients in the TAU-CBT condition fared considerably better
than those in the Courbasson et al. (2012) study, these differences may have been
due to the more robust TAU condition in the Navarro-Haro et al. (2018) study
in which patients received TAU-CBT rather than components of CBT,
 EATING DISORDERS 115

motivational interviewing, and relapse prevention strategies provided in the

Courbasson et al. (2012) study.
The remaining five studies, since the Bankoff et al. (2012) review have
investigated the effectiveness of DBT-MED with severe and complex ED
patients in a higher level of care. Federici and Wisniewski (2013) treated
seven ED patients utilizing the MED-DBT in a day treatment program, all of
whom presented with comorbid BPD, additional Axis I diagnoses, and
extensive histories of ED treatment failure. Treatment completion for all
seven women was associated with reductions in ED symptoms, suicidal and
self-injurious behaviors, therapy-interfering behaviors, psychiatric and med-
ical hospitalizations, and clinician burnout.
Extending these findings, by exploring not only ED symptoms but also the
impact of DBT on affect regulation, Ben-Porath, Federici, Wisniewski, and Warren
(2014) employed the MED-DBT adaptation to 65 patients admitted to a day
hospital treatment program. Results indicated a significant increase in weight
gain, a significant reduction in ED behaviors (e.g., restriction, bingeing and
purging) and a reduction in ED cognitions. Notably, findings indicated an
improvement in participants’ ability to regulate affect, suggesting that DBT treat-
ment may play an important role in producing changes in affect regulation (Ben-
Porath et al., 2014).
In a more recent study evaluating treatment in a day hospital program,
Brown et al. (2018) studied the impact of MED-DBT on 241 patients with
long standing EDs and significant comorbidity. Results of this open trial
demonstrated a significant improvement in weight and comorbidity and ED
symptoms, with 49% of patients meeting criteria for full or partial remission
at discharge and 37% at one-year follow-up.
Extending these findings, Brown et al. (2019a), utilizing the MED-DBT hier-
archy for complex and severe EDs, examined the impact of early vs. later skill
acquisition on ED outcomes in a partial hospitalization setting. Given that previous
research has established the importance of DBT skills in improvements in those
with BPD, these authors hypothesized that the acquisition of DBT skills in ED
patients with early change in DBT skills use (e.g., change in skill use from treatment
admission to first month) would demonstrate greater improvements in ED symp-
toms, mood, and emotion regulation as compared to individuals who had later
change in DBT skills use (e.g., change in skill use from first month to discharge).
While participants improved on all measures from admission to discharge, those
with early change in DBT skills use accounted for a larger proportion of the
variance in depressive symptoms, emotion dysregulation, and in particular, ED
symptoms, indicating the importance of assessing for early skill use and
acquisition.
Finally, Brown et al. (2019b) examined improvements in emotion regulation in
241 individuals receiving ED treatment in a day hospital setting. Results indicated
improvement in affect regulation, as measured by the DERS score, from admission
116 D. BEN-PORATH ET AL.

to discharge in all ED diagnostic groups, including AN-R, AN-BP, and BN.

However, only those individuals diagnosed with BN maintained those improve-
ments at follow-up. Of those diagnosed with AN-R, AN-BP, and BN, 24%, 36%,
and 26.2% respectively made significant and reliable change at post-treatment. RCI
indices were comparable from admission to follow-up for all groups with the
exception of the BN sample in which 42.1% at follow up had achieved reliable and
significant change on the DERS-total score.
In summary, the MED-DBT model shows promise in impacting ED
pathology as well as emotion regulation when offered in the context of partial
hospital or inpatient programs. However, firm conclusions and recommen-
dations about its use cannot be made in the absence of more rigorous studies
that employ a control group.

Conclusions and recommendations

The studies on DBT adapted for EDs have generally produced positive out-
comes, although the research has varied considerably with respect to the amount
and rigor. For example, the Stanford Model has the most rigorous and numerous
studies demonstrating efficacy but mostly in those diagnosed with BED.
Considerably fewer studies have been conducted using the Stanford Model
with BN; therefore, less strong assertions can be made about DBT with those
diagnosed with BN. The MED-DBT model has been evaluated in several open
trials within higher levels of care with promising results, but the lack of RCTs
prevents a definitive statement about its efficacy. Finally, research on applying
the RO-DBT model to AN-R is in its infancy, prohibiting solid conclusions or
recommendations regarding its efficacy or effectiveness.
In the meantime, clinicians are in need of guidance. Clinicians who treat
EDs are interested in the potential utility of a DBT model for those ED
patients who are not helped by other evidence-based approaches.
Additionally, clinicians who are trained in DBT are curious about how they
might use their expertise to address eating disorder thoughts and behaviors.
Lack of research data does not always dissuade clinicians from adopting
approaches, and this may be especially true for individuals who do not
respond to standard treatments, as there are even fewer guidelines and data
to inform clinical practice with ED patients that fail treatment.
In addition to reviewing the literature and describing the various DBT models
for EDs, the ultimate goal of this paper was to provide recommendations regard-
ing which model to use with adult ED patients. As referenced in Table 2, when
attempting to make a decision about the use of DBT with an adult ED patient, the
clinician must ask several questions: (1) What is the primary ED diagnosis? (2)
Has an adequate trial of an EBT for that ED diagnosis been tried? (3) Why might
DBT be indicated, and finally, (4) Which DBT model is indicated? Although not
directly addressed in this paper, it is also strongly recommended that the clinician
Table 2. Summary of when to consider using DBT to treat adult EDs.
Front line Type of
ED evidence-based DBT to
Diagnosis treatment When to consider DBT consider Comments
AN-R No approach When more well studied treatments have not RO-DBT An alternative to more well-studied treatments. Does not address eating directly.
identified as been effective or when emotional overcontrol Must have physician on team to ensure medical stability.
superior is hindering treatment effectiveness
BED CBT-ED When CBT-ED has not been effective or when Stanford An alternative to CBT. Well studied and effective.
emotional regulation is hindering treatment
effectiveness
BN CBT-ED When CBT-ED has not been effective or when Stanford More research needed on the use of this model with BN specifically.
emotional regulation is hindering treatment
effectiveness
Complex/ CBT-ED At least 2 of the following MED-DBT Standard DBT enhanced with strategies for ED symptomatology and alteration in
Multi- -CBT-ED has not been effective DBT targeting to adjust for the ED symptoms. Mostly studied in IOP and DTP.
diagnostic - comorbid diagnoses Preliminary results show effectiveness. Requires well designed RCT.
ED - significant emotion dysregulation
-. ED life threatening
- history of TIB
EATING DISORDERS
117
118 D. BEN-PORATH ET AL.

ask: “Do I have the skills to adequately address these problems or do I need more
training in order to provide this treatment effectively?” The recommendations
below are meant to act as a guideline, as well as a catalyst for clinicians to
determine areas of competence and areas where more research and/or training
is needed.
If the patient has an uncomplicated BED, and has already received
a course of CBT for ED, it is recommended that the Stanford model be
offered. This recommendation is somewhat tempered for patients with BN,
as there are fewer research studies with this population. If an individual has
a complex/co-morbid ED of any diagnosis, has not been helped by a course
of EBT, demonstrates TIBs, or reports a high degree of emotional dysregula-
tion, a program where their ED will be treated and conceptualized within the
MED-DBT model is tentatively recommended. More research is needed on
this model as there have been no RCTs in this area to date. Finally, if the
patient has AN-R and has not been helped by other, more well-studied
approaches, RO-DBT should be considered. It is important to note that
since this model does not focus on eating and weight gain, this treatment,
if attempted even experimentally, should be offered in the context of medical
management. With any of these recommendations, the clinician is advised to
adhere to a scientist-practitioner approach: Begin with what is known
empirically to be effective, offer it to patients, evaluate progress, make
changes in the context of consultation from other professionals, and present
the outcomes. In doing so, the field continues to move forward and improved
treatments options become available to adults with EDs.

ORCID
Fragiskos Gonidakis http://orcid.org/0000-0001-8212-280X
Emilio J. Compte http://orcid.org/0000-0002-6803-5950

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