Effects of borderline personality disorder symptoms on dialectical behavior therapy outcomes for eating disorders.

Existing literature on the effects of borderline personality disorder (BPD) and eating disorder (ED) comorbidity in terms of clinical presentation and treatment outcome has been limited and inconclusive. The present study examined whether clients with EDs and varying levels of BPD symptoms presented with more severe ED symptoms at admission, and whether they responded to dialectical behavior therapy (DBT)-based treatment. Participants (N = 176) were adults in a DBT-based partial hospitalization program for EDs at an academic medical center. Participants completed self-report measures at admission, 1-month postadmission, discharge, and 6-month follow-up. Results suggested that patients with elevated BPD symptoms at admission had greater ED symptoms during treatment, evidenced by small to moderate effect sizes. However, patients with high BPD symptoms demonstrated steeper declines in binge eating, fasting, and parasuicidal behavior early during treatment compared to patients with low BPD symptoms. Individuals with high BPD symptoms at admission (i.e., probable BPD diagnosis) were as likely to meet remission criteria and relapse as individuals with low BPD symptoms, though this null finding may be influenced by small cell sizes. Our findings also suggest that DBT skills use does not predict changes in symptoms. In sum, our findings suggest that while clients with higher BPD symptoms may improve during DBT-based partial hospitalization, their ED symptoms may remain more severe. Future studies are needed to determine whether adjunctive treatments improve outcomes for clients with EDs and comorbid BPD symptoms in DBT programs and whether skills use quality is a better predictor of ED symptom changes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Evaluating the use of lamotrigine to reduce mood lability and impulsive behaviors in adults with chronic and severe eating disorders.

BACKGROUND: Gold-standard psychological and pharmacological treatments for bulimic-spectrum eating disorders only result in remission for around 50% of patients; patients with affective lability and impulsivity represent a subgroup with particularly poor outcomes. Both dialectical behavior therapy (DBT), a treatment for emotion dysregulation, and lamotrigine, a mood stabilizer, have demonstrated promise for targeting affective lability and impulsivity; however, data exploring the combination of these interventions remain limited. OBJECTIVE: We followed a group of women with recurrent dysregulated eating behaviors (N = 62) throughout intensive DBT treatment and compared the symptom trajectory of those prescribed lamotrigine (n = 28) and those who were not (n = 34). METHOD: Participants completed surveys every 2 weeks throughout treatment. RESULTS: Group analyses suggested that all participants self-reported decreases in emotional reactivity, negative urgency, and symptoms of borderline personality disorder (BPD). The lamotrigine group reported greater elevations in BPD symptoms at baseline, but demonstrated steeper decreases in emotion and behavioral dysregulation than the non-matched comparison group. Within-subject analyses suggested that within the lamotrigine group, subjects reported greater decreases in symptoms following prescription of lamotrigine. CONCLUSIONS: Findings provide initial data suggesting that lamotrigine could be useful as an adjunctive treatment for patients with affective lability and impulsivity. LEVEL OF EVIDENCE: IV, time series without randomization.

Changes in cognitive and behavioral control after lamotrigine and intensive dialectical behavioral therapy for severe, multi-impulsive bulimia nervosa: an fMRI case study.

PURPOSE: Adults with bulimia nervosa (BN) and co-occurring emotional dysregulation and multiple impulsive behaviors are less responsive to existing interventions. Initial data suggest that the combination of Dialectical Behavior Therapy (DBT) and a mood stabilizer, lamotrigine, significantly reduces symptoms of affective and behavioral dysregulation in these patients. Identifying candidate neurobiological mechanisms of change for this novel treatment combination may help guide future randomized controlled trials and inform new and targeted treatment development. Here, we examined neurocognitive and symptom changes in a female patient with BN and severe affective and behavioral dysregulation who received DBT and lamotrigine. METHODS: Go/no-go task performance data and resting-state functional MRI scans were acquired before the initiation of lamotrigine (after 6 weeks in an intensive DBT program), and again after reaching and maintaining a stable dose of lamotrigine. The patient completed a battery of symptom measures biweekly for 18 weeks over the course of treatment. RESULTS: After lamotrigine initiation, the patient made fewer errors on a response inhibition task and showed increased and new connectivity within frontoparietal and frontolimbic networks involved in behavioral and affective control. Accompanying this symptom improvement, the patient reported marked reductions in bulimic symptoms, behavioral dysregulation, and reactivity to negative affect, along with increases in DBT skills use. CONCLUSION: Improved response inhibition and cognitive control network connectivity should be further investigated as neurocognitive mechanisms of change with combined DBT and lamotrigine for eating disorders. Longitudinal, controlled trials integrating neuroimaging and symptom measures are needed to fully evaluate the effects of this treatment. LEVEL OF EVIDENCE: IV: Evidence obtained from multiple time series with or without the intervention, such as case studies.

Early predictors of treatment outcome in a partial hospital program for adolescent anorexia nervosa.

OBJECTIVE: Previous research supports the relevance of early symptom change in eating disorder (ED) treatment; however, few studies have distinguished early weight change from early change in ED psychopathology, particularly in higher levels of care. Thus, the present study examined whether early change in weight and ED psychopathology predicted outcome for adolescents with anorexia nervosa (AN) in a partial hospitalization program. METHOD: Adolescents with AN (n = 99) completed assessments at admission, 1-month after treatment admission, discharge, and 6-month follow-up. RESULTS: Higher admission percent expected body weight (%EBW), greater early change in %EBW, longer duration of treatment, shorter length of illness, and earlier age of onset predicted greater change in %EBW at discharge, but not follow-up. Greater ED psychopathology at admission and greater early change in ED psychopathology predicted later change in ED symptoms at discharge, but not follow-up. Neither early change in %EBW nor ED psychopathology predicted likelihood of remission at discharge and follow-up. DISCUSSION: Results support the importance of early change in predicting later change in the same ED outcome variables and suggest that early change in both %EBW and ED psychopathology in adolescents may be an important area for future research.

Emotion Regulation Difficulties During and After Partial Hospitalization Treatment Across Eating Disorders.

Emotion regulation deficits are associated with eating disorder (ED) symptoms, regardless of eating disorder diagnosis. Thus, recent treatment approaches for EDs, such as dialectical behavior therapy (DBT), have focused on teaching patients skills to better regulate emotions. The present study examined changes in emotion regulation among adult patients with EDs during DBT-oriented partial hospital treatment, and at follow-up (M[SD] = 309.58[144.59] days from discharge). Exploratory analyses examined associations between changes in emotion regulation and ED symptoms. Patients with anorexia nervosa, restricting (AN-R, n = 77), and binge-eating/purging subtype (AN-BP, n = 46), or bulimia nervosa (BN, n = 118) completed the Difficulties in Emotion Regulation Scale (DERS) at admission, discharge, and follow-up. Patients with BN demonstrated significant improvements across all facets of emotion dysregulation from admission to discharge and maintained improvements at follow-up. Although patients with AN-BP demonstrated statistically significant improvements on overall emotion regulation, impulsivity, and acceptance, awareness, and clarity of emotions, from admission to discharge, these improvements were not significant at follow-up. Patients with AN-R demonstrated statistically significant improvements on overall emotion dysregulation from treatment admission to discharge. Changes in emotion regulation were moderately correlated with changes in ED symptoms over time. Results support different trajectories of emotion regulation symptom change in DBT-oriented partial hospital treatment across ED diagnoses, with patients with BN demonstrating the most consistent significant improvements.

Dialectical behavioral therapy for the treatment of adolescent eating disorders: a review of existing work and proposed future directions.

Over the past several decades, Dialectical Behavior Therapy (DBT) has been adapted for a range of presenting problems related to emotion dysregulation. Considerable enthusiasm exists regarding the use of DBT for treating eating disorders; however, to date, there have been no reviews summarizing empirical efforts to adapt DBT for eating disorders in youth. Accordingly, in the present narrative review, we provide a comprehensive summary of existing work testing DBT for adolescent eating disorders. First, we briefly review existing work applying DBT to eating disorders in adults and general adolescent samples. We then review research focused specifically on the use of DBT for adolescent eating disorders, including both those studies applying DBT as the primary treatment and investigations of DBT as an adjunctive treatment. Overall, initial results for DBT-based approaches are promising. However, rigorous empirical work testing DBT for treating adolescent eating disorders remains limited; the majority of existing research is comprised of case series and small-scale studies. Therefore, we close with specific recommendations for future research testing this approach.

Naturalistic outcomes for a day-hospital programme in a mixed diagnostic sample of adolescents with eating disorders.

Despite initial data suggesting positive treatment outcomes for adolescent eating disorder day-hospital programmes (DHPs), existing studies have included limited follow-up, small samples, and a focus on restricting-type eating disorders. To address these gaps, we explored naturalistic outcomes for an adolescent eating disorders DHP. Adolescent participants (N = 265) completed measurements at treatment admission, discharge (n = 170), and various lengths of follow-up (n = 126; Mfollow up = 278.87 days). Results from multilevel models indicated significant increases in body weight for the anorexia nervosa group throughout treatment and maintenance of increased body weight from discharge to follow-up. In bulimic spectrum disorders, binge eating and purging significantly decreased from intake to discharge and did not change from discharge to follow-up. Across the entire sample, eating disorder symptoms decreased from intake to discharge and did not change from discharge to follow-up. Further, anxiety and depression decreased over the course of treatment and continued to decrease over the follow-up period. The current investigation represents the first study to explore longitudinal DHP outcomes within adolescent bulimic spectrum eating disorders. Our findings also highlight many challenges inherent in conducting naturalistic research; it is critical that the field continue to develop solutions to the barriers inherent in conducting longitudinal research on eating disorder treatment.

Differences in emotion regulation difficulties among adults and adolescents across eating disorder diagnoses.

OBJECTIVE: Although much empirical attention has been devoted to emotion regulation (ER) in individuals with eating disorders, little is known about ER across a wide age range and among different ED subtypes. The current study sought to examine ER in a sample of eating disorder patients. METHOD: A total of 364 adults and adolescents with anorexia nervosa restricting subtype (AN-R), anorexia nervosa binge/purge subtype (AN-BP), or bulimia nervosa (BN) were assessed with the Difficulties in Emotion Regulation Scale (DERS). RESULTS: Older ages were associated with higher DERS total, nonacceptance, goals, and impulsivity scores. When controlling for age, patients with BN and AN-BP had higher overall DERS scores than those with AN, and there were some differences among diagnostic subtypes on specific facets of ER. CONCLUSIONS: These results indicate that treatments for emotion dysregulation may be applied across eating disorder diagnoses and ages, and inform how these strategies apply to different diagnostic groups.

Efficacy of a partial hospital programme for adults with eating disorders.

Partial hospital programmes (PHPs) have demonstrated efficacy in the treatment of eating disorders (EDs); however, few programmes have examined long-term outcomes across diagnoses, including subtypes of anorexia nervosa (AN). The present study examined the effectiveness of PHP for adult patients (n = 243) with AN-restricting subtype (n = 79), AN binge/purge subtype (n = 46), and bulimia nervosa (n = 118). These patients tended to have long-standing courses of illness (43%, illness duration >7 years) and high levels of psychiatric comorbidity (92.2%). Patients completed questionnaires at admission, discharge, and follow-up, M (SD) = 11.50 months (5.29). Through follow-up, all diagnoses demonstrated significant improvements in weight, ED psychopathology, and comorbid symptoms, with some exceptions for the AN binge/purge group. In exploratory analyses, 49% of patients met criteria for full or partial remission at discharge and 37% at follow-up. Results provide support for the effectiveness of PHP in improving ED outcomes in a severe sample through longer-term follow-up.

An open trial targeting emotional eating among adolescents with overweight or obesity.

Emotional eating is associated with obesity and disordered eating in adolescents, and thus, is an important target for treatment. We developed a program called PEER (Preventing Emotional Eating Routines), which incorporates emotion regulation skills with behavioral weight loss and parenting techniques for adolescents who are overweight or obese (OW/OB) and their parent. This open label trial evaluated the feasibility, acceptability, and initial efficacy of the PEER program. Thirty adolescents who were OW/OB (86.7% female; mean age = 14.6 years (SD = 1.2); Body Mass Index (BMI) = 34.0 kg/m2 (SD = 5.6); 33.3% White non-Hispanic) and their parent (66.7% biological mother) participated in a 4-month treatment and 3-month follow-up. The PEER program was well accepted. Initial efficacy showed significant decreases in emotional eating, and there were trends towards weight loss and a decrease in emotion dysregulation. This trial provides preliminary evidence for the feasibility, acceptability, and initial efficacy of the PEER program among adolescents who are OW/OB and their parent. Further treatment development and randomized controlled studies are needed.

The Impact of Alexithymia on Emotion Dysregulation in Anorexia Nervosa and Bulimia Nervosa over Time.

Research supports that anorexia nervosa-restricting subtype (AN-R) and bulimia nervosa (BN) are associated with emotion regulation difficulties and alexithymia. However, the impact of diagnosis on the relationship between these constructs is less well understood. The purpose of the present study was to examine whether eating disorder diagnosis moderated the association between admission alexithymia and emotion regulation through discharge. Adult patients with AN-R (n = 54) and BN (n = 60) completed assessments at treatment admission and discharge from a partial hospital program. Eating disorder diagnosis moderated the association between admission alexithymia levels and change in global emotion dysregulation, impulse control difficulties and access to emotion regulation strategies. At higher levels of admission alexithymia, there were no differences between AN-R and BN on emotion dysregulation, whereas at lower levels of alexithymia, AN-R patients demonstrated lower levels of emotion dysregulation. Results imply that difficulties with alexithymia appear to have a greater impact on emotion dysregulation for AN-R patients. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Psychometric Evaluation and Norms for the Multidimensional Assessment of Interoceptive Awareness (MAIA) in a Clinical Eating Disorders Sample.

Altered interoceptive awareness (IA) has been implicated in the pathophysiology of eating disorders; however, few comprehensive self-report measures of IA exist in eating disorders. The present study sought to validate the Multidimensional Assessment of Interoceptive Awareness (MAIA), originally developed to assess IA in individuals practicing mind-body therapies, in an eating disorder sample. Adult and adolescent patients (n = 376) completed assessments upon admission to a partial hospital programme. Analyses examined the factor structure of the MAIA, scale means, scale-scale correlations, internal consistency and construct validity. Analyses also examined associations between MAIA subscales and eating disorder symptoms. Results supported the original eight-factor structure of the MAIA. Internal consistency was acceptable, and the scales converged with associated measures. Importantly, Not Distracting, Self-regulation, Body Listening and Trusting were most strongly associated with eating disorder symptoms. Results support use of the MAIA among eating disorders and provide further support for the relevance of IA in eating disorders. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Treating Eating Disorders at Higher Levels of Care: Overview and Challenges.

Higher levels of care (HLC)-including inpatient hospitalization, residential treatment, partial hospitalization, and intensive outpatient treatment-are frequently utilized within routine care for eating disorders. Despite widespread use, there is limited research evaluating the efficacy of HLC, as well as clinical issues related to care in these settings. This review describes the different levels of care for eating disorders and briefly reviews the most up-to-date guidelines and research regarding how to choose a level of care. In addition, as HLC approaches for ED continue to be developed and refined, pragmatic and conceptual challenges have emerged that provide barriers to clinical efficacy and the execution of high-quality treatment research. This review includes a discussion of various issues specific to HLC, as well as a summary of recent literature addressing them.

A Narrative Review of Outcome Studies for Residential and Partial Hospital-based Treatment of Eating Disorders.

OBJECTIVE: The objective of this study was to review the current eating disorders outcome literature after residential or partial hospitalization programme (PHP) treatment. METHOD: Articles were identified through a systematic search of PubMed and PsycINFO. RESULTS: Twenty-two PHP and six residential treatment studies reported response at discharge and tended to find improvement. Fewer studies (nine PHP and three residential) reported outcome at some interval after discharge from treatment. These tended to find sustained improvement. A substantial proportion of patients were lost to follow-up, particularly for residential treatment. Only two follow-up studies used controlled trials; both showed efficacy for PHP compared with inpatient treatment with regard to maintaining symptom remission. CONCLUSIONS: Improvement at discharge may not predict long-term outcome. Long-term follow-up studies were confounded by high dropout rates. While higher levels of care may be essential for reversing malnutrition, there remains a lack of controlled trials showing long-term efficacy, particularly for residential treatment settings. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Deconstructing "Atypical" Eating Disorders: an Overview of Emerging Eating Disorder Phenotypes.

Recent changes to the diagnostic framework of eating disorders (ED's) in DSM-5 were introduced to reduce the large preponderance of cases falling within the residual and undifferentiated category. However, current reports continue to illustrate overrepresentation of cases in this residual category, suggesting that clinical reality comprises more diverse ED psychopathology than is accounted for in the current diagnostic spectrum. However, with emerging evidence preliminarily delineating several additional distinct phenotypes, we aim to provide a narrative overview of emerging ED phenotypes which (i) are not currently located as a specific diagnostic category in diagnostic criteria for ED's, (ii) centrally feature ED psychopathology, and (iii) have emerging empirical evidence suggesting the distinct nature of the syndrome. A greater awareness of these emerging phenotypes will likely facilitate accurate diagnostic practice and may also serve to facilitate further empirical efforts.

The Integration of Family-Based Treatment and Dialectical Behavior Therapy for Adolescent Bulimia Nervosa: Philosophical and Practical Considerations.

Dialectical behavior therapy (DBT) and family-based treatment (FBT) are two evidence-based interventions that have been applied in the treatment of bulimia nervosa (BN) in adolescents. While DBT focuses on providing skills for coping with emotion dysregulation that often co-occurs with BN, FBT targets the normalization of eating patterns. The purpose of the current article is to introduce an integration of both treatments to provide a more comprehensive approach that targets the full scope of the disorder. We provide a review of the conceptual similarities and differences between FBT-BN and DBT along with strategies to guide a blended treatment approach. Given the strengths and limitations of either independent treatment, DBT and FBT-BN complement one another and together can address the range of symptoms and behaviors typically seen in adolescent BN.

Integrating Family-Based Treatment and Dialectical Behavior Therapy for Adolescent Bulimia Nervosa: Preliminary Outcomes of an Open Pilot Trial.

Adolescent bulimia nervosa (BN) remains relatively understudied, and the complex interaction between core eating psychopathology and emotional regulation difficulties provides ongoing challenges for full symptom remission. In an open pilot trial, we aimed to investigate the efficacy of a program integrating family-based treatment (FBT) and dialectical behavior therapy (DBT) in treating adolescent BN, without exclusion criteria. Participants were 35 adolescents who underwent partial hospital treatment for BN, and outcomes included measures of core BN pathology and emotional regulation difficulties, as well as parental measures of self-efficacy, completed at intake and discharge. Results indicate significant improvements in overall eating disorder pathology, t(68) = 4.52, p = .002, and in core BN symptoms, including objective binge episodes, t(68) = 2.01, p = .041, and self-induced vomiting, t(68) = 2.90, p = .005. Results also illustrated a significant increase in parental efficacy throughout the course of treatment, t(20) = .081, p = .001, although no global improvement in difficulties in emotion regulation was noted, t(68) = 1.12, p = .285. These preliminary findings support the utility of this integration of FBT and DBT, although raise interesting questions as to the mechanism of symptom remission.

Adapting Family-Based Treatment for Adolescent Anorexia Nervosa Across Higher Levels of Patient Care.

An increasing body of evidence supports the use of family-based treatment (FBT) in medically stable outpatient presentations of adolescent anorexia nervosa, although there is relatively less research on adapting evidence-based treatment approaches in more intensive levels of patient care. The integration of FBT, which centrally leverages parental involvement in more intensive levels of care which typically require greater clinical management, requires careful consideration. We provide an overview of several key practical and theoretical considerations when adjusting the delivery of FBT across more intensive levels of patient care, providing clinical guidelines for the delivery of FBT while ensuring fidelity to the core theoretical tenets. Implications for clinical practice and future research are discussed.