Skip to main content

Advertisement

SpringerLink
Log in

Early Versus Later Improvements in Dialectical Behavior Therapy Skills Use and Treatment Outcome in Eating Disorders

  • Original Article
  • Published:
Cognitive Therapy and Research Aims and scope Submit manuscript

Abstract

Dialectical behavior therapy (DBT) has demonstrated initial efficacy for the treatment of eating disorders (EDs). However, no study has examined potential processes that may contribute to observed improvements in DBT for EDs. The present study sought to investigate changes in DBT skills use throughout treatment as a predictor of symptom change in a DBT-based partial hospital program (PHP) for adults with EDs. Adults [n = 135; M(SD) age = 25.08 (7.88)] with EDs completed self-report measures at treatment admission, one-month post-admission, and discharge from PHP. DBT skills use, as measured by the DBT Ways of Coping Checklist, increased by 12.65% from admission to one-month post-admission and increased by 24.10% from admission to discharge. Early (admission to month 1) and later (month 1 to discharge) improvements in DBT skills use predicted greater improvements in ED, depressive, and emotion dysregulation symptoms from treatment admission to discharge. Notably, early versus later change in skills use was a stronger predictor of outcome. Results are consistent with the theoretical model of DBT and add to a growing literature on DBT for EDs.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

    Book  Google Scholar 

  • Bankoff, S. M., Karpel, M. G., Forbes, H. E., & Pantalone, D. W. (2012). A systematic review of dialectical behavior therapy for the treatment of eating disorders. Eating Disorders, 20(3), 196–215. https://doi.org/10.1080/10640266.2012.668478.

    Article  PubMed  Google Scholar 

  • Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck depression inventory-II. San Antonio, 78(2), 490–498.

    Google Scholar 

  • Ben-Porath, D. D., Federici, A., Wisniewski, L., & Warren, M. (2014). Dialectical behavior therapy: Does it bring about improvements in affect regulation in individuals with eating disorders? Journal of Contemporary Psychotherapy, 44(4), 245–251.

    Article  Google Scholar 

  • Ben-Porath, D. D., Wisniewski, L., & Warren, M. (2010). Outcomes of a day treatment program for eating disorders using clinical and statistical significance. Journal of Contemporary Psychotherapy, 40(2), 115–123.

    Article  Google Scholar 

  • Berg, K. C., Peterson, C. B., Frazier, P., & Crow, S. J. (2011). Convergence of scores on the interview and questionnaire versions of the Eating Disorder Examination: A meta-analytic review. Psychological Assessment, 23(3), 714.

    Article  Google Scholar 

  • Braun, M. T., & Oswald, F. L. (2011). Exploratory regression analysis: A tool for selecting models and determining predictor importance. Behavior Research Methods, 43(2), 331–339.

    Article  Google Scholar 

  • Brown, T. A., Cusack, A., Anderson, L. K., Trim, J., Nakamura, T., Trunko, M. E., & Kaye, W. H. (2018). Efficacy of a partial hospital programme for adults with eating disorders. European Eating Disorders Review. https://doi.org/10.1002/erv.2589.

    Article  PubMed  Google Scholar 

  • Chen, E. Y., Cacioppo, J., Fettich, K., Gallop, R., McCloskey, M. S., Olino, T., & Zeffiro, T. A. (2017). An adaptive randomized trial of dialectical behavior therapy and cognitive behavior therapy for binge-eating. Psychological Medicine, 47(4), 703–717. https://doi.org/10.1017/S0033291716002543.

    Article  CAS  PubMed  Google Scholar 

  • Del Conte, G., Lenz, A. S., & Hollenbaugh, K. M. (2016). A pilot evaluation of dialectical behavior therapy for adolescents within a partial hospitalization treatment milieu. Journal of Child and Adolescent Counseling, 2(1), 16–32.

    Article  Google Scholar 

  • Fairburn, C. G., Agras, W. S., Walsh, B. T., Wilson, G. T., & Stice, E. (2004). Prediction of outcome in bulimia nervosa by early change in treatment. American Journal of Psychiatry, 161(12), 2322–2324.

    Article  Google Scholar 

  • Fairburn, C. G., & Beglin, S. J. (1994). Assessment of eating disorders: Interview or self-report questionnaire? International Journal of Eating Disorders, 16(4), 363–370.

    CAS  PubMed  Google Scholar 

  • Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54.

    Article  Google Scholar 

  • Hayes, A. F., & Rockwood, N. J. (2017). Regression-based statistical mediation and moderation analysis in clinical research: Observations, recommendations, and implementation. Behaviour Research and Therapy, 98, 39–57.

    Article  Google Scholar 

  • Haynos, A. F., & Fruzzetti, A. E. (2011). Anorexia nervosa as a disorder of emotion dysregulation: Evidence and treatment implications. Clinical Psychology: Science and Practice, 18(3), 183–202.

    Google Scholar 

  • Hilbert, A., Hildebrandt, T., Agras, W. S., Wilfley, D. E., & Wilson, G. T. (2015). Rapid response in psychological treatments for binge eating disorder. Journal of Consulting and Clinical Psychology, 83(3), 649.

    Article  Google Scholar 

  • Ilardi, S. S., & Craighead, W. E. (1994). The role of nonspecific factors in cognitive-behavior therapy for depression. Clinical Psychology: Science and Practice, 1(2), 138–155.

    Google Scholar 

  • Iverson, K. M., Shenk, C., & Fruzzetti, A. E. (2009). Dialectical behavior therapy for women victims of domestic abuse: A pilot study. Professional Psychology: Research and Practice, 40(3), 242.

    Article  Google Scholar 

  • Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59(1), 12–19.

    Article  CAS  Google Scholar 

  • Lavender, J. M., Wonderlich, S. A., Engel, S. G., Gordon, K. H., Kaye, W. H., & Mitchell, J. E. (2015). Dimensions of emotion dysregulation in anorexia nervosa and bulimia nervosa: A conceptual review of the empirical literature. Clinical Psychology Review, 40, 111–122.

    Article  Google Scholar 

  • Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder: New York: Guilford Press.

    Google Scholar 

  • Linehan, M. M., & Chen, E. Y. (2005). Dialectical behavior therapy for eating disorders. In M. A. Reinecke, & A. Freeman (Eds.), Encyclopedia of cognitive behavior therapy (pp. 168–171). New York: Springer.

    Chapter  Google Scholar 

  • Linehan, M. M., Korslund, K. E., Harned, M. S., Gallop, R. J., Lungu, A., Neacsiu, A. D., …. Murray-Gregory, A. M. (2015). Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: A randomized clinical trial and component analysis. JAMA Psychiatry, 72(5), 475–482. https://doi.org/10.1001/jamapsychiatry.2014.3039.

    Article  CAS  PubMed  Google Scholar 

  • Linehan, M. M., & Wilks, C. R. (2015). The course and evolution of dialectical behavior therapy. American Journal of Psychotherapy, 69(2), 97–110.

    Article  Google Scholar 

  • Lynch, T. R., Chapman, A. L., Rosenthal, M. Z., Kuo, J. R., & Linehan, M. M. (2006). Mechanisms of change in dialectical behavior therapy: Theoretical and empirical observations. Journal of Clinical Psychology, 62(4), 459–480.

    Article  Google Scholar 

  • Meyers, L., Voller, E. K., McCallum, E. B., Thuras, P., Shallcross, S., Velasquez, T., & Meis, L. (2017). Treating veterans with PTSD and borderline personality symptoms in a 12-week intensive outpatient setting: Findings from a pilot program. Journal of Traumatic Stress, 30(2), 178–181.

    Article  Google Scholar 

  • Mond, J. M., Hay, P. J., Rodgers, B., & Owen, C. (2006). Eating Disorder Examination Questionnaire (EDE-Q): Norms for young adult women. Behaviour Research and Therapy, 44(1), 53–62. https://doi.org/10.1016/j.brat.2004.12.003.

    Article  CAS  PubMed  Google Scholar 

  • Neacsiu, A. D., Eberle, J. W., Kramer, R., Wiesmann, T., & Linehan, M. M. (2014). Dialectical behavior therapy skills for transdiagnostic emotion dysregulation: A pilot randomized controlled trial. Behaviour Research and Therapy, 59, 40–51. https://doi.org/10.1016/j.brat.2014.05.005.

    Article  PubMed  Google Scholar 

  • Neacsiu, A. D., Rizvi, S. L., & Linehan, M. M. (2010a). Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder. Behaviour Research and Therapy, 48(9), 832–839. https://doi.org/10.1016/j.brat.2010.05.017.

    Article  PubMed  PubMed Central  Google Scholar 

  • Neacsiu, A. D., Rizvi, S. L., Vitaliano, P. P., Lynch, T. R., & Linehan, M. M. (2010b). The dialectical behavior therapy ways of coping checklist: Development and psychometric properties. Journal of Clinical Psychology, 66(6), 563–582. https://doi.org/10.1002/jclp.20685.

    Article  PubMed  Google Scholar 

  • Rizvi, S. L., Hughes, C. D., Hittman, A. D., & Oliveira, V., P (2017). Can trainees effectively deliver dialectical behavior therapy for individuals with borderline personality disorder? Outcomes from a training clinic. Journal of Clinical Psychology, 73(12), 1599–1611.

    Article  Google Scholar 

  • Safer, D. L., & Joyce, E. E. (2011). Does rapid response to two group psychotherapies for binge eating disorder predict abstinence? Behaviour Research and Therapy, 49(5), 339–345.

    Article  Google Scholar 

  • Safer, D. L., Robinson, A. H., & Jo, B. (2010). Outcome from a randomized controlled trial of group therapy for binge eating disorder: Comparing dialectical behavior therapy adapted for binge eating to an active comparison group therapy. Behavior Therapy, 41(1), 106–120. https://doi.org/10.1016/j.beth.2009.01.006.

    Article  PubMed  PubMed Central  Google Scholar 

  • Safer, D. L., Telch, C. F., & Agras, W. S. (2001). Dialectical behavior therapy adapted for bulimia: A case report. International Journal of Eating Disorders, 30(1), 101–106.

    Article  CAS  Google Scholar 

  • Schafer, J. L., & Graham, J. W. (2002). Missing data: Our view of the state of the art. Psychological Methods, 7(2), 147–177.

    Article  Google Scholar 

  • Soler, J., Pascual, J. C., Tiana, T., Cebrià, A., Barrachina, J., Campins, M. J., … Pérez, V. (2009). Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: A 3-month randomised controlled clinical trial. Behaviour Research and Therapy, 47(5), 353–358.

    Article  Google Scholar 

  • Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology, 69(6), 1061.

    Article  CAS  Google Scholar 

  • Tonidandel, S., & LeBreton, J. M. (2011). Relative importance analysis: A useful supplement to regression analysis. Journal of Business and Psychology, 26(1), 1–9.

    Article  Google Scholar 

  • Valentine, S. E., Bankoff, S. M., Poulin, R. M., Reidler, E. B., & Pantalone, D. W. (2015). The use of dialectical behavior therapy skills training as stand-alone treatment: A systematic review of the treatment outcome literature. Journal of Clinical Psychology, 71(1), 1–20. https://doi.org/10.1002/jclp.22114.

    Article  PubMed  Google Scholar 

  • Webb, C. A., Beard, C., Kertz, S. J., Hsu, K. J., & Björgvinsson, T. (2016). Differential role of CBT skills, DBT skills and psychological flexibility in predicting depressive versus anxiety symptom improvement. Behaviour Research and Therapy, 81, 12–20.

    Article  Google Scholar 

  • Wilson, G. T. (1999). Rapid response to cognitive behavior therapy. Clinical Psychology: Science and Practice, 6(3), 289–292.

    Google Scholar 

  • Wisniewski, L., Safer, D., & Chen, E. (2007). Dialectical behavior therapy and eating disorders. In L. A. Dimeff & K. Koerner (Eds.), Dialectical behavior therapy in clinical practice: Applications across disorders and settings (pp. 174–221). New York, NY: Guilford Press.

    Google Scholar 

  • Yager, J., Devlin, M. J., Halmi, K. A., Herzog, D. B., Mitchell, I. I. I., Powers, J. E., P., & Zerbe, K. J. (2014). Guideline watch (August 2012): Practice guideline for the treatment of patients with eating disorders. Focus, 12(4), 416–431.

    Article  Google Scholar 

  • Yager, J., Devlin, M. J., Halmi, K. A., Herzog, D. B., Mitchell, J. E., Powers, P. S., & Zerbe, K. J. (2005). Guideline watch: Practice guideline for the treatment of patients with eating disorders. Focus, 3(4), 546–551.

    Article  Google Scholar 

Download references

Acknowledgements

The authors thank Lauren Gomez and Tiffany Nakamura for their assistance with data collection, the patients who participated in this research, and the current and past clinical staff for their clinical expertise and support of this research.

Author information

Authors and Affiliations

  1. Department of Psychiatry, University of California, San Diego, La Jolla, San Diego, CA, USA

    Tiffany A. Brown, Anne Cusack, Leslie Anderson, Erin E. Reilly, Laura A. Berner, Christina E. Wierenga, Jason M. Lavender & Walter H. Kaye

Authors
  1. Tiffany A. Brown
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Anne Cusack
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Leslie Anderson
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Erin E. Reilly
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Laura A. Berner
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Christina E. Wierenga
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jason M. Lavender
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Walter H. Kaye
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Tiffany A. Brown.

Ethics declarations

Conflict of Interest

Tiffany A. Brown, Anne Cusack, Leslie Anderson, Erin E. Reilly, Laura A. Berner, Christina E. Wierenga, Jason M. Lavender, and Walter H. Kaye declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the University of California, San Diego and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Animal Rights

No animal studies were carried out by the authors for this article.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Brown, T.A., Cusack, A., Anderson, L. et al. Early Versus Later Improvements in Dialectical Behavior Therapy Skills Use and Treatment Outcome in Eating Disorders. Cogn Ther Res 43, 759–768 (2019). https://doi.org/10.1007/s10608-019-10006-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10608-019-10006-1

Keywords

Search

Navigation