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How does DBT treat BPD that is co-occurring with eating disorders?

Clive Robins · Accepted Answer

First, I should make clear that I am not an expert in eating disorders. I can, however, give some general guidelines. DBT follows a hierarchy of treatment target priorities. In Stage 1 treatment, this is, in order, reducing life-threatening behaviors, reducing therapy-interfering behaviors, reducing serious quality-of-life interfering behaviors, and increasing behavioral skills to replace problem behaviors. So the first question to address is whether the eating disorder is currently life-threatening. For example, is the client seriously underweight and continuing to lose weight, or are they purging by vomiting frequently or severely enough that they risk damaging the esophagus or producing electrolyte imbalance. If this is suspected, evaluation by a specialist medical professional is very important and in severe cases, hospitalization may be necessary. Also, if the patient is underweight and severely restricting nutrition, their brain functioning may be compromised to a point where DBT or any other form of psychotherapy is not feasible and again medical attention is necessary first. In cases of severe restricting EDs, my approach has always been to require a medical evaluation, and consider referring to an eating disorders specialist or program to stabilize weight and restriction before doing DBT. However, in many cases, the ED, while serious is not as medically severe as described above. In that case, we would consider it a serious quality-of-life-interfering behavior (having a calorie-starved brain may also be a therapy-interfering behavior). So in a given session, the eating disorder may be the highest priority target, unless there has been an increase in life-threatening or serious therapy-interfering behavior, or some other target such as substance abuse is considered higher priority. How would the ED be treated? DBT incorporates use of other empirically supported behavioral treatments, such as the CBT-E program developed by Christopher Fairburn and his colleagues, which has some support for some types of ED in adults, particularly for binge eating disorder, bulimia and EDNOS, and Appetite Awareness Training developed by Linda Craighead. Many patients benefit also from standard DBT skills training, particularly in mindfulness (including mindful eating), distress tolerance, and emotion regulation, along with standard DBT strategies including behavioral analyses and solution analyses of binge and purge episodes. Several randomized trials  by Debra Safer, Christy Telch, Eunice Chen and their colleagues have supported such an approach, and Lucene Wiesnewski has written extensively about combining DBT and standard CBT for eating disorders. For children and adolescents with anorexia, the Maudsley model of family treatment is, I believe, the only treatment with any demonstrated support, and I am not aware of any treatment for anorexia in adults that has empirical support, although as I said, I am not an eating disorders expert, so there may be something recent of which I am not aware.

Question 4

Why is DBT the commonly recommended therapy approach for BPD?

Clive Robins · Accepted Answer

Because it has by far the largest base of empirical support from randomized controlled trials (RCTs). Several other treatments have demonstrated some merit in RCTs, including schema-focused therapy, mentalization therapy, and transference-focused psychotherapy, but they each have only one or two such trials. Standard DBT for BPD has been supported in at least 13 RCTs as of my last count a few years ago. This includes studies with participants diagnosed with BPD and recent suicidal behavior, and BPD and substance abuse. Adaptations of comprehensive DBT have also been supported in at least another 10 RCTs for participants with BPD and PTSD (the DBT-PE protocol of Melanie Harned and colleagues), BPD traits and an eating disorder, suicidal adolescents with BPD traits, mixed personality disorders, as well as participants who may or may not have BPD who had adolescent bipolar disorder, eating disorder, substance abuse, or childhood sexual abuse-related PTSD, and pre-adolescent children with disruptive mood-dysregulation disorder (Perepletchikova et al). The skills training component of DBT alone has also been supported in 2 RCTs with participants with BPD and as a stand-alone or adjunctive treatment in at least 12 RCTs for either eating disorders, mood disorders, ADHD or in transdiagnostic groups.

Question 5

Can DBT help a person overcome BPD or simply learn to manage it more effectively?

Clive Robins · Accepted Answer

If by "manage it more effectively" you mean their behavior improves a lot, but in some way they still have BPD, this may actually be a false dichotomy. As a behaviorist, I do not think of BPD as some internal thing a person "has", so that even if their behavior improves to the point where they have few if any "symptoms", they still really have it. But I'm not sure if that's what you meant. BPD, as defined in the DSM, is a collection of behaviors that go together often enough it is considered a diagnosis. If we change those behaviors, we change the diagnosis. Unfortunately, almost no trials of psychotherapy for BPD look at change in diagnosis as an outcome measure, rather focusing on changes in levels of various individual behaviors and "symptoms", so there's not much evidence regarding whether DBT or any other treatment helps a person "overcome" BPD.  However, in one trial that my colleague Cedar Koons and I conducted (Koons, Robins, Tweed, et al., 2001, Behavior Therapy) of 6 months of DBT versus treatment as usual in a women's VA mental health clinic, the women receiving DBT had a greater reduction in number of DBT criteria met (out of a possible 9, of which at least 5 are required for diagnosis, they went from a mean of 6.8 to 3.6, compared to the TAU moving from 6.7 to 4.2, a significant difference). 30% of those in DBT and 50% of those in TAU still met BPD criteria at the end of treatment. Anecdotally, I've had numerous clients go from meeting BPD criteria to no longer doing so over the course of treatment. This does not of course necessarily mean that they no longer had any problems in life or even did not need or benefit from further treatment, but I do believe DBT and probably other treatments can help clients not only live better lives but actually no longer meet criteria for BPD. Across different randomized studies, DBT has reduced hospitalization rates and days, suicide attempts, non-suicidal self-injury, suicidal ideation, substance use, eating disordered behavior, anger expression, dissociation, and depression, among other things.

Question 6

Is there a specific order in which DBT skills should be taught and practised with clients with BPD?

Clive Robins · Accepted Answer

DBT skills are organized into modules of mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Mindfulness skills are considered "core" skills because, in order to use any of the other skills effectively, one needs to remain mindful of one's goals, and of one's actions and their effects, without judgment. Therefore, mindfulness skills should be taught first. Skills usually are taught and practiced in a group context, which is optimal not only for the efficiency of teaching several clients at one time but more importantly for the opportunities it provides for clients to role-play or rehearse new behaviors with one another, to provide validation and support to one another and learn from each other's discussions of attempts to practice during the week for homework, and questions raised about the skills, among other things. If it is a closed group, i.e. a cohort of clients begin group together and go through all modules together with no new clients allowed to join, the skills manual suggests beginning with mindfulness, then interpersonal skills, as these may be the least likely to lead to clients feeling invalidated because we are helping them to change their interpersonal environment, rather than focusing on changing their own tolerance for distress or their emotional responses. Following that, mindfulness skills module again, then emotion regulation, mindfulness again, then distress tolerance. As you can see, the mindfulness module, though short (typically only two sessions) gets lots of repetition for deeper learning and practice, to emphasize its importance, and to help clients connect mindfulness skills to the longer (typically 5 to 7 sessions) module that follows. However, in my experience, most clinics and clinicians do not run closed groups, as there are likely to be dropouts over the course of a 6-month curriculum while at the same time there may be a waiting list for group. I usually recommend that new clients be allowed to join a group if there is room each time the mindfulness module comes around again. As a result, different clients will get the other skills in different orders. To my knowledge, there has been no research on whether order matters, but anecdotally from my own experience it does not seem to. If for some reason you are doing skills training just with an individual, perhaps because of extreme social anxiety or a client who has proved to be too disruptive to the group or too few clients to do a group, we recommend having a different clinician do the skills training in a different session than the DBT individual therapy. Otherwise, it is too easy for client and therapist to abandon the curriculum in favor of discussing whatever clinical situation seems urgent that day. If that is not possible, an individual clinician can try to do both in separate weekly sessions, and in the worst case scenario where perhaps finances get in the way of that, I would do individual therapy and try to weave in teaching whatever skills are most relevant to the clinical situation being problem-solved that day. This is far from ideal however. Whether the skills are taught in group or individually, and in whatever order, I recommend that the individual therapist provide at least some training and handouts on the subset of distress tolerance skills referred to as "crisis survival", particularly with suicidal and self-injuring clients.

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Question 8

How can DBT help when the issues resulting from BPD are so disruptive that therapy is unable to focus on the underlying maintaining factors (e.g. trauma and self-worth issues)?

Clive Robins · Accepted Answer

I would like to make several points her. First, trauma and self-worth issues are not necessarily the underlying maintaining factors in all cases of BPD, though they are important in many. Clients with BPD do report high rates of trauma but it is far from universal. Second, by issues being "disruptive", I'm guessing that you may be thinking of the string emotional dysregulation they often experience and the behaviors that leads to such as self-injury, substance abuse, anger outbursts and so forth. Indeed it is difficult and even unwise for therapy to focus on trauma when a person is showing by their behaviors that they cannot currently handle the strong emotions that trauma-work necessarily generates. Similarly, it is hard for someone to have much feeling of self-worth when they frequently engage in behaviors that wreck their lives. Therefore, in DBT, we take a staged approach to treatment, in which some behaviors need to be the primary focus first. If there are life-threatening behaviors or behaviors on that spectrum like strong suicidal ideation or deliberate self-injury, that is the first priority. If a client comes to a session and that has occurred, it will be the primary focus of the session. If not, behaviors lower in the priority hierarchy can be addressed, which might include therapy-interfering behavior or quality-of-life interfering such as substance abuse or depression or phobia. If the person has PTSD symptoms such as nightmares, startle response, dissociation, then at this initial stage of treatment, we try to help with skills to manage and reduce those problems, but do not directly address the trauma. For some clients, when there is greater stability of behavior, less dysregulation, there may be a second stage of treatment focused on trauma or more generally on reducing avoidance of difficult emotions and their cues. This is when empirically supported treatments for PTSD such as Prolonged Exposure or Cognitive Processing Therapy would commence. Not all clients require or desire this stage of treatment. A third stage of treatment would focus on helping the client who is now behaving in less disruptive ways to develop greater self-esteem, improve their relationships with others, etc.

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Question 10

Given the strong link between BPD and trauma, I was wondering if DBT is helpful in dealing with trauma?

Clive Robins · Accepted Answer

There is indeed a higher prevalence of trauma in the histories of individuals diagnosed with BPD than most other diagnoses. Most people with BPD meet criteria for one or more Axis I disorders and PTSD is prominent among those. For those with BPD and PTSD, standard DBT alone, at least in research trials of one year of treatment, is actually not very effective in treating PTSD, even when it reduces many of the behaviors associated with BPD. The treatments found to be effective for treating PTSD all have in common the element of repeated exposure to representations of the trauma, along with other elements that differ somewhat from one treatment to another. The evidence is strongest for Prolonged Exposure, developed by Edna Foa and colleagues. Equally strong effects have been found for Cognitive Processing Therapy, developed by Patricia Resick, but so far there have been fewer randomized trials of CPT than of PE. Eye Movement Desensitization and Reprocessing (EMDR) also has some support and also involves imaginal exposure. All of these treatments inherently result in strong emotional responses while re-imagining the trauma. For clients with BPD who are currently suicidal or self-injuring, this can be very risky. These clients typically are trying to escape difficult emotions by those behaviors. They are not ready to do trauma-focused work in an outpatient setting. However, when sufficiently stabilized and able to demonstrate that they can  contact difficult emotions and tolerate them without such extreme escape behaviors, they can benefit from exposure work. In fact, Melanie Harned and Marsha Linehan have developed DBT-PE, a protocol in which, once a client has been in standard DBT and shows sufficient stability (please refer to Melanie's work for details) for at least 2 months, individual weekly PE sessions are conducted in addition to usual DBT individual and skills group. Randomized trial data suggest it is very effective in treating PTSD while continuing to benefit the BPD behaviors. An adaptation of DBT for PTSD by Martin Bohus and colleagues that does not require waiting until there is no self-injury has also shown very good results, but please note that that is in a long-term (by US standards) inpatient setting in Germany.

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