Efficacy of Dialectical Behavior Therapy (DBT) and DBT-Informed Interventions for Binge Eating in Adolescents: A Systematic Review

Suicide is a leading cause of death among 10- to 24-year-old individuals in the United States; evidence on effective treatment for adolescents who engage in suicidal and self-harm behaviors is limited. To evaluate the efficacy of dialectical behavior therapy (DBT) compared with individual and group supportive therapy (IGST) for reducing suicide attempts, nonsuicidal self-injury, and overall self-harm among high-risk youths. This randomized clinical trial was conducted from January 1, 2012, through August 31, 2014, at 4 academic medical centers. A total of 173 participants (pool of 195; 22 withdrew or were excluded) 12 to 18 years of age with a prior lifetime suicide attempt (≥3 prior self-harm episodes, suicidal ideation, or emotional dysregulation) were studied. Adaptive randomization balanced participants across conditions within sites based on age, number of prior suicide attempts, and psychotropic medication use. Participants were followed up for 1 year. Study participants were randomly assigned to DBT or IGST. Treatment duration was 6 months. Both groups had weekly individual and group psychotherapy, therapist consultation meetings, and parent contact as needed. A priori planned outcomes were suicide attempts, nonsuicidal self-injury, and total self-harm assessed using the Suicide Attempt Self-Injury Interview. A total of 173 adolescents (163 [94.8%] female and 97 [56.4%] white; mean [SD] age, 14.89 [1.47] years) were studied. Significant advantages were found for DBT on all primary outcomes after treatment: suicide attempts (65 [90.3%] of 72 receiving DBT vs 51 [78.9%] of 65 receiving IGST with no suicide attempts; odds ratio [OR], 0.30; 95% CI, 0.10-0.91), nonsuicidal self-injury (41 [56.9%] of 72 receiving DBT vs 26 [40.0%] of 65 receiving IGST with no self-injury; OR, 0.32; 95% CI, 0.13-0.70), and self-harm (39 [54.2%] of 72 receiving DBT vs 24 [36.9%] of 65 receiving IGST with no self-harm; OR, 0.33; 95% CI, 0.14-0.78). Rates of self-harm decreased through 1-year follow-up. The advantage of DBT decreased, with no statistically significant between-group differences from 6 to 12 months (OR, 0.65; 95% CI, 0.12-3.36; P = .61). Treatment completion rates were higher for DBT (75.6%) than for IGST (55.2%), but pattern-mixture models indicated that this difference did not informatively affect outcomes. The results of this trial support the efficacy of DBT for reducing self-harm and suicide attempts in highly suicidal self-harming adolescents. On the basis of the criteria of 2 independent trials supporting efficacy, results support DBT as the first well-established, empirically supported treatment for decreasing repeated suicide attempts and self-harm in youths. ClinicalTrials.gov Identifier: NCT01528020.

This article explores the efficacy of dialectical behavior therapy (DBT) for young people aging out of the Department of Children and Families system. The project was conducted with participants at a residential program for “transitional youth” who have serious emotional disturbance and emerging mental illness (N = 15). The research method combined a posttest-only comparison group design, with pretest-posttest observations for the DBT group. The research question explored the efficacy of DBT for this population, and used a mixed-method approach combining both quantitative and qualitative data collection. All participants received individual therapy, with 24/7 wraparound residential services. The DBT intervention consisted of an additional two hours of weekly skills-training groups. The mean length of exposure to the DBT intervention was 12.4 months. The quantitative measures included the Modified Global Assessment of Functioning Scale, and the Purposeful Productive Activity and Quality of Life Scale. The qualitative portion of the study involved semi-structured interviews and focus groups.Members of the DBT group improved from pretest to posttest, and when judged against the comparison group improvement was in terms of global functioning, social relationships, and productive use of time or “intentionality,” but not in terms of vocational functioning. The qualitative data suggest that DBT group members used the groups to work on specific interpersonal relationship, emotion regulation, and distress tolerance skills, as well as to get feedback and support from others in the group. The potential implications of these findings for clinical practice may be to suggest DBT as a promising, evidence-based intervention for this vulnerable and heretofore underserved population.

Sustained efficacy of dialectical behaviour therapy for borderline personality disorder

An existing body of research demonstrates the efficacy of Dialectical Behavior Therapy (DBT) Skills in reducing a range of psychiatric symptomatology in the United States, although the relevance of DBT Skills in low- and middle-income countries in the Global South has been understudied. Focusing on India, a middle-income country, in this qualitative study, we explored the relevance of DBT Skills for emerging adults-typically individuals aged 18-29 years-using focus groups with counseling psychology graduate students. Students (N = 22, 90% women) participated in initial focus groups where DBT Skills were outlined and were asked whether these skills would be relevant for emerging adults in India, and what adaptations may be needed. Then, students received a virtual four-week DBT Skills training program in which they learned extensively about DBT Skills and subsequently participated in focus groups to discuss the relevance of those skills for emerging adults in India. Incorporating the adaptations they recommended, students then facilitated DBT Skills groups with emerging adults in India for eight weeks and then participated in focus groups to discuss the relevance of the skills. Thematic analysis was used to analyze the data from the three sets of focus groups. Twelve themes were identified and organized into three separate domains: (a) views about optimal interventions; (b) relevance of DBT Skills; and (c) sociocultural adaptations to DBT Skills. Overall, findings suggest relevance of DBT Skills for emerging adults in India with specific adaptations to emotion regulation, and more broadly to all modules by integrating collectivistic values and local cultural norms.

Introduction: Individuals with borderline personality disorder have many problems in emotion regulation and quality of life. Regarding this, the aim of the current study was to investigate the effectiveness of dialectical behavior therapy on the improvement of emotion regulation and quality of life among women with borderline personality disorder in Shahr-e Kord, Iran, in 2015. Materials and Methods: This semi-experimental study was conducted on women with borderline personality disorder referring to the psychology and counseling centers of Shahr-e Kord city in 2015 using a pretest-posttest control group design. The study population was selected using convenience sampling technique out of the women voluntarily participating in a treatment course held by the researchers. The inclusion criteria were: 1) borderline personality diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2) a minimum of high school education (diploma degree), 3) age range of 20-40 years, and 4) at least one suicide attempt. The participants were then randomly assigned into two groups of intervention (n=10) and control (n=10). The intervention group was subjected to eight 90-minute sessions of dialectical behavior therapy; however, the control group received no intervention. The data were collected using the Emotion Regulation Scale and Quality of Life Questionnaire. Data analysis was performed in SPSS software (version 18) using covariance. Results: According to the results, there was a significant difference between the control and intervention groups in terms of emotion regulation (F=7.61, P=0.01) and quality of life (F=13.68, P=0.001) after the intervention. Conclusion: Based on the findings, it seems that dialectical behavior therapy improved the emotion regulation and quality of life among the women with borderline personality disorder.

PurposeThe role of body image in adolescent binge eating is widely confirmed, albeit the various facets of this relationship are still mostly unexplored. Within the multidimensional body image framework, this study hypothesized the indirect effects of three body image coping strategies (positive rational acceptance, appearance fixing, avoidance) in the expected relationship between the perceived impact of body image on individuals’ quality of life and binge eating symptoms.MethodsParticipants were 715 adolescents aged 15–21 years (49.1% girls) recruited in Italian schools. An anonymous self-report online survey was administered. A multiple mediation model was tested.ResultsA more positive perceived impact of body image on quality of life was a negative predictor of adolescents’ binge eating, controlling for individual levels of body satisfaction. Three indirect effects were found in this relationship: on one hand, the positive body image impact reduced binge eating via increasing positive rational acceptance (M1), and via reducing avoidance (M2); on the contrary, the positive body image impact also enhanced binge eating via increasing appearance fixing (M3).ConclusionsThe body image impact on quality of life can be alternatively protective—when adaptive coping is solicited, and maladaptive strategies are reduced—or a risk factor, which may increase binge eating by soliciting appearance fixing.Level IIIEvidence obtained from cohort or case–control analytic studies.

Gender and racial/ethnic differences in binge eating symptoms in a nationally representative sample of adolescents in the United States

The last three decades have witnessed significant advances in psychotherapy. Numerous scholarly articles and books have been devoted to pertinent topics in the field, making it difficult for the practicing clinician to keep up with this rapidly growing area. The purpose of this article is to provide some guidelines on how to evaluate the empirical literature in psychotherapy and then to explore three key areas: evidence-based psychotherapies for patients with psychiatric disorders, individual variables that predict differential outcome to treatment, and the therapeutic alliance. Finally, two case examples will be presented to illustrate how knowledge of the empirical literature can facilitate an evidence-based approach to the daily practice of psychotherapy in general psychiatry.

Although low self-esteem and body disinvestment have been recognized as potential risk factors for disordered eating, no studies have explored how these factors may work together to predict binge eating in adolescents. Therefore, we hypothesized a path model for girls and boys separately to investigate whether the body’s investment dimensions (feelings towards the body, physical touch, body care, body protection) mediate the relationship between self-esteem and binge eating, and age moderate such relationships. Participants were 1046 Italian students aged between 11 and 19 years (472 girls, Mage = 14.17; 574 boys, Mage = 14.60) screened through self-report measures. Both models showed an acceptable fit (males: χ2(22) = 30.441; RMSEA = 0.026; CFI = 0.99; TLI = 0.97; SRMR = 0.023; females: χ2(22) = 34.723; RMSEA = 0.35; CFI = 0.98; TLI = 0.95; SRMR = 0.029). Negative body feelings and reduced body protection fully mediated the relationship between self-esteem and binge eating, regardless of gender. Our findings highlight the importance of interventions promoting body emotional investment to reduce adolescents’ vulnerability to binge eating.

ObjectiveCognitions and behaviors characteristic of binge eating are associated with a polymorphism in the FTO gene, robustly related to body mass index (BMI) and obesity risk. We investigated the association between binge eating and the individual and combined effect of 32 SNPs robustly associated with BMI in a population-based sample. We hypothesized that higher BMI and binge eating might share a common genetic etiology.MethodsBinge eating was assessed in adolescents from the Avon Longitudinal Study of Parents and Children at age 14 (n = 5,958) and 16 years (n = 4,948). We tested associations between 32 BMI-related SNPs and binge eating in crude and BMI-, age-, and gender-adjusted regression models.ResultsCrude analyses showed an association between binge eating and rs1558902 (FTO) that persisted after adjustment for BMI (OR = 1.20, P = 8 × 10−3). A weighted allelic score consisting of all 32 BMI-related SNPs was associated with binge eating (P = 8 × 10−4); this association attenuated (P = 0.08) when rs1558902 was removed from the weighted allelic score.ConclusionsBMI-related genes are associated with adolescent binge eating, in particular an FTO polymorphism. Although replication is needed, our findings have biological plausibility and are consistent with a postulated effect of FTO on appetite and food intake. Future studies should aim to understand the mechanisms underlying the relationship between FTO, binge eating, and obesity.

In this study, key informant interviews were conducted with 13 administrators from nine community-based mental health agencies implementing dialectical behavior therapy in order to assess their perspectives on implementation. Four major themes were identified. They include opinions about dialectical behavior therapy and its fit with existing practices, resource concerns (for example, reimbursement issues, time commitment, and staff training), staff selection for training and staff turnover, and ongoing client referrals. Understanding agency administrators' unique perspectives and addressing their concerns is critical to treatment implementation given administrators' role in determining whether and how a treatment will be implemented. Better understanding of the fit between dialectical behavior therapy and existing service structures, the impact of staff turnover on implementation, and the resources required for implementation are all needed to ensure successful implementation and sustainability.

This study evaluated whether dialectical behavior therapy (DBT) was more efficacious than treatment by nonbehavioral psychotherapy experts in reducing co-occurring Axis I disorders among suicidal individuals with borderline personality disorder (BPD). Women with BPD and recent and repeated suicidal and/or self-injurious behavior (n = 101) were randomly assigned to 1 year of DBT or community treatment by experts (CTBE), plus 1 year of follow-up assessment. For substance dependence disorders (SDD), DBT patients were more likely to achieve full remission, spent more time in partial remission, spent less time meeting full criteria, and reported more drug- and alcohol-abstinent days than did CTBE patients. These findings suggest that improvements in co-occurring SDD among suicidal BPD patients are specific to DBT and cannot be attributed to general factors associated with nonbehavioral expert psychotherapy. Further, group differences in SDD remission were not explained by either psychotropic medication usage or changes in BPD criterion behaviors. DBT and CTBE did not significantly differ in the reduction of anxiety disorders, eating disorders, or major depressive disorder.

Inhibitory control effects in adolescent binge eating and consumption of sugar-sweetened beverages and snacks

BackgroundStep-down dialectical behaviour therapy (DBT) is a treatment consisting of 3 months of residential DBT plus 6 months of outpatient DBT. The program was specifically developed for people suffering from severe borderline personality disorder (BPD). The present study examines the effectiveness and cost-effectiveness of step-down DBT compared to 12 months of regular, outpatient DBT.MethodsEighty-four participants reporting high levels of BPD-symptoms (mean age 26 years, 95% female) were randomly assigned to step-down versus standard DBT. Measurements were conducted at baseline and after 3, 6, 9 and 12 months. The Lifetime Parasuicide Count and BPD Severity Index (BPDSI) were used to assess suicidal behaviour, non-suicidal self-injury (NSSI) and borderline severity. Costs per Quality Adjusted Life Year (QALY) were calculated using data from the EQ-5D-3L and the Treatment Inventory Cost in Psychiatric Patients (TIC-P).ResultsIn step-down DBT, 95% of patients started the program, compared to 45% of patients in outpatient DBT. The probability of suicidal behaviour did not change significantly over 12 months. The probability of NSSI decreased significantly in step-down DBT, but not in outpatient DBT. BPDSI decreased significantly in both groups, with the improvement leveling off at the end of treatment. While step-down DBT was more effective in increasing quality of life, it also cost significantly more. The extra costs per gained QALY exceeded the €80,000 threshold that is considered acceptable for severely ill patients in the Netherlands.ConclusionsA pragmatic randomized controlled trial in the Netherlands showed that 9 months of step-down DBT is an effective treatment for people suffering from severe levels of BPD. However, step-down DBT is not more effective than 12 months of outpatient DBT, nor is it more cost-effective. These findings should be considered tentative because of high noncompliance with the treatment assignment in outpatient DBT. Furthermore, the long-term effectiveness of step-down DBT, and moderators of treatment response, remain to be evaluated.Trial registrationwww.clinicaltrials.govNCT01904227. Registered 22 July 2013 (retrospectively registered).

Lesbian and Gay people (LGP) experience higher rates of mental health difficulties, including self-harm, suicidal behaviours, as well as inequalities in health care, than their heterosexual peers. Dialectical Behaviour Therapy (DBT) is an evidence-based treatment for self-harm and suicidal behaviours, though there is little research on LGP's experiences of DBT. This research aims to explore LGP's experiences of completing a full DBT programme. A qualitative design with semi-structured individual interviews was utilised. The results were analysed using Interpretative Phenomenological Analysis. Six lesbian and two gay adults, aged between 22 and 47 years, living in the United Kingdom took part. All participants had completed a full programme of DBT within the 2 years prior to the interview. Four superordinate themes emerged from the data: (1) The DBT journey; (2) Connections and Sense of Community during DBT; (3) Sexuality both visible and invisible in DBT and (4) A Gender, Sexuality and Relationship Diverse (GSRD) affirmative future for DBT. Several clinical implications are suggested to improve DBT for LGP, for example to consider having other LGP within DBT groups, to create a more GSRD-affirming DBT (changes to the DBT manual, DBT therapists, DBT programme and physical DBT space), to adapt DBT techniques to manage sexuality-related difficulties and to adopt a GSRD-centric framework. Overall, DBT appears to be beneficial for LGP.