1 Using Dialectical Behavioural Therapy with Eating Disorders Dr Caroline Reynolds Consultant Psychiatrist Richardson Eating Disorder Service
2 Contents What is dialectical behavioural therapy (DBT)? How has it been used with eating disorders? The REDS experience
3 What is DBT?
4 Origins of DBT Marsha Linehan ; 1993 Evolved from problems applying standard CBT to severe and chronically suicidal patients meeting criteria for Borderline Personality Disorder (BPD). Integration of western psychological practice with a perspective drawn from Eastern (zen) practice Multiple RCT s showing effective in reducing suicidal and self harm behaviours
5 Principles of DBT Not manualised a principle driven therapy that includes protocols two main principles; many different protocols and strategies Two principles: dialectics and behaviourism
6 Dialectics reconciliation of opposites in a continual process of synthesis Thesis antithesis -> synthesis Opposite of black and white thinking E.g. I am really fat vs. you are very thin
7 Dialectics In psychotherapy Emphasis on change can lead to increasing distress Emphasis on acceptance means no change occurs In DBT Acceptance and change Validation and problem solving
8 Behaviourism Behaviours are learned Behaviours can be analysed in terms of A,B,C Frequency of a behaviour can be increased by the responses of others (reinforcement) Just because a certain behaviour leads to a certain response does not mean it is intentional or manipulative. Contingency management=altering environment and responses of others to reinforce desired behaviours
9 DBT assumptions about patients Patients want to improve Patients are doing the best they can Patients need to do better, try harder and be more motivated Patients cannot fail in DBT Patients may not have caused all their own problems but they have to solve them anyway The lives of suicidal BPD patients are unbearable as they are currently being lived.
10 Biosocial theory of BPD Some individuals born more emotionally vulnerable Some environments can be invalidating Rejects communication of experiences Reinforces escalation of behaviour Over simplifies ease of problem solving BPD is result of transaction between vulnerable individual and invalidating environment
11 DBT Functions and modes Function Mode Enhance capabilities Improve motivation Assure generalisation to natural environment Structure the environment Enhance therapist capabilities Skills training Individual therapy Telephone coaching Family work Communication Team consultation
12 Skills training Group format 1 hour homework; 1 hour skills training 3 eight week modules; 6 month cycle 4 sets of skills Distress tolerance Interpersonal effectiveness Emotion regulation Mindfulness
13 Individual therapy Weekly; for at least one year Pre-treatment (4 sessions) Establish shared goals Gain commitment to therapy; sign agreements Stage 1 achieving behavioural control Decreasing life threatening behaviours, therapy interfering behaviours quality of life effecting behaviours Stage 2 treating trauma (exposure) Stage 3 solving day to day problems in living Stage 4 capacity for joy (insight orientated)
14 Individual therapy Stage 1 Each session Review diary card Chain analysis of most dangerous behaviour (according to target hierarchy) Identify and learn more helpful behaviours Time to discuss other issues only if no target behaviours have occurred
15 Diary card
16 Chain analysis
17 Telephone coaching Allows real time coaching in use of new skills Reinforcing appropriate help seeking behaviour Patients encouraged to call therapist BEFORE engaging in target behaviour Forbidden to call for 24 hours after self harming or other target behaviour
18 Structuring the environment Contingency management with treatment programme and community Family interventions Communication with other professionals involved consultation to the patient
19 Consultation team Role of Consultation team Keep the therapist within the DBT framework Increase adherence to DBT principles Address problems that occur in course of treatment delivery Increase/maintain therapist motivation Reduce or head off therapist burnout Meet weekly; leader; agenda; notes Consultation team agreements
20 Overall goal of DBT: A LIFE WORTH LIVING!
21 How has DBT been used with eating disorders?
22 DBT and eating disorders (ED) Good theoretical reasons why DBT could be used for treatment of ED Characterised by problem behaviours Associated with emotional dysregulation High co morbidity with BPD (34% BPD have an ED) Possible shared aetiology Patients with co-morbid BPD may respond less well to treatments for ED
23 How has DBT been used in ED? Across different diagnoses (AN, BN, BED) Predominantly with bingeing With and without co morbid BPD With a range of different modifications Few RCT s Even fewer trials comparing to other psychotherapies Small numbers
24 DBT for BED Telch 2000: 20 weeks modified skills group; reduced bingeing, depression and comfort eating; 70% well at 6 month follow up; n=11; no control group. Telch 2001: 20 week skills group compared to waiting list; reduced bingeing, less eating concerns; 56% well at follow up; n=44 Safer 2010: 20 weeks individual skills training compared to TAU; reduced binging and lower drop outs compared to controls but no difference at 12 months; n=101 Klein 2012: modified skills training for BED/BN showed reduced bingeing and improved scores on EDI; high drop out rate; n=5; no control group
25 DBT for BN Safer 2001: 20 weeks individual skills training vs. waiting list. Significant reduction in binge purge symptoms; n=31 Salbach-Andrae 2008: 25 week DBT programme with all components; adolescents; improvement in all restrictive AN; no change in BN; n=12; no control group Hill 2011: 12 week appetite focussed DBT vs. waiting list control. Reduced symptoms at 6 weeks, sustained at follow up; n=58
26 DBT for AN No published studies UK trial underway with restrictive AN New form of DBT adapted by Thomas Lynch ( radical openness ) Patients taught skills in being flexible, open to new experience and expression of emotion
27 DBT for ED with BPD Palmer 2003: full DBT programme including extra module for 18 months. No dropouts; significant reduction in ED behaviours and no self harm at follow up; n=7; no control group Chen 2008: BN or BED; 6 month standard DBT with minor modifications. Large effect size for binge eating, EDE scores and global adjustment; medium effect for self harm; further reduction in self harm at 6 month follow up; n=8, no control. Kroger 2010: 3 month IP programme; AN or BN; at 15 month 54% BN and 33% AN remitted; 44% AN become BN; self harm not assessed; n=24; no control group.
28 DBT for ED with BPD Ben-Porath 2009: partial hospital; all modes of standard DBT with some modifications. 40% had BPD and ED; 60% ED alone. No difference in ED outcomes between the groups. BPD group had significant improved emotion regulation; n=40; no control group. Federici 2010: 20 week skills group as adjunct to non- DBT individual therapy in individuals with BPD, recurrent self injury and BN/BED. Significantly reduced self harm behaviours. No significant reduction in bingeing or purging; n=33; no control group.
29 The REDS experience
30 The REDS experience Team of 4 staff underwent intensive DBT training October 2011/April 2012 DBT programme began running January 2012 All DBT components for minority Skills group as key component Studies show skills group alone effective in reducing binges (Telch 2000;2001)
31 The REDS DBT programme Level 1 5 mode Skills group Level 2 Coaching skills Level 3 Skills group only
32 3 levels REDS DBT programme Level 1 full DBT program (individual therapy, skills group, generalisation) Level 2 in patients, Skills group plus nurse coaching Level 3- Skills group as an add on to outpatient care
33 Inclusion criteria for REDS skills group History of binging/purging History of one or more other impulsive behaviour (self harm, substance misuse, shoplifting etc) Willing and able to commit to weekly sessions and homework BMI greater than 14
34 Method Patients recruited as per inclusion criteria Skills group run as per manual, with minor adaptations Patients asked to complete Current Behaviour Questionnaire (CBQ) at start and end of each module Patient Satisfaction Questionnaire at the end of three modules
35 Current Behaviour Questionnaire
36 Outcomes All female; Diagnosis AN, BN or EDNOS All having individual therapy; some in patient; some dietetics; other group work; 9 patients completed full three modules; one patient did not complete a CBQ after module 1
37 Outcomes Frequency in the last month Bingeing Self Induced Vomiting Other Purging Alcohol Drugs Prescription drugs Self harm Behaviour Suicide A & E Emergency admission Before Group Post module 1 Post module 2 Post module 3
38 Outcomes A trend towards a reduction in all behaviours is seen from start to end of module 3 Sample too small for statistical significance Greatest decrease was in self induced vomiting
39 Patient experience Patients rated various aspects of the group on a 0-10 Likert scale Interesting (9.4 sd 1.1) Relevant (9.3 sd 1.5) Supportive (9.6 sd 0.8) 6/7 patients used skills quite a lot or a great deal 6/7 patients found them to be quite or extremely helpful
40 Patient experience I have found all of the skills extremely useful it has made my life a lot more liveable and given me hope for my future I have learned a great deal and it has helped me to live a more positive life I am much happier and more balanced, my family and friends see the change in me and love being around me now I am more aware of my emotions and now I can control them. My impulsive behaviours have reduced and I m much calmer
41 What worked well Support from others in group Listening to how others in group used skills Sharing experiences and hearing from each other Being able to support one another and give advice Examples from real life Leaders interested, dedicated, committed, sensitive, understanding, supportive, can relate to them as humans
42 Limitations Small sample size No control group Bias from self report
43 Conclusions Evidence so far shows a reduction of impulsive behaviours in patients who attend REDS skills group Patients find skills group acceptable and helpful Programme to continue with ongoing evaluation
44 Summary DBT is an evidence based treatment for borderline personality disorder Good theoretical reasons why DBT could work in ED as well Evidence suggests a positive effect but absence of RCT s in this area
46 References Linehan, M. M. (1993). Cognitive Behavioural Treatment for Borderline Personality Disorder. New York: Guilford Press. Linehan, M. M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press. Bankoff, S. M., Karpel, M. G., Forbes, H. E., and Pantalone, D. W. (2012). A systematic review of Dialectical Behaviour Therapy for the treatment of eating disorders. Eating Disorders, 20, Reynolds, C; Metcalfe, L; Ridley, C. Evaluation of the skills group component of Dialectical Behaviour Therapy in an adult Eating Disorder Service. Poster ; EDSect Conference November 2013