Overview

Eating disorders are complex mental health conditions that are a significant cause of both physical and psychosocial morbidity. They are more common in people assigned female at birth (AFAB) than those assigned male at birth (AMAB), especially during adolescence.¹

Eating disorders can be broadly divided into three diagnostic categories; anorexia nervosa, bulimia nervosa, and atypical eating disorders (such as binge-eating disorder). However, these disorders have many similar features and patients’ diagnoses may frequently differ.¹

Although significant progress has been made in studying the symptoms and treatment of eating disorders, many individuals with these disorders report limited improvement with treatment. Traditional treatment approaches may not adequately address the delicate web of emotional, psychological and behavioural patterns. In recent years, Dialectical Behavior Therapy (DBT) has emerged as a promising and effective treatment strategy and several researchers have adopted or applied it in patients with eating disorders.² 

In this article, we will explore the principles and applications of DBT in the context of eating disorders, and shed light on how this therapeutic approach can offer a comprehensive and compassionate treatment for those struggling with these conditions.

What are eating disorders?

Before delving into DBT and its principles, we need to comprehend the nature and complexity of eating disorders. These conditions are not solely about an individual’s relationship with food. They encompass a complex interplay of emotional, psychological, and societal factors. 

Anorexia nervosa (AN) and bulimia nervosa (BN) are complex, disorders of multiple determinants and an unknown etiology.³ Both syndromes have an excessive preoccupation with weight and body image, yet have distinctive patterns of weight regulation and behaviours. 

Anorexia nervosa (AN)

In AN, an individual seemingly purposefully restricts their food intake, which culminates in profound emaciation, weight loss and weakness.

Bulimia nervosa (BN)

Individuals with BN, on the other hand, suffer recurring cycles of binge eating which they compensate for by actions like self-induced vomiting, abusing laxatives/diuretics, and pathologically extreme exercise and restrictive diets.

Binge eating disorder (BED)

The Diagnostic and Statistical Manual (DSM)-III includes a category of atypical eating disorder for patients with disordered eating who cannot be classified into other categories. ⁴

Binge eating disorder (BED) is a condition which involves eating a lot of food in a small amount of time. These episodes of overeating are also referred to as ‘binges’. Unlike other types of eating disorders like bulimia nervosa, those with BED often do not follow through with ways to get rid of the food they have eaten.

Individuals with eating disorders often grapple with distorted body image, intense fear of gaining weight, and at times a feeling of worthlessness. This quest for control over one's body and food intake might become a coping mechanism for managing overwhelming emotions.

What is dialectical behaviour therapy (DBT)

DBT was developed by psychologist Dr. Marsha M. Linehan and was originally aimed at treating individuals with Borderline Personality Disorder.⁵ However, it was successful in addressing emotional regulation and self-destructive behaviours which has made it applicable to other mental health conditions as well, including eating disorders. 

Although DBT has many similarities with other cognitive-behavioural approaches, there are several critical and unique elements which must be in place for the treatment to be considered DBT. At its core, DBT combines cognitive-behavioural techniques with mindfulness and emphasises the dialectical philosophy of balancing acceptance of oneself and the potential for change. This involves acknowledging and accepting the current reality while simultaneously working dedicatedly and actively towards positive change. In terms of eating disorders, DBT proves invaluable in helping individuals navigate the tumultuous journey to recovery.

The four modules of DBT

DBT comprises four interrelated modules, each of which targets specific aspects of emotional regulation and behaviour change. These modules are:⁶

Mindfulness

This involves cultivating an awareness of the present moment and circumstance without judgement. The mindfulness skills are derived from traditional Buddhist meditation practices based on being aware and fully present in the present moment, experiencing one's emotions, thoughts and sensations completely, without judging or reacting to them. This module encourages people to observe and describe their experiences with food and body image without passing judgements or getting overwhelmed with emotions.

Distress tolerance 

This aims at equipping individuals with skills to manage crises without resorting to destructive coping mechanisms and behaviours. This module emphasises the importance of accepting a distressing situation and the development of healthier coping mechanisms to deal with distress and emotional turmoil. 

Emotion regulation 

This teaches patients to identify and manage intense emotions and foster emotional well-being. It also teaches them to understand the nature and functions of emotions, reduce emotional vulnerability, and enhance emotional intelligence. It enhances skills in problem-solving, analysing reality and taking actions opposite to reflexive behavioural tendencies associated with specific emotions. The module intends to give the patient a fresh look at emotions and to decrease emotional avoidance. 

Interpersonal effectiveness

Enhancing communication and relationship skills to navigate social interactions effectively. This module helps patients assert their needs, set boundaries, and maintain self-respect. The goal is to decrease interpersonal avoidance and promote interpersonal behaviour that is likely to receive positive reinforcement.

Dialectical behaviour therapy applications in eating disorders

Mindfulness during mealtime 

In the context of eating disorders, mindfulness plays an important role in transforming a patient’s relationship with food. Mindful eating involves being fully present during meals, savouring each bite, and paying attention to the body’s cues regarding hunger and fullness. This practice allows individuals to stay connected and understand their bodies, fostering a more intuitive approach to eating.⁷ ​​For example, DBT adapted for the treatment of bulimia nervosa and binge-eating disorder was associated with a promising decrease in binge/purge behaviours.

Distress tolerance and coping strategies

One of the challenges in treating eating disorders is managing the emotional distress that often triggers disordered eating, purging and destructive behaviours. DBT's distress tolerance module equips individuals with effective coping strategies, decreasing participants’ vulnerability to negative emotions which are associated with the urge to binge and purge. 

Emotion regulation 

Emotion dysregulation is a characteristic feature of eating disorders, meaning the emotion regulation module of DBT is particularly important. By addressing the emotional origins of disordered eating, individuals can create long-term changes in their behaviours. Integrating emotional regulation into the treatment of eating disorders can lead to significant improvements in emotional well-being and a reduction in disordered eating behaviours.⁸

Building supportive connections

Eating disorders often thrive in isolation and loneliness. The interpersonal effectiveness module of DBT aims to manage this by enhancing communication and relationship skills. Individuals learn to build supportive relationships, communicate their needs, set healthy boundaries, and navigate relationships to create a network of understanding and encouragement. This is crucial to the recovery process.

Challenges of dialectic behavioural therapy

While DBT is a promising prospect in the field of eating disorder management, it is essential to acknowledge that the path to recovery is individualised, unique and a multifaceted journey. Not every person responds to therapy in the same way, and various factors contribute to the outcome of the treatment. This includes co-morbid conditions, treatment adherence by the patient, and support systems.

Moreover, it can sometimes be difficult to find comprehensive DBT programs with qualified therapists. Integrating DBT into mainstream mental health services and increasing awareness among healthcare providers is likely to gradually address these barriers.

Summary

Dialectical behaviour therapy is a beacon of hope for those living with and navigating the complex treatment of eating disorders. By combining cognitive-behavioural techniques with mindfulness practices, DBT addresses the interplay between emotions, thought processes, and behaviours that characterise these conditions in a manner that focuses on resilience and self-compassion. 

As the medical and scientific communities continue to explore and develop the applications of DBT, it is important to increase awareness among the general public and accessibility for all. For individuals, families, and healthcare providers, embracing the philosophy of DBT, and focusing on striking a balance between acceptance and change paves the way for a brighter and more hopeful future in managing eating disorders.