Dialectical behavior therapy (DBT) has been shown to be effective in treating anorexia nervosa (AN), as patients with the disorder who underwent DBT saw low dropout rates and increased BMIs which were sustained 6 months later. While standard DBT has been shown to be effective, a DBT program that was augmented to focus on overcontrolled emotions and behaviors which contribute to AN was more helpful in encouraging long term results.

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DBT has shown effectiveness in treating anorexia nervosa, bulimia nervosa, and binge eating disorder. Studies have shown that using dialectical behavior therapy and mindfulness strategies as treatment for these patients is effective in curbing the negative behaviors associated with their respective disorders. Adapting DBT to emphasize the causal factors of these disorders has shown to be more effective than the use of standard DBT.


Usefulness of Dialectical Behavior Therapy in treating eating disorders

This list includes different types of methods for treating and/or managing different feeding and eating disorders. These include, but are not limited to the following:
-	Mindfulness for Patients with Eating Disorders
-	Cognitive-Behavioral Therapy vs. Behavioral Weight Loss (BWL) as Treatment for Binge-Eating Disorder
-	Mindfulness-Based Interventions for Binge Eating Disorders
-	Dialectical Behavior Therapy for treating Bulimia Nervosa
-	Dialectical Behavior Therapy for treating Anorexia Nervosa
-	Subjective Experiences of Eating Disorder Treatments
-	Pharmacological Treatment for Binge Eating Disorders
-	Enhanced Cognitive Behavioral Therapy (CBT-E) for Eating Disorders
-	Family-Based Treatment of Eating Disorders in Adolescents

Treatment & Management Methods for Feeding and Eating Disorders

Anorexia nervosa is an eating disorder defined by maintaining a body weight significantly below average, which is achieved through methods like starvation or excessive exercise. A central characteristic of this disorder is a distorted body image, a form of body dysmorphia, where individuals perceive themselves as overweight despite being underweight.

Anorexia Nervosa

Chen, E.Y., Segal, K., Weissman, J., Zeffiro, T.A., Gallop, R., Linehan, M.M., Bohus, M. and Lynch, T.R. (2015), Adapting dialectical behavior therapy for outpatient adult anorexia nervosa—A pilot study. Int. J. Eat. Disord., 48: 123-132. https://doi-org.ezproxy.bu.edu/10.1002/eat.22360

Adapting Dialectical Behavior Therapy For OutpatientAdult Anorexia Nervosa—A Pilot Study

•Purpose

•Method

•Results

•Conclusion 

•Limitations

Adapting Dialectical Behavior Therapy For Outpatient Adult Anorexia Nervosa—A Pilot Study: Article Summary

Though cognitive behavior therapy is generally considered the treatment of choice for bulimia nervosa, dialectical behavior therapy (DBT) may be particularly effective in treating bulimia nervosa due to its targeting of emotional dysregulation problems, which often underlie the eating disorder. One study has shown a significant decrease in binge/purging behaviors in patients with bulimia nervosa who underwent DBT with a focus on emotional regulation, though more research into this area is necessary.

Dialectical Behavior Therapy for treating Bulimia Nervosa

Dialectical behavior therapy (DBT) has shown positive outcomes in patients with binge eating disorder (BED), including a decrease in binge behaviors. In a study done in part by Dr. Marsha M. Linehan, a creator of DBT, 89% of the women receiving DBT had stopped binge eating by the end of treatment. Abstinence rates were reduced to 56% at the 6-month follow-up.  More research is needed with larger sample sizes to further support DBT as treatment for BED.

Dialectical Behavior Therapy for treating Binge Eating Disorder

Dialectical Behavior Therapy as Treatment for Anorexia Nervosa

Mindfulness interventions have been shown to be beneficial for those suffering with eating disorders including anorexia nervosa, binge eating disorder, and bulimia nervosa.

Mindfulness for patients with eating disorders

- Dialectic Behavior Therapy
- Mindfulness-Based Eating Awareness Training

Mindfulness-Based Interventions for Binge Eating Disorder

One study examined the current literature on the experiences and perspectives of those across healthcare interfaces for eating disorders, to include individuals with eating disorders, people close to or caring for those with eating disorders such as family and friends, and health professionals.

Subjective Experiences of Eating Disorder Treatments 

One study explored the different pharmacological treatments for BED. The study found that antidepressants, appetite suppressants, and anticonvulsants, specifically, desipramine, fluvoxamine, fluoxetine, sertraline, citalopram, dexfenfluramine, sibutramine, and topiramate can aid in BED treatment. 

Pharmacologic Treatment for Binge Eating Disorder

Enhanced cognitive behavior therapy (CBT-E) is a transdiagnostic approach that is designed to treat multiple clinical conditions, including the complete list of eating disorders identified in DSM-V, such as anorexia nervosa, bulimia nervosa, binge eating disorder (BED), among others. It is different from typical CBT in that it aims to treat the underlying pathological factors contributing to several disorders, rather than any one condition. 

CBT-E is comprised of four stages, yet the details of each stage differ based on the individual patient and their clinical circumstances.

The overarching goal of CBT-E is to assist the patient in first acknowledging their harmful eating patterns and body-image concerns so that they can eventually begin actively participating in therapeutic sessions targeted at addressing the emotions, beliefs/thoughts, and behaviors (e.g., body-image concerns, low self-esteem stressful life events, interpersonal relationship conflicts, etc.)  sustaining their condition. 

After the patient has begun to heal, CBT-E treatment provides them with coping mechanisms to manage challenges to their recovery so that they can maintain their progress.

Enhanced Cognitive Behavioral Therapy (CBT-E) for Eating Disorders 

The family-based treatment (FBT) method for eating disorders entails a clinician working with the adolescent patient and their family to establish a comprehensive care plan that extensively engages the patient's home/family life.

Comprised of three phases, FBT is characterized by granting the patient's family responsibility to monitor and oversee their child's eating behaviors in order to support the patient's sustainable adoption of healthy eating habits. As the patient progresses in their recovery, they are incrementally granted more autonomy over their dietary decisions and eating preferences.

Family-based Treatment of Eating Disorders in Adolescents

Research unfortunately indicates that anorexia nervosa treatment outcomes are not always ideal. Although oftentimes significant weight is restored by the end of treatment, psychological symptoms frequently go largely unaddressed, indicating a gap in current treatment procedures that may leave patients more vulnerable to relapse.

Anorexia Nervosa Treatment Outcomes

Depending on the severity of the case of bulimia nervosa, treatment methods may vary, but often include the following: 

- Purging cessation
- Nutritional support
- Monitoring 
- Medical treatment for complications
- Psychotherapy
- Psychiatric medication

Bulimia Nervosa Treatment

CBT is known as an effective treatment for binge-eating disorder (BED) in that it helps people to stop binge-eating, but it does not actually help people to lose weight (which is important because BED puts people at high risk for obesity and the health problems associated with that).  Because of this shortcoming, perhaps another treatment option is necessary to help people with BED to lose weight.

Cognitive-Behavioral Therapy vs. Behavioral Weight Loss (BWL) as Treatment for Binge-Eating Disorder

Multiple forms of treatment exist for binge eating disorder, each with different levels of efficacy in terms of prompting remission of binge-eating episodes, lessening psychological symptoms, and reducing body weight:

- Psychotherapy
- Structured self-help treatment
- Combined treatment
- Pharmacotherapy
- Behavioral weight loss treatment
- Self-help weight loss treatment
- Inpatient treatment 

Binge Eating Disorder Treatment Outcomes

In general, treatments for ARFID can be divided into two major groups: 

- Psychological treatment
- Adjunctive pharmacological treatment

Avoidant/Restrictive Food Intake Disorder (ARFID) Treatment

Several models exist to include family members in anorexia nervosa treatment. These models strive to put theory-based strategies into action, either by addressing intra- and inter-personal factors that maintain the disorder, by addressing behaviors of the illness, or by focusing on improving the well-being of the family as a whole: 

- CBT-oriented family module
- Systemic family therapy
- Maudsley model of family-based therapy (FBT)
- New Maudsley Model for Collaborative Care (NMCC)

Family Inclusion in Anorexia Nervosa Treatment

Neuromodulatory techniques are also being studied to directly affect the brain to regulate food intake and reduce AN’s psychological symptoms. Multiple forms on neuromodulation have been studied or are being studied currently, including the following:
- Transcranial direct-current stimulation (tDCS) 
- High-frequency repetitive transcranial magnetic stimulation (rTMS) 
- Deep brain stimulation (DBS)

Neuromodulation for Anorexia Nervosa Treatment

While there is a long tradition of studying health inequalities between social classes, the standard approach does not apply for anorexia. The intersection of the social relations of age, gender, and social background, with which they are related, accounts sociologically for the disparities in the frequency of EDs.


Anorexia in Social Relationships

Diagnostic Criteria for Anorexia Nervosa (DSM-V)

1. The individual restricts their consumption of food such that it is significantly lower than their body's energetic demand, resulting in a dramatic reduction in body weight. This reduction is evaluated in reference to the individual's expected weight, which itself varies according to their age, sex, and developmental trajectory.

2. The extreme fear of gaining weight and/or subcutaneous fat, which prevents weight restoration and/or maintenance of a healthy weight.

3. The distortion of the individual's body-image due to the their perception their body's weight or shape, low sense of self-worth because of their body's weight or shape, or the absence of an acknowledgment that their body weight is lower than what is clinically considered to be healthy.

Diagnostic Criteria for Anorexia Nervosa (DSM-V)

A model explaining the intra- and inter-personal maintenance factors for the continued duration of anorexia nervosa, not bound by Western sociocultural limitations. Intrapersonal factors combine to predispose individuals to anorexia nervosa and contribute to its maintenance, eliciting strong reactions from close others which then create interpersonal factors that further perpetuate the illness:

- Perfectionism/cognitive rigidity
- Experiential avoidance
- Pro-anorectic beliefs
- Expressed emotions

Cognitive-Interpersonal Maintenance Model of Anorexia Nervosa

Individuals diagnosed with anorexia nervosa will typically have a distorted body image, which refers to when one feels they look overweight despite not being overweight. Distorted body image is a type of body dysmorphia.

Distorted Body Image

The gut microbiome is a diverse, abundant microbial ecosystem that helps modulate homeostasis via a symbiotic relationship with its host. It has implications in multiple complex diseases by facilitating interactions between genes and the environment, but it is vulnerable to chronic environmental disturbances, such as the dietary fluctuations and nutritional deprivation inherent to anorexia nervosa. It is likely involved in AN pathophysiology by affecting energy metabolism, intestinal permeability, immune function, appetite, and behavior, but complicated by genetic risk factors, eating patterns, etc.. Intestinal bacteria may be involved in appetite and weight regulation along with comorbidities such as mood changes and gastrointestinal symptoms by acting on metabolic, neuroendocrine, and immune pathways.

- Dysbiosis in anorexia nervosa 
- Gut microbiota adaptations to starvation 
- Microbiome-based anorexia nervosa symptom mechanisms 
- Microbiome-based interventions for anorexia nervosa

Anorexia Nervosa and the Gut Microbiome

Individuals with anorexia nervosa face an elevated risk of developing other psychological problems. Commonly co-occurring conditions include anxiety disorders, mood disorders, and issues with substance abuse.

Psychological Comorbidities of Anorexia Nervosa

The prevalence of anorexia nervosa is estimated to range from just under 1% to over 4% among women. The rates of this disorder are significantly lower for men.

Prevalence of Anorexia Nervosa

An example of a public health initiative is an Italian advertising campaign that was created to increase public awareness about anorexia nervosa. This campaign was highlighted in a news story to broaden its reach.

Italian Advertising Campaign for Anorexia Nervosa Awareness

A 19-year-old student is brought in for a consultation by her concerned parents. She is 5'7" tall and weighs 98 pounds. Despite her significantly low body weight, she expresses an intense fear of gaining weight and frequently states that she feels 'fat,' often pointing to her stomach and thighs. Her parents report that she eats very small portions, avoids high-calorie foods entirely, and engages in a rigorous two-hour exercise routine every day. Based on this information, which psychological disorder is most likely being described? Justify your answer by identifying at least two key features from the scenario that align with the typical presentation of this disorder.

Clinical Scenario Analysis

The medical consequences of anorexia nervosa are primarily caused by severe starvation, as well as purging behaviors.

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