In addressing purging behaviors, a CBT clinician might focus on identifying triggers and challenging cognitive distortions, while a DBT clinician might validate the emotional distress behind the behavior and guide the client toward healthier emotion-regulation strategies.
In Navarro-Haro et al.’s (2018) study of 118 women diagnosed with both BPD and EDs (DBT group = 71; TAU CBT group = 47), both approaches reduced hospitalizations, suicide attempts, dysfunctional eating, and emotional suppression. Neither treatment emerged as definitively superior, but DBT may offer advantages for emotion regulation across diagnoses.
Clinically, many providers combine CBT and DBT principles, as CBT alone is often insufficient for BPD, while DBT may not fully address cognitive distortions central to ED pathology. For example, an individual admitted for Anorexia Nervosa might initially receive CBT for nutritional rehabilitation and cognitive restructuring; if borderline traits emerge, DBT modules may be introduced to address emotional instability and self-destructive behaviors.

Example of transdiagnostic treatment approaches in comorbid BPD and ED.

In comorbid cases, CBT often begins by targeting impulsive behaviors (e.g., binge eating, purging) through increased awareness of maladaptive actions and restructuring distorted thinking patterns. Clinicians may use reward-based procedures to promote internal attribution and prevent relapse (Navarro-Haro et al., 2018).

Saint Olaf College

The two approaches in treating comorbid BPD and ED:

- Cognitive Behavioral Therapy
- Dialectical Behavioral Therapy

Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) are both widely used to treat comorbid Borderline Personality Disorder (BPD) and Eating Disorders (EDs), but they approach symptom management differently.

Transdiagnostic Treatment Approaches for Comorbid BPD and ED.

Costa, J., Marôco, J., Pinto-Gouveia, J., Ferreira, C., & Castilho, P. (2016). Validation of the Psychometric Properties of the Self-Compassion Scale. Testing the Factorial Validity and Factorial Invariance of the Measure among Borderline Personality Disorder, Anxiety Disorder, Eating Disorder and General Populations. Clinical Psychology and Psychotherapy, 23(5), 460–468. https://doi.org/10.1002/cpp.1974

Bozzatello, P., Garbarini, C., Rocca, P., & Bellino, S. (2021). Borderline Personality Disorder: Risk Factors and Early Detection. Diagnostics (Basel, Switzerland), 11(11), 2142. https://doi.org/10.3390/diagnostics11112142
Khosravi, M. Eating disorders among patients with borderline personality disorder: understanding the prevalence and psychopathology. J Eat Disord 8, 38 (2020). https://doi.org/10.1186/s40337-020-00314-3

Dyson Tori, Thomas Susan J., Townsend Michelle L., Finch Adam, South Alexandra, Barkus Emma, Walter Emma, Mendonca Carley, Grenyer Brin F. S., Pickard Judy A. (2023). Salivary testosterone and cortisol levels in borderline personality disorder before and after a 12-week group dialectical behavior therapy intervention. Frontiers in Psychology, 14(14). https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2023.1195187

Federici, A. (2009). Dialectical Behaviour Therapy for the Treatment of Eating Disorders. NEDIC, NEDIC Eating Disorders Bulletin.

Lee, K. S., & Vaillancourt, T. (2024). Trajectories, comorbidity, and risk factors for adolescent disordered eating and borderline personality disorder features. Development and Psychopathology, 36(4), 1546–1557. doi:10.1017/S0954579423000792

Lee, S. S. M., Keng, S.-L., & Hong, R. Y. (2024). Validating the biosocial model of borderline personality disorder: Findings from a longitudinal study. Development and Psychopathology, 36(4), 1752–1762. doi:10.1017/S0954579423001116

Lester, R. J. (2009). Brokering Authenticity: Borderline Personality Disorder and the Ethics of Care in an American Eating Disorder Clinic. Current Anthropology, 50(3), 281–302. https://doi.org/10.1086/598782

Miller, A. E., Hotte-Meunier, A., Bain, T., Macdonald, E. P., Steiger, H., & Racine, S. E. (2025). A Qualitative Study of the Lived Treatment Experiences of Women With an Eating Disorder and Comorbid Borderline Personality Disorder. The International journal of eating disorders, 58(5), 860–867. https://doi.org/10.1002/eat.24390

Navarro-Haro, M. V., Botella, C., Guillen, V., Moliner, R., Marco, H., Jorquera, M., Baños, R., & Garcia-Palacios, A. (2018). Dialectical Behavior Therapy in the Treatment of Borderline Personality Disorder and Eating Disorders Comorbidity: A Pilot Study in a Naturalistic Setting. Cognitive Therapy and Research, 42(5), 636–649. https://doi.org/10.1007/s10608-018-9906-9

Newton, J. R. (2019). Borderline personality disorder and eating disorders: a trans-diagnostic approach to unravelling diagnostic complexity. Australasian Psychiatry : Bulletin of the Royal Australian and New Zealand College of Psychiatrists, 27(6), 556–558. https://doi.org/10.1177/1039856219852297

Ni, X., Chan, D., Chan, K., McMain, S., & Kennedy, J. L. (2009). Serotonin genes and gene–gene interactions in borderline personality disorder in a matched case-control study. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 33(1), 128–133. https://doi.org/10.1016/j.pnpbp.2008.10.022.

Ntshingila, N., Poggenpoel, M., Myburgh, C. P. H., & Temane, A. (2016). Experiences of women living with borderline personality disorder. Health SA = SA Gesondheid, 21(1), 110–119. https://doi.org/10.1016/j.hsag.2016.01.001

Sansone, R. A., & Sansone, L. A. (2007). Childhood Trauma, Borderline Personality, and Eating Disorders: A Developmental Cascade. Eating Disorders, 15(4), 333–346. https://doi.org/10.1080/10640260701454345

Sansone, R. A., & Sansone, L. A. (2010). Personality Disorders as Risk Factors for Eating Disorders: Clinical Implications. Nutrition in Clinical Practice, 25(2), 116–121. https://doi.org/10.1177/0884533609357563.

Steiger, H. (2004). Eating disorders and the serotonin connection: state, trait, and developmental effects. Journal of psychiatry & neuroscience: JPN, 29(1), 20–29.

Power, R. A., & Pluess, M. (2015). Heritability estimates of the Big Five personality traits based on common genetic variants. Translational psychiatry, 5(7), e604. https://doi.org/10.1038/tp.2015.96

Reference List: Comorbidity of Borderline Personality Disorder and Eating Disorders

Key Considerations of Marsha Linehan’s Biosocial Model for Eating Disorders and Borderline Personality Disorder (Lee et al. 2023):

- Invalidating Environment
- Emotional Vulnerability
- Inability to return to baseline quickly.
- Highly reactive.

Although this model was initially developed for BPD, it has become a useful model in interpreting eating disorders since eating disorders often are a means to cope with uncomfortable emotions or thoughts.

Is Linehan’s Biosocial Model Accurate Among Co-Occurring Disorders with BPD?


Navarro-Haro, M. V., Botella, C., Guillen, V., Moliner, R., Marco, H., Jorquera, M., Baños, R., & Garcia-Palacios, A. (2018). Dialectical Behavior Therapy in the Treatment of Borderline Personality Disorder and Eating Disorders Comorbidity: A Pilot Study in a Naturalistic Setting. Cognitive Therapy and Research, 42(5), 636–649. https://doi.org/10.1007/s10608-018-9906-9

Dialectical Behavior Therapy in the Treatment of Borderline Personality Disorder and Eating Disorders Comorbidity: A Pilot Study in a Naturalistic Setting.

DBT, in contrast, prioritizes crisis de-escalation and emotional regulation. Its four stages begin with reducing self-harm/suicidal behaviors, then fostering open communication and therapy engagement, followed by developing healthier coping mechanisms and refining impulse-control skills (Navarro-Haro et al., 2018).

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