Wise Eating: A Guided Dialectical Behavior Therapy‐Based APP for Binge Eating—A Randomized Controlled Trial

Dialectical Behaviour Therapy (DBT) has demonstrated effectiveness in reducing harmful behaviours associated with emotion dysregulation, including non-suicidal self-injury (NSSI) and binge eating. It has been hypothesized that the effects of DBT on NSSI and binge eating are the result of improvements in emotion regulation (ER); however, the extent to which changes in ER account for reductions in these behaviours is unclear. The present study leverages two unique clinical samples to examine the degree to which changes in ER influence changes in the frequency of NSSI and binge eating over the course of DBT. Participants included 189 Veterans receiving outpatient DBT and 117 civilians enrolled in a DBT Intensive Outpatient Program. Analyses examined changes in ER, binge eating and NSSI over the course of treatment, as well as the extent to which NSSI and binge eating frequency were influenced by changes in ER. In the Veteran sample, DBT led to improvements in ER abilities and significant reductions in NSSI and binge eating; however, changes in ER did not account for observed reductions in NSSI or binge eating. In the civilian sample, the effects of DBT on ER, NSSI and binge eating were nonsignificant. Our findings suggest that ER may not be the only mechanism through which DBT exerts its effects on NSSI and binge eating. The effects of DBT on ER and self-damaging behaviours may vary based on factors such as treatment setting, time in treatment and clinical severity of the sample.

Many Autistic adults without intellectual disability experience emotion dysregulation, which is associated with non-suicidal self-injury and suicidal behaviour. Dialectical behaviour therapy has been shown to be feasible, acceptable and potentially effective is supporting Autistic adults without intellectual disability with improved emotion regulation. Since dialectical behaviour therapy research is in its early stages in the field of autism, it is crucial to better understand the subjective experience of Autistic adults who received dialectical behaviour therapy to improve its pertinence for this population. Twenty-two Autistic adults presenting with emotion dysregulation with non-suicidal self-injury and/or suicidal behaviour/ideation who received a comprehensive dialectical behaviour therapy were interviewed using a semi-structured approach. A reflexive thematic analysis was conducted. Three superordinate themes were identified from the thematic analysis: (1) dialectical behaviour therapy is highly useful, structured and demanding; (2) dialectical behaviour therapy leads to changes in emotion labelling, emotion regulation and relationships; and (3) self-acceptance and feeling empowered to handle life's challenges. Ideas to foster the pertinence of dialectical behaviour therapy for Autistic adults were also collected. Our findings indicate that dialectical behaviour therapy was experienced as highly helpful despite the effort it requires. Participants reported changes in emotion experience, social relationships, self-concept and quality of life, probably due to increased emotion awareness, emotion control and self-regulation. Suggestions include the increased use of modelling to foster skills acquisition.Lay AbstractMany Autistic adults struggle with their emotion regulation. Dialectical behaviour therapy is the main therapy available to teach emotion regulation skills to people with this kind of struggle. Prior work has shown that dialectical behaviour therapy might be effective for Autistic people. Yet interest in dialectical behaviour therapy is new in the field of autism, so it is important to understand whether and how the therapy may help Autistic adults better live with their emotions. This article uses interviews conducted with 22 Autistic people following dialectical behaviour therapy. We outline several factors that might make dialectical behaviour therapy effective for Autistic people. For instance, dialectical behaviour therapy seems to help Autistic people better label and understand their emotions, but also accept and respect themselves. Nevertheless, dialectical behaviour therapy is demanding and some changes are suggested to improve the effects of dialectical behaviour therapy, such as providing a less intensive format to diminish fatigue. Our article provides evidence for the usefulness of dialectical behaviour therapy to help Autistic adults better deal with their emotions and improve their quality of life. Building from the experience of Autistic people, our study highlights the perceived benefits of dialectical behaviour therapy and the potential changes (e.g. reduction of text) to improve the utility of dialectical behaviour therapy for Autistic adults.

Background/Objectives: With the rapid progression of technology, applications have been proposed as a promising alternative to conventional psychotherapeutic treatment. Nonetheless, research on unguided self-help applications for binge eating remains scarce, with most existing studies utilizing cognitive behavioral therapy (CBT) principles. Therefore, this paper presents the protocol for a randomized controlled trial designed to evaluate the efficacy and acceptability of eMOTE, a standalone application designed specifically for women in Portugal who binge eat. eMOTE, adapted from dialectical behavior therapy (DBT), is unique in that it focuses on teaching emotion regulation skills while also integrating core CBT strategies. Methods: At least 68 females who self-report binge eating episodes will be randomized into an intervention group with access to eMOTE for eight weeks or a delayed waitlist, which will have access to eMOTE after the T1 assessment. Assessments will be conducted at baseline (T0), post-intervention (T1), and at 2-month follow-up (T2). The primary outcomes will include objective and subjective binge eating frequency and binge eating symptomatology, while secondary outcomes will assess global levels of ED psychopathology, shape concern, weight concern, eating concern, dietary restraint, compensatory behaviors, mindfulness, emotion regulation difficulties, intuitive eating, psychological distress, and body mass index. Conclusions: This study will contribute to the limited literature on the use of smartphone technology as an alternative to traditional psychotherapy. Furthermore, this standalone application will offer insights into the use of emotion regulation and food monitoring components designed for adult females experiencing binge eating episodes.

The effect of dialectical behaviour therapy on binge eating, difficulties in emotion regulation and BMI in overweight patients with binge-eating disorder: A randomized controlled trial

Dialectical behavior therapy (DBT) is a specialized treatment that has a growing evidence base for binge-spectrum eating disorders. However, cost and workforce capacity limit wide-scale uptake of DBT since it involves over 20 in-person sessions with a trained professional (and six sessions for guided self-help format). Interventions translated for delivery through modern technology offer a solution to increase the accessibility of evidence-based treatments. We developed the first DBT-specific skills training smartphone application (Resilience: eDBT) for binge-spectrum eating disorders and evaluated its efficacy in a randomized clinical trial. Participants reporting recurrent binge eating were randomized to Resilience (n = 287) or a waitlist (n = 289). Primary outcomes were objective binge eating episodes and global levels of eating disorder psychopathology. Secondary outcomes were behavioral and cognitive symptoms, psychological distress, and the hypothesized processes of change (mindfulness, emotion regulation, and distress tolerance). Intention-to-treat analyses showed that the intervention group reported greater reductions in objective binge eating episodes (incidence rate ratio = 0.69) and eating disorder psychopathology (d = -0.68) than the waitlist at 6 weeks. Significant group differences favoring the intervention group were also observed on secondary outcomes, except for subjective binge eating, psychological distress, and distress tolerance. Primary symptoms showed further improvements from 6 to 12 weeks. However, dropout rate was high (48%) among the intervention group, and engagement decreased over the study period. A novel, low-intensity DBT skills training app can effectively reduce symptoms of eating disorders. Scalable apps like these may increase the accessibility of evidence-based treatments.

Binge eating behaviours in bipolar disorders

Objectives: This study aims to investigate the effect of Emotion-Focused Therapy (EFT) on depression, anxiety, and Difficulty in Emotion Regulation (DER) in women with Binge Eating Disorder (BED). Methods: This is a quasi-experimental study with pre-test/post-test/follow-up design using a control group. Study population consists of all women referred to the obesity clinics in Tehran in 2019. Of these, 40 were selected using a purposive sampling method and were randomly divided into two groups of intervention (n=20) and control (n=20). The intervention group received 10 sessions of EFT, each session for 90 minutes. Data collection tools were the Beck Anxiety Inventory (BAI), the Beck Depression Inventory II (BDI-II), Difficulties in Emotion Regulation Scale (DERS), and Binge Eating Scale (BES), which were completed before and after the intervention. Data were analyzed using descriptive statistics and repeated measure ANIVA in SPSS v. 21 software. Results: Group EFT significantly reduced the mean anxiety, depression, DER and severity of binge eating after intervention and over the 2-month follow-up period in BED women (P<0.05). Conclusion: The EFT can reduce anxiety, depression, DER and binge eating severity in BED women, and its effect remains constant after two months. It can be useful in the treatment of BED.

Autistic adolescents are at higher risk of self-harm, suicidal behaviours, and emotion dysregulation compared with their non-autistic peers. Dialectical behaviour therapy (DBT) is an evidence-based treatment for self-harm and suicidal behaviour with emerging literature of the application of DBT for autistic populations. Despite this, no qualitative research has investigated the experiences of autistic adolescents of standard DBT. Therefore, this study aimed to explore autistic adolescents’ experiences of non-adapted DBT. Ten adolescents who had or were seeking an autism diagnosis, and were in a DBT programme, completed semi-structured interviews. Qualitative data from the interviews were analysed using reflexive thematic analysis. Themes were generated for each objective. Objective 1 included themes about the lived experience of autistic adolescents accessing DBT, including: ‘The impact of invalidation’, ‘Fostering acceptance and understanding’, ‘What does autism mean to me?’, and ‘Autism and mental health difficulties’. The themes regarding Objective 2 were about the experiences of the various modes of DBT and were organised by each client-facing mode. Objective 3 included themes highlighting the experience of utilising DBT skills in daily life, which included: ‘Barriers to skills use’, ‘Supporting skills use’, and ‘Skills practice or masking?’. Finally, Objective 4 included themes regarding the recommendations participants had for optimising DBT for autistic people: ‘Improving written materials’ and ‘General accessibility advice’. These findings suggest for DBT therapists to embody cultural humility, curiosity, validation, and flexibility when building neuro-affirmative competencies for supporting autistic individuals. Results are discussed in relation to the application and acceptability of DBT for this group. Key learning aims (1) Recent publications (e.g. Keenan et al., 2023) have explored the experience of autistic adults accessing DBT and highlighted the need for clinicians to work collaboratively with clients and make reasonable adjustments to improve autistic adults’ understanding and adherence to DBT. (2) To date, no qualitative studies have explored the experience of autistic adolescents accessing the Rathus and Miller (2015) Adolescent DBT model. The current study explores the views of autistic adolescents on how autism is discussed and considered by clinicians when supporting them to access different components of DBT when describing the strengths and barriers they experience. (3) Adopting a bottom-up approach, we identify key themes from adolescents’ perspectives on how to support them to access and engage with different DBT components, ranging from making environmental adaptations to meet individual sensory needs to improve accessibility, to providing more opportunities for personalised learning using neuro-affirmative examples that can improve generalisability of skills in everyday life. We provide recommendations for clinicians to consider on ways of adapting the process and content of DBT to increase accessibility and engagement for autistic adolescents in treatment.

Mindfulness, emotion regulation, and distress tolerance are hypothesised mechanisms that underpin Dialectical Behaviour Therapy (DBT) for binge eating, yet their role in app-based interventions is unclear. This study examined whether (1) a digital DBT app improved these skills compared to a control condition and (2) baseline skill levels predicted post-treatment symptom change. This secondary analysis drew on data from a randomised controlled trial (n = 576) of adults with recurrent binge eating. Participants in the intervention (n = 287) completed a six-week self-guided DBT app, while controls (n = 289) were waitlisted. Mindfulness, emotion regulation, and distress tolerance were assessed at baseline, post-test, and 12-week follow-up. Outcomes were binge eating episodes and the Eating Disorder Examination Questionnaire (EDEQ). Linear mixed models tested treatment effects, while univariate and multivariate models assessed baseline predictors. The app produced small-to-moderate improvements in four emotion regulation facets—lack of emotional clarity (d = -0.33), limited strategies (d = -0.22), difficulty with goal-directed behaviour (d = -0.28), and non-acceptance (d = -0.30)—and in the mindfulness facet of observing (d = 0.28). No group differences emerged for distress tolerance. Baseline non-acceptance predicted EDEQ improvement in univariate analyses, but not objective binge eating or multivariate models. A self-guided DBT app may strengthen components of mindfulness and emotion regulation. These results may point towards possible mechanisms through which DBT treatments work. That core DBT skills at baseline were unrelated to outcomes suggesting that they may bear little prognostic value, however may be suitable for broad implementation.

Manualized therapies continue to gain in popularity among therapists. These “newer” therapies have a growing body of evidence documenting their effectiveness in treating mental illness. These burgeoning efficacy data and the typically limited number of treatment sessions have not escaped third-party payers. In fact, insurance pressure has contributed to the momentum enjoyed recently by therapies such as interpersonal therapy (IPT), cognitive-behavioral therapy (CBT), and dialectical behavior therapy (DBT). Dialectical behavior therapy is the brainchild of Marsha Linehan, who created it to treat patients with borderline personality disorder. The central idea is that such patients have competing dialects that cause significant emotional stress. As a means of coping, these patients often engage in self-harm as a maladaptive means of regulating emotions. Traditional DBT requires significant resources as patients undergo both individual and group therapy during a course of treatment. The group component is psychoeducational and primarily didactic in nature. Several core modules of skill sets focusing on emotion regulation, distress tolerance, and mindfulness are presented to the patients. During individual sessions, parasuicidal behaviors are normally the primary target. Additionally, patients are coached in the application of skills taught during the group sessions with emphasis on practice to obtain skill mastery. Typically, a team of therapists skilled in DBT are required to coordinate both the group and individual sessions. These logistical challenges can restrict the practice of DBT to academic centers where educational or research subsidies are provided. Dialectical Behavior Therapy in Private Practice challenges the above assertions. The book provides an argument that DBT is not beyond the reach of a solo practitioner. Breaking with tradition, the author suggests that DBT can be used in a more piecemeal approach where limited resources require such an adaptation. Moreover, extensive research is presented that documents DBT's efficacy well beyond its original target of patients with borderline personality disorder. The book is designated for both seasoned as well as novice DBT therapists. In the first 2 chapters, the theoretical underpinnings of DBT are compared with other psychotherapy frameworks and evidence for the DBT approach is presented. Chapter 3 examines the possible psychological and neurobiological factors underlying a patient's emotional sensitivity. DBT's central thesis that emotional sensitivity (high emotional arousal, delayed return to baseline, and hypervigilance to threats) leads to maladaptive avoidance and escape behaviors is developed in the next chapter. This is followed by a chapter that establishes the goal of DBT as balancing acceptance of emotional problems and pain with specific skill strategies to change them. The author then illustrates the generalizability of DBT by applying it to various mental disorders outside of the traditional personality disorders. The final 2 chapters focus on the nuts and bolts of the specific skill sets patients need to master in DBT. Thomas Marra is obviously quite versed in the practice of DBT and has developed an exhaustive list of mnemonics aimed at assisting both clinicians and patients in remembering the specific skills. Typical patient dialects as well as excerpts of therapy sessions illustrating key conflicts are utilized to demonstrate how DBT can be used to understand a wide array of patients. These vignettes make the theory and practical skills much more understandable for the reader. Furthermore, the extensive citations to authority and research studies examining DBT across the mental health spectrum make the book a valuable addition to a reference library. However, these citations and instructional comments render the text quite dense and thus not appropriate for patients or individuals who want a brief introduction to DBT. Perhaps one of the greatest assets of the book is that Dr. Marra has included a CD-ROM with PowerPoint presentations for all of the key modules, which are turnkey for those interested in implementing a group therapy component. This CD-ROM also provides worksheets and handouts for individual therapy sessions aimed at skill building. Although the PowerPoint slides appear “homemade,” lacking slick graphics or animation, and carry an admonition that they cannot be changed or adapted by the purchaser, for the novice therapist they serve as an invaluable starting point. The countless hours of preparation they save make it possible to initiate a DBT program with only minimal additional outlay in terms of materials and are well worth the price of the text.

Practical psychotherapy: Adaptation of dialectical behavior therapy by a VA Medical Center.

Previous studies investigated the impact of weight-related abuse (WRA) on eating pathology. However, the circumstances of such an effect are still unclear. Our study aimed to examine the relationship between verbal WRA and binge eating (BE) behavior via attentional bias (AB) to threat cues and difficulties in emotion regulation. We conducted a parallel mediation model. On the basis of the purposive sampling method, 183 individuals with obesity and overweight (70.5% female and 28.4% male; Meanage=32.78), from February to June 2019, were recruited from a nutrition clinic in Tehran. The participants completed the BE scale (BES), the weight-related abuse questionnaire (WRAQ), the difficulties in emotion regulation scale (DERS), and the dot probe task (DPT). AB to threat cues had a significantly negative association with verbal WRA and BE. Difficulties in emotion regulation showed a significant positive association with verbal WRA and BE. The parallel mediation model showed a direct effect of verbal WRA on BE. Moreover, the bootstrap analysis revealed that difficulties in emotion regulation could mediate the association between verbal WRA and BE. Our findings suggest that experiences of verbal WRA can contribute to cognitive bias to negative emotion, maladaptive emotion regulation strategies, and behavioral problems like BE.

The current study examined two condensed adaptations of dialectical behavior therapy (DBT) for binge eating. Women with full- or sub-threshold variants of either binge eating disorder or bulimia nervosa were randomly assigned to individually supported self-monitoring using adapted DBT diary cards (DC) or group-based DBT, each 15 sessions over 16 weeks. DC sessions focused on problem-solving diary card completion issues, praising diary card completion, and supporting nonjudgmental awareness of eating-related habits and urges, but not formally teaching DBT skills. Group-based DBT included eating mindfulness, progressing through graded exposure; mindfulness, emotion regulation, and distress tolerance skills; and coaching calls between sessions. Both treatments evidenced large and significant improvements in binge eating, bulimic symptoms, and interoceptive awareness. For group-based DBT, ineffectiveness, drive for thinness, body dissatisfaction, and perfectionism also decreased significantly, with medium to large effect sizes. For DC, results were not significant but large in effect size for body dissatisfaction and medium in effect size for ineffectiveness and drive for thinness. Retention for both treatments was higher than recent trends for eating disorder treatment in fee-for-service practice and for similar clinic settings, but favored DC, with the greater attrition of group-based DBT primarily attributed to its more intensive and time-consuming nature, and dropout overall associated with less pretreatment impairment and greater interoceptive awareness. This preliminary investigation suggests that with both abbreviated DBT-based treatments, substantial improvement in core binge eating symptoms is possible, enhancing potential avenues for implementation beyond more time-intensive DBT.

BackgroundUniversity is a period of increased vulnerability to mental health challenges, with anxiety and difficulties in emotion regulation among the most prevalent. Culturally adapted Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) group interventions can support student well-being, yet scalable options remain limited. To address this gap, group CBT for anxiety management and group DBT for emotion regulation were culturally adapted for university students in Türkiye. Adaptations involved revising content and language, removing culturally mismatched elements, and incorporating culturally relevant and age-appropriate material.PurposeThis project aims to assess the feasibility and effectiveness of delivering culturally adapted group CBT for anxiety management and group DBT for emotion regulation.MethodsThe project includes three steps: (i) a comprehensive systematic review of group CBT and DBT interventions worldwide; (ii) translation, adaptation, localization, and development of 8-session group interventions; and (iii) implementation, data collection, and analysis. Participants are allocated to either the CBT group for anxiety management or the DBT group for emotion regulation.ResultsStandardized measures of anxiety or emotion regulation are administered at baseline, post-intervention, and six-week follow-up for both experimental and waitlist arms. Qualitative data are collected through semi-structured interviews conducted after intervention completion.ConclusionsIn this project, the feasibility and effectiveness of culturally adapted CBT and DBT group interventions for university students in Türkiye will be evaluated. Findings will inform wider-scale application of evidence-based therapies in university counseling centres in Global South and guide the design of a future randomized controlled trial.Clinical Trials InformationNCT07096154 and NCT07096141 on clinicaltrials.gov.

Longitudinal associations between emotion regulation skills, negative affect, and eating disorder symptoms in a clinical sample of individuals with binge eating