Eat Weight Disord DOI 10.1007/s40519-015-0177-0
BRIEF REPORT
Dialectical behavior therapy skills training reduces binge eating among patients seeking weight-management services: preliminary evidence Aislin R. Mushquash • Mandy McMahan
Received: 28 November 2014 / Accepted: 8 January 2015 Ó Springer International Publishing Switzerland 2015
Binge eating involves rapidly and uncontrollably eating a large amount of food in a short time period. Research suggests that binge eating is common among people seeking bariatric1 (weight-management) services with prevalence rates upwards of 50 %. Binge eating is associated with poorer weight loss and weight regain after bariatric services or alternative attempts at weight loss [1, 2]. Given the high rates of binge eating among people seeking bariatric services and its negative impact on weight-loss outcomes [1–3], targeting binge eating in patients seeking bariatric services may be useful to enable optimal treatment response. However, programs aimed at targeting binge eating are not routinely offered in bariatric programs. This manuscript describes the implementation and evaluation of a targeted intervention for binge eating among a group of patients accessing bariatric services. The intervention used in the present study was adapted from Linehan’s [4] manualized dialectical behavior therapy (DBT) and Safer, Telch, and Chen’s [5] manualized dialectical behavior therapy for binge eating (DBT-BE). The theory underlying this treatment is based upon the affect regulation model that suggests binge eating is used in an attempt to manage painful or unpleasant emotional states [6, 7]. Available evidence suggests that DBT-BE is effective in reducing binge eating among community-dwelling,
A. R. Mushquash (&) St. Joseph’s Care Group Mental Health Outpatient Programs, 710 Victoria Avenue East, Thunder Bay, ON P7C5P7, Canada e-mail: [email protected]; [email protected]
adults with eating disorders [8]. However, to date, no research has tested whether DBT-BE is effective in reducing binge eating among patients seeking bariatric services. The present study addresses this gap by testing the impact that a 10-week DBT-BE skills group has on binge eating and associated psychosocial functioning among patients seeking bariatric services. We hypothesized binge eating and associated psychosocial functioning would improve following participation in the DBT-BE skills group.
Method Participants and procedure This study was reviewed and approved by a hospital research ethics board. All patients seeking services with the bariatric care center complete a series of questionnaires, including the questionnaire for eating and weight patternsrevised (QEWP-R), during a general intake meeting. The QEWP-R obtains binge eating frequency and other criteria for the diagnosis of binge eating disorder. The therapists (the first and second author) reviewed patients’ responses to the QEWP-R and contacted those who (1) met the diagnostic and statistical manual of mental disorders (DSM-5) criteria for binge eating disorder, (2) lived within commuting distance to the center, and (3) were waiting for bariatric services. The therapists informed the patients about the upcoming DBT-BE skills group. If patients were 1
M. McMahan Thunder Bay Regional Health Sciences Centre, 980 Oliver Road, Thunder Bay, ON P7B6V4, Canada
Bariatric services refer to any weight-management service offered through a Bariatric Care Centre. These services can include bariatric surgery or non-surgical medical weight management intervention. Additional details are provided in the method section..
123
Eat Weight Disord
interested in receiving more information about the group they were booked for an initial appointment with one of the therapists. During this initial appointment, patients had an opportunity to ask questions and provide informed consent to participate in the DBT-BE skills group. If they chose to join, participants completed a series of baseline questionnaires. Overall, 20 patients were contacted and informed about the group and 11 chose to participate. Of the patients who chose to participate, two were pursuing bariatric surgery and nine were pursuing medical weight management (i.e., 26-week program that includes 12-weeks of meal replacement, gradual transition to food, educational group meetings, and ongoing medical monitoring). To be eligible for bariatric surgery, patients need to be 18 or older and have a body mass index (BMI) [40 kg/m2 or [35 kg/m2 with significant obesity-related medical comorbidities (e.g., hypertension, type 2 diabetes mellitus). To be eligible for medical weight management, patients need to be 18 or older and have a BMI[35 kg/m2 or a BMI between 30 and 35 kg/m2 with at least two medical comorbidities. All participants completed the DBT-BE group prior to undergoing bariatric surgery or beginning the medical weight management program. Intervention The intervention was led by the two therapists (the first and second authors) and involved 10 weekly, 2-hour group therapy sessions. Sessions focused on skill development in four areas: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. Mindfulness skills focus on developing moment-to-moment awareness of one’s experiences (e.g., eating) in a nonjudgmental way. Emotion regulation skills involve developing an understanding of emotions and vulnerabilities to negative emotions, increasing positive emotions, and changing emotions through opposite-to-emotion action. Distress tolerance skills teach adaptive means of enduring stressors and painful experiences without turning to maladaptive methods of coping (e.g., binge eating). Interpersonal effectiveness skills focus on identifying goals in interpersonal situations and assertively communicating one’s needs. The four skill areas address factors that are relevant to the occurrence and maintenance of binge eating including tendencies to eat mindlessly and turning to food in an effort to cope with unpleasant emotions, crises, and problems in relationships. Following each group session, participants were assigned homework (i.e., practice strategies discussed in group). Participants also completed a diary card each week that focused on tracking their behaviors, emotions, and use of the DBT skills.
123
Measures The measures were administered at baseline and posttreatment. All measures have good reliability and validity. Severity of binge eating was assessed with the 16-item Binge Eating Scale. For each item, participants are asked to choose one of four statements (scored 0–3) that best reflect their experience. Higher scores are indicative of more severe binge eating. Evidence suggests this scale has strong psychometric properties. The Emotional Eating Scale is a 25-item scale that assesses the extent to which specific emotional states (e.g., anger, sadness) contribute to eating urges. Participants rate their desire to eat in response to each emotion (e.g., angry, sad, excited) along a 5-point scale from 1 (no desire to eat) to 5 (an overwhelming urge to eat). Higher scores correspond to greater emotion-driven eating urges. The scale is comprised of three subscales: anger/frustration, anxiety, and depression. The Negative Mood Regulation Scale is a 30-item scale that measures expectancies regarding one’s ability to alter negative moods. Along a 5-point scale from 1 (strongly disagree) to 5 (strongly agree), participants rate the extent to which they believe that using various strategies can improve their negative mood states. Higher scores reflect stronger beliefs that one can alleviate their negative mood states through adaptive means. Rosenberg Self-Esteem Scale consists of 10 items that assess global self-worth. Participants rate their response along a 4-point scale from 0 (strongly disagree) to 3 (strongly agree), with lower scores indicating lower selfesteem. The Patient Health Questionnaire-9 is a 9-item scale that assesses the severity of depressive symptoms. On a 4-point scale from 0 (not at all) to 3 (nearly every day), participants indicate the frequency with which they experienced each symptom over the previous 2-week period. The General Anxiety Disorder Scale-7 measures generalized anxiety symptoms. Participants rate the frequency that they were bothered by each symptom over the previous 2-week period on a 4-point scale from 0 (not at all) to 3 (nearly every day). Analyses Paired samples t tests examined changes in outcome variables from baseline to post-treatment. We used Cohen’s d for calculating the effect size for the difference between two correlated measurements. Cohen defined effect sizes as small (d = .2), medium (d = .5), and large (d = .8). Given the small sample size in this pilot study, nonparametric effects were also measured using Wilcoxon signed ranks tests.
Eat Weight Disord Table 1 Means, standard deviations, Cronbach’s alphas, and effect sizes
Baseline
Post-treatment
SD
a
a
Effect size
7.79
.86
.87
10.66
.91
.06
8.69
.91
.04
15.55
5.04
.83
.44
.85
105.37
13.80
.86
.62
.91
10.89
4.19
.84
.75
Variables
M
M
SD
1. Binge Eating Scale
28.72
4.88
.71
22.06
2. Emotional Eating Scale—anger/frustration
32.56
10.70
.87
31.96
3. Emotional Eating Scale—anxiety
21.19
8.24
.85
21.39
4. Emotional Eating Scale—depression
17.00
4.95
.77
5. Negative Mood Regulation Scale
96.60
12.85
6. Rosenberg Self-Esteem Scale
15.00
6.30
7. Patient Health Questionnaire
8.57
4.93
.85
6.29
5.50
.87
.73
8. Generalized Anxiety Disorder Scale
6.00
4.51
.84
5.14
6.62
.96
.26
Results Sample characteristics Participants averaged 44.56 years of age (SD = 16.31) and the majority self-identified as Caucasian (81.8 %) and female (90.9 %). Based on self-report weight and height, participants had an average body mass index of 50.92 at baseline (SD = 8.84; range = 38.27–61.79) and 46.78 post-treatment (SD = 9.13; range = 36.49–64.01). Retention The majority of participants who began the group also completed the group (i.e., 91 %). However, one participant was absent from group on the last day so did not complete the post-treatment measures. Treatment outcomes Means, standard deviations, and effect sizes for measures at baseline and post-treatment are presented in Table 1. On average participants showed a significant reduction in binge eating severity from baseline to post-treatment, t(8) = 2.63, p \ .05. Nonparametric tests were also statistically significant (Z = -2.07, p \ .05). Across all other variables (i.e., emotional eating, negative mood regulation, self-esteem, generalized anxiety, depressive symptoms), parametric tests and nonparametric tests yielded no statistically significant differences (p [ .05) from baseline to post-treatment despite some sizable effect sizes (see Table 1). Nonparametric tests also failed to reach statistical significance (p [ .05). Discussion The present study tested the impact that a 10-week DBTBE skills group has on binge eating and associated
psychosocial functioning among patients seeking bariatric services. Hypotheses were partially supported with binge eating significantly decreasing from baseline to posttreatment. Results of this small pilot study are promising and suggest that a DBT-BE skills group would be useful in addressing binge eating for patients who are pursuing bariatric (weight-management) services. The lack of significant change in associated psychosocial functioning may suggest that changes in these variables requires additional time and integration of the skills and/or treatment focused specifically on these difficulties. Low dropout rates also suggest that DBT-BE is acceptable to patients. In fact, dropout rates in this study were much lower than rates reported in other studies targeting binge eating with DBT [8]. However, participants involved in the DBT-BE group were on the waitlist for bariatric services and this may have had an impact on their motivation and may have contributed to a lower than expected dropout rate. Despite promising results, this study has some limitations including a reliance on self-report data, a small sample size, and a potentially biased selection process (e.g., patients expressing interest in the group may be more motivated than other patients). In addition, the sample was mainly Caucasian women, thus generalizability of the results to other patient groups is unknown. We also did not include a control group in this pilot study. Therefore, a logical next step is to conduct additional research utilizing a randomized controlled design with a larger sample to study the effects of DBT-BE on binge eating and associated psychosocial functioning prior to beginning bariatric services. Moreover, follow-up assessments (e.g., 6-month post-treatment or after completing bariatric services), are needed to determine whether improvements in binge eating are sustained and whether changes in binge eating can improve weight-loss outcomes. Conflict of interest A. R. Mushquash and M. McMahan declare that they have no conflict of interest.
123
Eat Weight Disord Ethical Standards All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent Informed consent was obtained from all individual participants included in the study.
References 1. Colles SL, Dixon JB, O’Brien PE (2008) Grazing and loss of control related to eating: two high-risk factors following bariatric surgery. Obesity 16(3):615–622. doi:10.1038/oby.2007.101 2. Meany G, Conceic¸a˜o E, Mitchell JE (2014) Binge eating, binge eating disorder and loss of control eating: effects on weight outcomes after bariatric surgery. Eur Eat Disord Rev 22(2):87–91. doi:10.1002/erv.2273
123
3. Niego SH, Kofman MD, Weiss JJ, Geliebter A (2007) Binge eating in the bariatric surgery population: a review of the literature. Int J Eat Disord 40(4):349–359. doi:10.1002/eat.20376 4. Linehan MM (1993) Cognitive behavioral therapy of borderline personality disorder. Guilford Press, New York 5. Safer DL, Telch CF, Chen EU (2009) Dialectical behaviour therapy for binge eating and bulimia. Guilford Press, UK 6. Heatherton TF, Baumeister RF (1991) Binge eating as escape from self-awareness. Psychol Bull 110(1):86–108. doi:10.1037/00332909.110.1.86 7. Wisniewski L, Kelly E (2003) The application of dialectical behavior therapy to the treatment of eating disorders. Cognit Behav Pract 10(2):131–138. doi:10.1016/S1077-7229(03)80021-4 8. Safer DL, Robinson AH, Jo B (2010) Outcome from a randomized controlled trial of group therapy for binge eating disorder: comparing dialectical behavior therapy adapted for binge eating to an active comparison group therapy. Behavior Therapy 41(1):106–120. doi:10.1016/j.beth.2009.01.006
BRIEF REPORT
Dialectical behavior therapy skills training reduces binge eating among patients seeking weight-management services: preliminary evidence Aislin R. Mushquash • Mandy McMahan
Received: 28 November 2014 / Accepted: 8 January 2015 Ó Springer International Publishing Switzerland 2015
Binge eating involves rapidly and uncontrollably eating a large amount of food in a short time period. Research suggests that binge eating is common among people seeking bariatric1 (weight-management) services with prevalence rates upwards of 50 %. Binge eating is associated with poorer weight loss and weight regain after bariatric services or alternative attempts at weight loss [1, 2]. Given the high rates of binge eating among people seeking bariatric services and its negative impact on weight-loss outcomes [1–3], targeting binge eating in patients seeking bariatric services may be useful to enable optimal treatment response. However, programs aimed at targeting binge eating are not routinely offered in bariatric programs. This manuscript describes the implementation and evaluation of a targeted intervention for binge eating among a group of patients accessing bariatric services. The intervention used in the present study was adapted from Linehan’s [4] manualized dialectical behavior therapy (DBT) and Safer, Telch, and Chen’s [5] manualized dialectical behavior therapy for binge eating (DBT-BE). The theory underlying this treatment is based upon the affect regulation model that suggests binge eating is used in an attempt to manage painful or unpleasant emotional states [6, 7]. Available evidence suggests that DBT-BE is effective in reducing binge eating among community-dwelling,
A. R. Mushquash (&) St. Joseph’s Care Group Mental Health Outpatient Programs, 710 Victoria Avenue East, Thunder Bay, ON P7C5P7, Canada e-mail: [email protected]; [email protected]
adults with eating disorders [8]. However, to date, no research has tested whether DBT-BE is effective in reducing binge eating among patients seeking bariatric services. The present study addresses this gap by testing the impact that a 10-week DBT-BE skills group has on binge eating and associated psychosocial functioning among patients seeking bariatric services. We hypothesized binge eating and associated psychosocial functioning would improve following participation in the DBT-BE skills group.
Method Participants and procedure This study was reviewed and approved by a hospital research ethics board. All patients seeking services with the bariatric care center complete a series of questionnaires, including the questionnaire for eating and weight patternsrevised (QEWP-R), during a general intake meeting. The QEWP-R obtains binge eating frequency and other criteria for the diagnosis of binge eating disorder. The therapists (the first and second author) reviewed patients’ responses to the QEWP-R and contacted those who (1) met the diagnostic and statistical manual of mental disorders (DSM-5) criteria for binge eating disorder, (2) lived within commuting distance to the center, and (3) were waiting for bariatric services. The therapists informed the patients about the upcoming DBT-BE skills group. If patients were 1
M. McMahan Thunder Bay Regional Health Sciences Centre, 980 Oliver Road, Thunder Bay, ON P7B6V4, Canada
Bariatric services refer to any weight-management service offered through a Bariatric Care Centre. These services can include bariatric surgery or non-surgical medical weight management intervention. Additional details are provided in the method section..
123
Eat Weight Disord
interested in receiving more information about the group they were booked for an initial appointment with one of the therapists. During this initial appointment, patients had an opportunity to ask questions and provide informed consent to participate in the DBT-BE skills group. If they chose to join, participants completed a series of baseline questionnaires. Overall, 20 patients were contacted and informed about the group and 11 chose to participate. Of the patients who chose to participate, two were pursuing bariatric surgery and nine were pursuing medical weight management (i.e., 26-week program that includes 12-weeks of meal replacement, gradual transition to food, educational group meetings, and ongoing medical monitoring). To be eligible for bariatric surgery, patients need to be 18 or older and have a body mass index (BMI) [40 kg/m2 or [35 kg/m2 with significant obesity-related medical comorbidities (e.g., hypertension, type 2 diabetes mellitus). To be eligible for medical weight management, patients need to be 18 or older and have a BMI[35 kg/m2 or a BMI between 30 and 35 kg/m2 with at least two medical comorbidities. All participants completed the DBT-BE group prior to undergoing bariatric surgery or beginning the medical weight management program. Intervention The intervention was led by the two therapists (the first and second authors) and involved 10 weekly, 2-hour group therapy sessions. Sessions focused on skill development in four areas: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. Mindfulness skills focus on developing moment-to-moment awareness of one’s experiences (e.g., eating) in a nonjudgmental way. Emotion regulation skills involve developing an understanding of emotions and vulnerabilities to negative emotions, increasing positive emotions, and changing emotions through opposite-to-emotion action. Distress tolerance skills teach adaptive means of enduring stressors and painful experiences without turning to maladaptive methods of coping (e.g., binge eating). Interpersonal effectiveness skills focus on identifying goals in interpersonal situations and assertively communicating one’s needs. The four skill areas address factors that are relevant to the occurrence and maintenance of binge eating including tendencies to eat mindlessly and turning to food in an effort to cope with unpleasant emotions, crises, and problems in relationships. Following each group session, participants were assigned homework (i.e., practice strategies discussed in group). Participants also completed a diary card each week that focused on tracking their behaviors, emotions, and use of the DBT skills.
123
Measures The measures were administered at baseline and posttreatment. All measures have good reliability and validity. Severity of binge eating was assessed with the 16-item Binge Eating Scale. For each item, participants are asked to choose one of four statements (scored 0–3) that best reflect their experience. Higher scores are indicative of more severe binge eating. Evidence suggests this scale has strong psychometric properties. The Emotional Eating Scale is a 25-item scale that assesses the extent to which specific emotional states (e.g., anger, sadness) contribute to eating urges. Participants rate their desire to eat in response to each emotion (e.g., angry, sad, excited) along a 5-point scale from 1 (no desire to eat) to 5 (an overwhelming urge to eat). Higher scores correspond to greater emotion-driven eating urges. The scale is comprised of three subscales: anger/frustration, anxiety, and depression. The Negative Mood Regulation Scale is a 30-item scale that measures expectancies regarding one’s ability to alter negative moods. Along a 5-point scale from 1 (strongly disagree) to 5 (strongly agree), participants rate the extent to which they believe that using various strategies can improve their negative mood states. Higher scores reflect stronger beliefs that one can alleviate their negative mood states through adaptive means. Rosenberg Self-Esteem Scale consists of 10 items that assess global self-worth. Participants rate their response along a 4-point scale from 0 (strongly disagree) to 3 (strongly agree), with lower scores indicating lower selfesteem. The Patient Health Questionnaire-9 is a 9-item scale that assesses the severity of depressive symptoms. On a 4-point scale from 0 (not at all) to 3 (nearly every day), participants indicate the frequency with which they experienced each symptom over the previous 2-week period. The General Anxiety Disorder Scale-7 measures generalized anxiety symptoms. Participants rate the frequency that they were bothered by each symptom over the previous 2-week period on a 4-point scale from 0 (not at all) to 3 (nearly every day). Analyses Paired samples t tests examined changes in outcome variables from baseline to post-treatment. We used Cohen’s d for calculating the effect size for the difference between two correlated measurements. Cohen defined effect sizes as small (d = .2), medium (d = .5), and large (d = .8). Given the small sample size in this pilot study, nonparametric effects were also measured using Wilcoxon signed ranks tests.
Eat Weight Disord Table 1 Means, standard deviations, Cronbach’s alphas, and effect sizes
Baseline
Post-treatment
SD
a
a
Effect size
7.79
.86
.87
10.66
.91
.06
8.69
.91
.04
15.55
5.04
.83
.44
.85
105.37
13.80
.86
.62
.91
10.89
4.19
.84
.75
Variables
M
M
SD
1. Binge Eating Scale
28.72
4.88
.71
22.06
2. Emotional Eating Scale—anger/frustration
32.56
10.70
.87
31.96
3. Emotional Eating Scale—anxiety
21.19
8.24
.85
21.39
4. Emotional Eating Scale—depression
17.00
4.95
.77
5. Negative Mood Regulation Scale
96.60
12.85
6. Rosenberg Self-Esteem Scale
15.00
6.30
7. Patient Health Questionnaire
8.57
4.93
.85
6.29
5.50
.87
.73
8. Generalized Anxiety Disorder Scale
6.00
4.51
.84
5.14
6.62
.96
.26
Results Sample characteristics Participants averaged 44.56 years of age (SD = 16.31) and the majority self-identified as Caucasian (81.8 %) and female (90.9 %). Based on self-report weight and height, participants had an average body mass index of 50.92 at baseline (SD = 8.84; range = 38.27–61.79) and 46.78 post-treatment (SD = 9.13; range = 36.49–64.01). Retention The majority of participants who began the group also completed the group (i.e., 91 %). However, one participant was absent from group on the last day so did not complete the post-treatment measures. Treatment outcomes Means, standard deviations, and effect sizes for measures at baseline and post-treatment are presented in Table 1. On average participants showed a significant reduction in binge eating severity from baseline to post-treatment, t(8) = 2.63, p \ .05. Nonparametric tests were also statistically significant (Z = -2.07, p \ .05). Across all other variables (i.e., emotional eating, negative mood regulation, self-esteem, generalized anxiety, depressive symptoms), parametric tests and nonparametric tests yielded no statistically significant differences (p [ .05) from baseline to post-treatment despite some sizable effect sizes (see Table 1). Nonparametric tests also failed to reach statistical significance (p [ .05). Discussion The present study tested the impact that a 10-week DBTBE skills group has on binge eating and associated
psychosocial functioning among patients seeking bariatric services. Hypotheses were partially supported with binge eating significantly decreasing from baseline to posttreatment. Results of this small pilot study are promising and suggest that a DBT-BE skills group would be useful in addressing binge eating for patients who are pursuing bariatric (weight-management) services. The lack of significant change in associated psychosocial functioning may suggest that changes in these variables requires additional time and integration of the skills and/or treatment focused specifically on these difficulties. Low dropout rates also suggest that DBT-BE is acceptable to patients. In fact, dropout rates in this study were much lower than rates reported in other studies targeting binge eating with DBT [8]. However, participants involved in the DBT-BE group were on the waitlist for bariatric services and this may have had an impact on their motivation and may have contributed to a lower than expected dropout rate. Despite promising results, this study has some limitations including a reliance on self-report data, a small sample size, and a potentially biased selection process (e.g., patients expressing interest in the group may be more motivated than other patients). In addition, the sample was mainly Caucasian women, thus generalizability of the results to other patient groups is unknown. We also did not include a control group in this pilot study. Therefore, a logical next step is to conduct additional research utilizing a randomized controlled design with a larger sample to study the effects of DBT-BE on binge eating and associated psychosocial functioning prior to beginning bariatric services. Moreover, follow-up assessments (e.g., 6-month post-treatment or after completing bariatric services), are needed to determine whether improvements in binge eating are sustained and whether changes in binge eating can improve weight-loss outcomes. Conflict of interest A. R. Mushquash and M. McMahan declare that they have no conflict of interest.
123
Eat Weight Disord Ethical Standards All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent Informed consent was obtained from all individual participants included in the study.
References 1. Colles SL, Dixon JB, O’Brien PE (2008) Grazing and loss of control related to eating: two high-risk factors following bariatric surgery. Obesity 16(3):615–622. doi:10.1038/oby.2007.101 2. Meany G, Conceic¸a˜o E, Mitchell JE (2014) Binge eating, binge eating disorder and loss of control eating: effects on weight outcomes after bariatric surgery. Eur Eat Disord Rev 22(2):87–91. doi:10.1002/erv.2273
123
3. Niego SH, Kofman MD, Weiss JJ, Geliebter A (2007) Binge eating in the bariatric surgery population: a review of the literature. Int J Eat Disord 40(4):349–359. doi:10.1002/eat.20376 4. Linehan MM (1993) Cognitive behavioral therapy of borderline personality disorder. Guilford Press, New York 5. Safer DL, Telch CF, Chen EU (2009) Dialectical behaviour therapy for binge eating and bulimia. Guilford Press, UK 6. Heatherton TF, Baumeister RF (1991) Binge eating as escape from self-awareness. Psychol Bull 110(1):86–108. doi:10.1037/00332909.110.1.86 7. Wisniewski L, Kelly E (2003) The application of dialectical behavior therapy to the treatment of eating disorders. Cognit Behav Pract 10(2):131–138. doi:10.1016/S1077-7229(03)80021-4 8. Safer DL, Robinson AH, Jo B (2010) Outcome from a randomized controlled trial of group therapy for binge eating disorder: comparing dialectical behavior therapy adapted for binge eating to an active comparison group therapy. Behavior Therapy 41(1):106–120. doi:10.1016/j.beth.2009.01.006
