Cognitive Therapy and Research

, Volume 43, Issue 4, pp 759–768 | Cite as

Early Versus Later Improvements in Dialectical Behavior Therapy Skills Use and Treatment Outcome in Eating Disorders

  • Tiffany A. BrownEmail author
  • Anne Cusack
  • Leslie Anderson
  • Erin E. Reilly
  • Laura A. Berner
  • Christina E. Wierenga
  • Jason M. Lavender
  • Walter H. Kaye
Original Article


Dialectical behavior therapy (DBT) has demonstrated initial efficacy for the treatment of eating disorders (EDs). However, no study has examined potential processes that may contribute to observed improvements in DBT for EDs. The present study sought to investigate changes in DBT skills use throughout treatment as a predictor of symptom change in a DBT-based partial hospital program (PHP) for adults with EDs. Adults [n = 135; M(SD) age = 25.08 (7.88)] with EDs completed self-report measures at treatment admission, one-month post-admission, and discharge from PHP. DBT skills use, as measured by the DBT Ways of Coping Checklist, increased by 12.65% from admission to one-month post-admission and increased by 24.10% from admission to discharge. Early (admission to month 1) and later (month 1 to discharge) improvements in DBT skills use predicted greater improvements in ED, depressive, and emotion dysregulation symptoms from treatment admission to discharge. Notably, early versus later change in skills use was a stronger predictor of outcome. Results are consistent with the theoretical model of DBT and add to a growing literature on DBT for EDs.


Dialectical behavior therapy Eating disorders Skills use Predictors Partial hospital program 



The authors thank Lauren Gomez and Tiffany Nakamura for their assistance with data collection, the patients who participated in this research, and the current and past clinical staff for their clinical expertise and support of this research.

Compliance with Ethical Standards

Conflict of Interest

Tiffany A. Brown, Anne Cusack, Leslie Anderson, Erin E. Reilly, Laura A. Berner, Christina E. Wierenga, Jason M. Lavender, and Walter H. Kaye declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the University of California, San Diego 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.

Animal Rights

No animal studies were carried out by the authors for this article.


  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.Google Scholar
  2. Bankoff, S. M., Karpel, M. G., Forbes, H. E., & Pantalone, D. W. (2012). A systematic review of dialectical behavior therapy for the treatment of eating disorders. Eating Disorders, 20(3), 196–215. Scholar
  3. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck depression inventory-II. San Antonio, 78(2), 490–498.Google Scholar
  4. Ben-Porath, D. D., Federici, A., Wisniewski, L., & Warren, M. (2014). Dialectical behavior therapy: Does it bring about improvements in affect regulation in individuals with eating disorders? Journal of Contemporary Psychotherapy, 44(4), 245–251.Google Scholar
  5. Ben-Porath, D. D., Wisniewski, L., & Warren, M. (2010). Outcomes of a day treatment program for eating disorders using clinical and statistical significance. Journal of Contemporary Psychotherapy, 40(2), 115–123.Google Scholar
  6. Berg, K. C., Peterson, C. B., Frazier, P., & Crow, S. J. (2011). Convergence of scores on the interview and questionnaire versions of the Eating Disorder Examination: A meta-analytic review. Psychological Assessment, 23(3), 714.Google Scholar
  7. Braun, M. T., & Oswald, F. L. (2011). Exploratory regression analysis: A tool for selecting models and determining predictor importance. Behavior Research Methods, 43(2), 331–339.Google Scholar
  8. Brown, T. A., Cusack, A., Anderson, L. K., Trim, J., Nakamura, T., Trunko, M. E., & Kaye, W. H. (2018). Efficacy of a partial hospital programme for adults with eating disorders. European Eating Disorders Review. Scholar
  9. Chen, E. Y., Cacioppo, J., Fettich, K., Gallop, R., McCloskey, M. S., Olino, T., & Zeffiro, T. A. (2017). An adaptive randomized trial of dialectical behavior therapy and cognitive behavior therapy for binge-eating. Psychological Medicine, 47(4), 703–717. Scholar
  10. Del Conte, G., Lenz, A. S., & Hollenbaugh, K. M. (2016). A pilot evaluation of dialectical behavior therapy for adolescents within a partial hospitalization treatment milieu. Journal of Child and Adolescent Counseling, 2(1), 16–32.Google Scholar
  11. Fairburn, C. G., Agras, W. S., Walsh, B. T., Wilson, G. T., & Stice, E. (2004). Prediction of outcome in bulimia nervosa by early change in treatment. American Journal of Psychiatry, 161(12), 2322–2324.Google Scholar
  12. Fairburn, C. G., & Beglin, S. J. (1994). Assessment of eating disorders: Interview or self-report questionnaire? International Journal of Eating Disorders, 16(4), 363–370.Google Scholar
  13. Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54.Google Scholar
  14. Hayes, A. F., & Rockwood, N. J. (2017). Regression-based statistical mediation and moderation analysis in clinical research: Observations, recommendations, and implementation. Behaviour Research and Therapy, 98, 39–57.Google Scholar
  15. Haynos, A. F., & Fruzzetti, A. E. (2011). Anorexia nervosa as a disorder of emotion dysregulation: Evidence and treatment implications. Clinical Psychology: Science and Practice, 18(3), 183–202.Google Scholar
  16. Hilbert, A., Hildebrandt, T., Agras, W. S., Wilfley, D. E., & Wilson, G. T. (2015). Rapid response in psychological treatments for binge eating disorder. Journal of Consulting and Clinical Psychology, 83(3), 649.Google Scholar
  17. Ilardi, S. S., & Craighead, W. E. (1994). The role of nonspecific factors in cognitive-behavior therapy for depression. Clinical Psychology: Science and Practice, 1(2), 138–155.Google Scholar
  18. Iverson, K. M., Shenk, C., & Fruzzetti, A. E. (2009). Dialectical behavior therapy for women victims of domestic abuse: A pilot study. Professional Psychology: Research and Practice, 40(3), 242.Google Scholar
  19. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59(1), 12–19.Google Scholar
  20. Lavender, J. M., Wonderlich, S. A., Engel, S. G., Gordon, K. H., Kaye, W. H., & Mitchell, J. E. (2015). Dimensions of emotion dysregulation in anorexia nervosa and bulimia nervosa: A conceptual review of the empirical literature. Clinical Psychology Review, 40, 111–122.Google Scholar
  21. Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder: New York: Guilford Press.Google Scholar
  22. Linehan, M. M., & Chen, E. Y. (2005). Dialectical behavior therapy for eating disorders. In M. A. Reinecke, & A. Freeman (Eds.), Encyclopedia of cognitive behavior therapy (pp. 168–171). New York: Springer.Google Scholar
  23. Linehan, M. M., Korslund, K. E., Harned, M. S., Gallop, R. J., Lungu, A., Neacsiu, A. D., …. Murray-Gregory, A. M. (2015). Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: A randomized clinical trial and component analysis. JAMA Psychiatry, 72(5), 475–482. Scholar
  24. Linehan, M. M., & Wilks, C. R. (2015). The course and evolution of dialectical behavior therapy. American Journal of Psychotherapy, 69(2), 97–110.Google Scholar
  25. Lynch, T. R., Chapman, A. L., Rosenthal, M. Z., Kuo, J. R., & Linehan, M. M. (2006). Mechanisms of change in dialectical behavior therapy: Theoretical and empirical observations. Journal of Clinical Psychology, 62(4), 459–480.Google Scholar
  26. Meyers, L., Voller, E. K., McCallum, E. B., Thuras, P., Shallcross, S., Velasquez, T., & Meis, L. (2017). Treating veterans with PTSD and borderline personality symptoms in a 12-week intensive outpatient setting: Findings from a pilot program. Journal of Traumatic Stress, 30(2), 178–181.Google Scholar
  27. Mond, J. M., Hay, P. J., Rodgers, B., & Owen, C. (2006). Eating Disorder Examination Questionnaire (EDE-Q): Norms for young adult women. Behaviour Research and Therapy, 44(1), 53–62. Scholar
  28. Neacsiu, A. D., Eberle, J. W., Kramer, R., Wiesmann, T., & Linehan, M. M. (2014). Dialectical behavior therapy skills for transdiagnostic emotion dysregulation: A pilot randomized controlled trial. Behaviour Research and Therapy, 59, 40–51. Scholar
  29. Neacsiu, A. D., Rizvi, S. L., & Linehan, M. M. (2010a). Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder. Behaviour Research and Therapy, 48(9), 832–839. Scholar
  30. Neacsiu, A. D., Rizvi, S. L., Vitaliano, P. P., Lynch, T. R., & Linehan, M. M. (2010b). The dialectical behavior therapy ways of coping checklist: Development and psychometric properties. Journal of Clinical Psychology, 66(6), 563–582. Scholar
  31. Rizvi, S. L., Hughes, C. D., Hittman, A. D., & Oliveira, V., P (2017). Can trainees effectively deliver dialectical behavior therapy for individuals with borderline personality disorder? Outcomes from a training clinic. Journal of Clinical Psychology, 73(12), 1599–1611.Google Scholar
  32. Safer, D. L., & Joyce, E. E. (2011). Does rapid response to two group psychotherapies for binge eating disorder predict abstinence? Behaviour Research and Therapy, 49(5), 339–345.Google Scholar
  33. Safer, D. L., Robinson, A. H., & 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. Scholar
  34. Safer, D. L., Telch, C. F., & Agras, W. S. (2001). Dialectical behavior therapy adapted for bulimia: A case report. International Journal of Eating Disorders, 30(1), 101–106.Google Scholar
  35. Schafer, J. L., & Graham, J. W. (2002). Missing data: Our view of the state of the art. Psychological Methods, 7(2), 147–177.Google Scholar
  36. Soler, J., Pascual, J. C., Tiana, T., Cebrià, A., Barrachina, J., Campins, M. J., … Pérez, V. (2009). Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: A 3-month randomised controlled clinical trial. Behaviour Research and Therapy, 47(5), 353–358.Google Scholar
  37. Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology, 69(6), 1061.Google Scholar
  38. Tonidandel, S., & LeBreton, J. M. (2011). Relative importance analysis: A useful supplement to regression analysis. Journal of Business and Psychology, 26(1), 1–9.Google Scholar
  39. Valentine, S. E., Bankoff, S. M., Poulin, R. M., Reidler, E. B., & Pantalone, D. W. (2015). The use of dialectical behavior therapy skills training as stand-alone treatment: A systematic review of the treatment outcome literature. Journal of Clinical Psychology, 71(1), 1–20. Scholar
  40. Webb, C. A., Beard, C., Kertz, S. J., Hsu, K. J., & Björgvinsson, T. (2016). Differential role of CBT skills, DBT skills and psychological flexibility in predicting depressive versus anxiety symptom improvement. Behaviour Research and Therapy, 81, 12–20.Google Scholar
  41. Wilson, G. T. (1999). Rapid response to cognitive behavior therapy. Clinical Psychology: Science and Practice, 6(3), 289–292.Google Scholar
  42. Wisniewski, L., Safer, D., & Chen, E. (2007). Dialectical behavior therapy and eating disorders. In L. A. Dimeff & K. Koerner (Eds.), Dialectical behavior therapy in clinical practice: Applications across disorders and settings (pp. 174–221). New York, NY: Guilford Press.Google Scholar
  43. Yager, J., Devlin, M. J., Halmi, K. A., Herzog, D. B., Mitchell, I. I. I., Powers, J. E., P., & Zerbe, K. J. (2014). Guideline watch (August 2012): Practice guideline for the treatment of patients with eating disorders. Focus, 12(4), 416–431.Google Scholar
  44. Yager, J., Devlin, M. J., Halmi, K. A., Herzog, D. B., Mitchell, J. E., Powers, P. S., & Zerbe, K. J. (2005). Guideline watch: Practice guideline for the treatment of patients with eating disorders. Focus, 3(4), 546–551.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of PsychiatryUniversity of California, San DiegoSan DiegoUSA

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