April 23, 2001 -- A form of therapy originally developed to keep people from attempting suicide also seems to help bulimics break out of the binge/purge cycle. "Dialectical behavior therapy," as it's called, teaches new ways to control and manage emotions, replacing dangerous behaviors with much healthier options.
"Dialectical behavior therapy, or DBT, says that binge eating is a way of dealing with unbearable feelings," lead researcher Debra L. Safer, MD, tells WebMD. "It's a way of distracting oneself, it's a behavior that regulates [mood]. According to this therapy, an inability to self-soothe is at the core of bulimia."
DBT has been used increasingly for treating 'parasuicidal' behaviors like cutting or overdosing on sleeping pills, says Safer, a staff psychiatrist in the department of psychiatry and behavioral sciences at Stanford University School of Medicine. "These people hurt themselves to feel better, and there seems to be a direct analogy between those behaviors and binge eating. Bulimics are using food to avoid painful emotional states."
In fact, many bulimics report entering a detached, trancelike state while binging and purging. "But you can't progress through life if you blunt all your feelings," says Safer.
Her team assigned 31 bulimic women either to 20 weekly 50-minute dialectical behavior therapy sessions or to a 20-week "waiting period." All the women had had at least one binge/purge episode per week -- out-of-control eating followed by self-induced vomiting or laxative use -- during the previous 3 months. None were emaciated, severely depressed, undergoing another type of therapy, taking antidepressants, or actively abusing drugs or alcohol.
"In DBT, patients are not told that their feelings are wrong, but rather that they need to find a more positive way to manage them," says Safer. "They learn mindfulness -- stepping back and being conscious of the moment without judging it as good or bad -- and other emotion-regulating skills, so that their feelings have less influence on their behavior."
They also learn distress tolerance -- coping with situations as they are -- and methods of self-soothing and distraction, and they practice these skills until they replace the automatic binge/purge response.
After 20 weeks, four women in the DBT group had stopped binging and purging completely, while several others reported significant reductions in the frequency of binge/purse episodes. There was no improvement in the waiting group.
Other types of therapy for bulimia tend to focus on dieting and distorted body image. But in DBT, "emotions are primary," says Safer. "We don't even talk about food. For some reason, whether biological or environmental, [bulimics] don't have skills for dealing with their emotions. Food is used to create walls because they don't have a way to let what's going on outside be outside, while remaining calm inside.
Because binging and purging suppresses emotional distress so well, "the pattern is ... reinforced and hard to break," Safer continues. "The first important skill to learn is stepping back from whatever is so overwhelming and just looking at it without engaging in compulsive behaviors to avoid it."
Not everyone with bulimia responds to DBT, says Safer.
"This is not a panacea," she says. "It doesn't work well for those who insist on maintaining a very low body weight or who purge 10 times a day and more. It seems to be most effective for those whose eating is very emotionally driven."
DBT is geared toward people with personality disorders, says Katherine Halmi, MD, professor of psychiatry at Weill Cornell Medical College and director of the eating disorders program at New York Presbyterian Hospital. "I don't think it is worthwhile to study this therapy in bulimics per se," she tells WebMD.
"DBT targets specific interpersonal problems and a way of relating to people," says Halmi. "Some people with bulimia don't have that problem. They may have anxiety problems, for example, and DBT does nothing for that."
Even in patients who do respond to DBT, it doesn't happen overnight.
"It's an ongoing process; it takes practice," says Safer. "But once you feel less ashamed, angry, or fearful, life does change. It becomes much more positive."