BEHAVIORTHERAPY31,569--582, 2000

Group Dialectical Behavior Therapy for Binge-Eating

Disorder: A Preliminary, Uncontrolled Trial
CHRISTY E TELCH

W. STEWART AGRAS
Stanford University School of Medicine

MARSHA M . LINEHAN
University of Washington

This study provides preliminary data regarding the efficacy of Dialectical Behavior
Therapy (DBT) adapted for the treatment of binge-eating disorder (BED). Eleven
women with BED participated in this uncontrolled trial and were administered the
Eating Disorder Examination together with measures of weight, mood, and affect
regulation at baseline and posttreatment. Data on binge eating and weight were also
collected at 3- and 6-month follow-up. There were no dropouts from treatment and
82% of the women were no longer binge eating by treatment end. Improvement in
emotion regulation was also evidenced posttreatment. The improvement in binge
eating was maintained during follow-up. These results lend support for continued re-
search into the applications of DBT for treating BED.

Binge-eating disorder (BED) is a proposed new diagnostic category in the

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American
Psychiatric Association, 1994). The principal feature in BED, binge eating, is
defined exactly as it is for bulimia nervosa (BN), the consumption of a large
amount of food accompanied by a sense of loss of control over eating. In
addition to recurrent binge-eating episodes, the research criteria for BED
include indicators of impaired control over eating, significant distress about
the binge eating, and the absence of regular compensatory behaviors. Most
individuals with BED are overweight and research has demonstrated that the
prevalence of binge eating increases with the severity of obesity (Bruce &
Agras, 1992; Spitzer et al., 1992; Telch, Agras, & Rossiter, 1988). The multi-

This study was supported by a grant (MH54641) from the National Institutes of Health.
Sincere appreciation go to Susan Wiser, co-therapist, and Shireen Rizvi, research assistant,
for their valuable contributions to this research.
Address correspondence to W. Stewart Agras, Department of Psychiatry and Behavioral Sci-
ences, 401 Quarry Road, Room 1326, Stanford, CA 94305-5722.

569 005-7894/00/0569-058251.00/0
Copyright2000 by Associationfor Advancementof BehaviorTherapy
All rightsfor reproductionin any formreserved.
570 TELCH ET AL.

site field trials validating the BED criteria found that 30% of participants in
the weight control programs surveyed met criteria for BED (Spitzer et al.,
1992, 1993). It appears that BED is a prevalent disorder associated with the
serious health problem of obesity, significant eating disorder pathology, and
psychiatric comorbidity (Eldredge & Agras, 1996; Marcus, Wing, Ewing,
Kern, Gooding, et al., 1990; Schwalberg, Barlow, Alger, & Howard, 1992;
Telch & Stice, 1998; Wilson, Nonas, & Rosenblum, 1993; Yanovski, Nelson,
Dubbert, & Spitzer, 1993).
Because binge eating is central to both BN and BED, therapies effective in
the treatment of BN have been adapted and applied to the treatment of BED.
These include cognitive-behavioral treatment (CBT), interpersonal psycho-
therapy (IPT), and pharmacotherapy (Agras, 1997; Castonguay, Eldredge, &
Agras, 1995; Marcus, 1997; Wilfley & Cohen, 1997). Overall, CBT has been
the most frequently studied treatment for BED and results have demonstrated
that CBT reduces the frequency of binge-eating episodes and that, on average,
50% of individuals stop binge eating by treatment end (Castonguay et al.;
Wilfley & Cohen). Generally, findings with regard to weight loss and depres-
siofi are not statistically significant, although the results of a 1-year follow-up
of CBT demonstrated that women who stopped binge eating during treatment
lost more weight and maintained that weight loss over the follow-up period
compared to women who continued to binge (Agras, Telch, Arnow, Eldredge,
& Marnell, 1997). Attrition rates for CBT range from 17% to 35%, with the
average being about 25% (Wilfley & Cohen).
Other treatments for BED have been less well studied. Two reviews of the
limited data on pharmacotherapy for BED (Agras, 1997; Walsh & Devlin,
1995) suggest that antidepressants may lead to short-term reductions in binge
eating, however, it appears that antidepressants alone do not result in signifi-
cant weight loss or reduction in depressive symptoms. Two studies have dem-
onstrated that the combination of behavioral therapy and antidepressant
medication enhances weight loss in obese binge eaters (Agras et al., 1994;
Marcus, Wing, Ewing, Kern, McDermott, et al., 1990). A single study com-
pared CBT and IPT (Wilfley et al., 1993) and results showed significant
reductions in binge eating in both treatment conditions compared to a wait-
list control, although abstinence rates were disappointing (28% CBT and
44% IPT) and no significant effects were found on weight loss or depression.
Collectively these data suggest that (a) BED does not improve without
treatment, (b) all treatments appear to be effective in reducing binge eating
for about half of the participants, and (c) weight loss may be enhanced by the
use of behavioral weight-loss treatment or pharmacotherapy. Clearly, alterna-
tive treatments need to be developed for the substantial number of individuals
who do not respond to currently available treatments.
Etiological theories of eating disorders posit that negative affect may play a
key role in the development and maintenance of binge eating, and evidence
from prospective, descriptive, and experimental investigations support this
claim. From this theoretical perspective, binge eating is conceptualized as a
 DBT FOR B I N G E - E A T I N G D I S O R D E R 571

maladaptive affect-regulation strategy that is maintained by the temporary

reduction in distressing affective states. Descriptive studies have demonstrated
that negative moods frequently precipitate binge-eating episodes (Arnow,
Kenardy, & Agras, 1992; Davis, Freeman, & Garner, 1988). A recent pro-
spective investigation revealed that negative affect, among other factors, pre-
dicted the onset of binge eating and compensatory behaviors in a community
sample of female adolescents (Stice & Agras, 1998). Two experimental labo-
ratory studies found that an induced negative mood compared to a neutral
mood significantly increased loss of control over eating and the occurrence of
binge eating in women with BED (Agras & Telch, 1998; Telch & Agras, 1996).
Despite strong support for the theory that binge eating may serve an affect-
regulation function, to date treatments of BED have not focused on affect
regulation. Dialectical behavior therapy (DBT; Linehan, 1993a, 1993b) for
borderline personality disorder (BPD) specifically addresses affect-regulation
dysfunction. From the DBT theoretical perspective, emotion dysregulation is
a core feature of BPD and seriously maladaptive behaviors such as parasui-
cidal acts are viewed as attempts to regulate strong emotions. BPD individu-
als are thought to lack important emotion-regulation and distress-tolerance
skills and DBT teaches patients new, adaptive emotion-regulation skills to
enhance patients' capabilities. In a randomized clinical trial comparing DBT
with treatment-as-usual in the community, DBT patients were significantly
less likely than treatment-as-usual patients to engage in parasuicide during
the treatment year and had fewer and less medically severe parasuicides at
each assessment point (Linehan, Armstrong, Suarez, Allmond, & Heard, 1991).
The primary hypothesis underlying the use of DBT as applied to BED is
that individuals with BED have difficulty regulating negative emotions, and
that under conditions of high negative arousal, binge eating rapidly reduces
aversive emotional experiences and thus is maintained by negative reinforce-
ment. Laboratory studies have shown that negative emotional arousal leads to
binge eating, and that binge eating leads to reduction of such arousal (Agras &
Telch, 1998; Telch & Agras, 1996). The exact mechanism underlying the effec-
tiveness of binge eating may vary from person to person and from situation to
situation. For example, binge eating may work by distracting attention from the
cues eliciting negative emotions, by decreasing physiological arousal, or by vir-
tue of its being an action opposite from the current emotion (e.g., goal-directed
activity vs. passive helplessness). It is hypothesized that treatment outcome
is mediated by three factors: (a) acquisition and strengthening of adaptive methods
of emotion regulation; (b) enhanced ability to tolerate negative emotions; (c)
increased awareness of the longer-term aversive consequences of binge eating
and the positive consequences of alternative behaviors. Treatment outcome is
hypothesized to be moderated by factors such as comorbid psychopathology,
particularly depression and anxiety, personality disorder, impulsivity, and inter-
personal functioning, all of which are associated with negative emotional state.
A recent case study described the successful treatment of a woman with
BED using DBT skills training (Telch, 1997). The current research builds on
572 TELCH El AL.

this study, providing an initial test of DBT modified for use with BED in an
uncontrolled trial.

Methods
Participants were recruited through newspaper advertisements announcing
a research study at Stanford University offering free treatment for women
who binge eat. There were 113 responses, and 93 women were contacted for
an initial telephone screening. Study inclusion criteria were female, between
the ages of 18 and 65 years, who met full DSM-1Vresearch diagnostic criteria
for BED. Exclusion criteria were (a) current involvement in psychotherapy,
weight loss treatment, or use of psychotropic medications, (b) current sub-
stance abuse or dependence, and (c) current suicidality or psychosis. Seventy-
four women were excluded during the telephone screen. The primary reasons
for exclusion were not meeting criteria for BED (n = 41), currently receiving
treatment (n = 22), and unavailable for the study duration (n = 11). Nineteen
women were invited for clinical interviews to further assess eligibility for
study participation, 5 of these women did not meet criteria for BED, and 3
were not interested in continuing with the study. Hence, 11 women meeting
study criteria were entered into the treatment trial. The study was described
in detail and written informed consent to participate was obtained prior to
conducting the clinical interviews.
The average age of the sample was 45 years (SD = 11.7) and 5 women had
never married (45.5%), 4 were married (36.4%), and 2 were widowed (18.2%).
Seven women graduated college (63.7%), 2 had completed some college
(18.2%), and 2 graduated high school (18.2%). Participants' ethnicity was
primarily white, not of Hispanic origin (90.9%, n = 10), and one woman
(9.1%) was Pacific Islander. The average age participants reported first
becoming overweight was 14.3 years (SD = 10.4) and the first dieting
attempt was reported at a mean age of 17.6 years (SD = 7.9). The average
age at onset of binge eating was 19.6 years (SD = 12.5) and the reported
duration of binge eating problems averaged 26.5 years (SD = 13.9).
The lifetime prevalence of major depression was 63.6% and 4 women
(36.4%) met criteria for a current diagnosis of dysthymia. Lifetime preva-
lence for any anxiety disorder was 63.6% (n = 7) and 5 women (45.5%) cur-
rently met criteria for an anxiety disorder. Our exclusion criteria eliminated
anyone with a current substance abuse or dependence problem; however, the
lifetime prevalence rate for substance abuse/dependence was 45.5% (n = 5).
One woman (9.1%) met lifetime criteria for BN. Axis II personality disorders
were diagnosed in 4 women (36.4%) and included self-defeating, avoidant,
narcissistic, and obsessive-compulsive personality disorders. Finally, 7 of the
11 women (63.6%) reported having received past psychological treatment.
These findings are similar to those reported in prior studies of women with
BED (Agras et al., 1994; Schwalberg et al., 1992; Wilfley & Cohen, 1997;
Yanovski et al., 1993).
 DBT FOR B I N G E - E A T I N G D I S O R D E R 573

Assessment
The structured clinical interviews were conducted by experienced assessors
trained specifically in the administration of the interview. All instruments
described below (except the SCID interviews) were administered at baseline
and posttreatment. In addition, at 3 and 6 months following the end of treat-
ment, a modified Eating Disorder Examination was administered by tele-
phone to collect data regarding binge-eating episodes and diagnostic criteria
for BED. The follow-up telephone interviews also recorded participants' self-
reported weight and continued practice of the skills taught during treatment.
Eating Disorder Examination (EDE). The EDE is a semistructured inter-
view that assesses the main behavioral and attitudinal features of eating disor-
ders (Fairburn & Cooper, 1993), and was used in this study to determine the
BED diagnosis (an addendum to the EDE was included to measure all of the
DSM-IV criteria for BED). The EDE focuses on the past 28 days and pro-
vides a measure of both the number of days and number of episodes of binge
eating that occurred. Only episodes that met the EDE definition of an objec-
tive binge episode (OBE; an unequivocally large amount of food and loss
of control over eating) were used in this study. The EDE also contains four
subscales (Restraint, Eating Concern, Weight Concern, and Shape Concern)
that measure the associated cognitive and attitudinal disturbances. Subscale
scores range from 0 to 6, with higher scores indicating greater eating disorder
attitudinal disturbance. Interrater agreement is above 0.9 for all subscales
and behaviors, and test-retest agreement is above 0.7 except for subjective
bulimic episodes (0.4; Rivzi, Peterson, Crow, & Agras, in press).
Weight. Weight was measured in lightweight clothing with shoes removed
on a balance beam scale. All participants were weighed on the day of the first
group treatment meeting and this weight was used as the baseline measure.
Structured Clinical Interview for DSM-IV (SCID) Axis I Disorders and Per-
sonality Disorders (SCID II). The SCID interviews (Spitzer, Williams, Gib-
bon, & First, 1990a, 1990b) were conducted to provide descriptive informa-
tion about comorbid psychiatric disorders in our sample. The SCID assesses
current and lifetime Axis I psychiatric disorders using criteria in accordance
with the DSM-IV while the SCID II is used for the diagnosis of Axis II per-
sonality disorders. The reliability and validity of both SCID interviews has
been well documented (O'Boyle & Self, 1990; Renneberg, Chambless, Dowdall,
Fauerbach, & Gracely, 1992; Segal, Hersen, & Van Hasselt, 1994; Strakowski
et al., 1993).
Binge Eating Scale (BES). The BES (Gormally, Black, Daston, & Rardin,
1982) is a 16-item questionnaire assessing binge-eating problems and is com-
monly used to assess severity of binge eating in BED. A score of 27 and
above indicates severe binge-eating problems while a score of 17 and below
designates no binge-eating problems.
Emotional Eating Scale (EES). The EES is a 25-item self-report question-
naire (Arnow, Kenardy, & Agras, 1995) that assesses the relationship between
specific negative emotional states and eating by asking a subject to indicate
574 T E L C H ET AL.

on a 5-point Likert scale the extent to which 25 different feelings (e.g., sad,
irritated, guilty, uneasy) lead you to feel an urge to eat. Studies of the scale's
psychometric properties have indicated that the scale is internally consistent
and demonstrates adequate temporal stability (Arnow et al.). The EES con-
tains three separate subscales: Anger/frustration, Anxiety, and Depression.
Research has demonstrated that higher levels of binge eating were associated
with the desire to eat when experiencing negative affect (Amow et al.).
Rosenberg Self-Esteem Scale (RSE). The RSE (Rosenberg, 1979) is a 10-
item questionnaire measuring beliefs and attitudes regarding general self-
worth. Higher scores on the RSE indicate higher self-esteem. Research has
documented the reliability and validity of this scale (Demo, 1985; Rosenberg).
Beck Depression Inventory (BDI). The BDI (Beck, Ward, Mendelson,
Mock, & Erbaugh, 1961) is a 21-item scale assessing somatic, affective, cog-
nitive, and behavioral symptoms of depression. Research has documented the
reliability and validity of this scale (Beck, Steer, & Garbin, 1988).
Positive and Negative Affect Schedule (PANAS). The PANAS (Watson,
Clark, & Tellegen, 1988) is a brief, 20-item self-report scale that consists of
two 10-item mood scales, each containing descriptive terms that are rela-
tively pure markers of either positive affect (e.g., excited, proud, strong,
active, enthusiastic) or negative affect (e.g., distressed, hostile, afraid, guilty,
ashamed). The Positive and Negative Affect scales of the PANAS have dem-
onstrated high internal consistency, excellent convergent and discriminant
validity, and temporal stability (Watson et al.). Each of the 20 emotion
descriptors is rated on a 5-point scale ranging from very slightly or not at all
to extremely, and the participant is asked to "indicate the extent to which you
have felt this way during the past week." Higher scores on both the Positive
and Negative Affect scales indicate higher positive or negative emotionality.
Negative MoodRegulationScale (NMR). This 30-item self-report ques-
tionnaire (Catanzaro & Mearns, 1990) measures the expectancy that a behav-
ior or cognition will alleviate a negative mood state. These generalized
expectancies for negative mood regulation are hypothesized to predict suc-
cessful attempts to cope with negative mood states and be correlated with
adjustment and health. The NMR utilizes a 5-point Likert scale format and
items consist of expectancy statements about coping behaviors. The higher
the total score on the NMR, the higher the expectancy that one can regulate
negative moods. The NMR has demonstrated adequate internal consistency,
discriminant validity, and temporal stability (Catanzaro & Mearns).

Treatment
The primary goal of treatment was to eliminate binge eating by ameliorat-
ing the emotion dysregulation hypothesized to be central in women with
BED. This was accomplished by teaching adaptive emotion-regulation skills.
A 20-session treatment manual adapted from Linehan's treatment manuals
for DBT (1993a, 1993b) was developed for the purposes of this research. The
treatment consisted of 20 weekly group sessions, each lasting 2 hours. The treat-
 DBT FOR B I N G E - E A T I N G D I S O R D E R 575

ment has three principal skills-training phases, each building on the previous
sessions: mindfulness skills (Sessions 3 to 6), emotion-regulation skills (Ses-
sions 7 to 12), distress-tolerance skills (Sessions 13 to 18). (See Wiser &
Telch, 1999, for a more detailed description of the procedures). The first two
sessions provided a rationale for the treatment, the goals of treatment, and
elicited verbal and written commitment to these goals. In explaining the
rationale for treatment, it was pointed out that women with BED have diffi-
culty regulating their emotions. This includes recognizing and labeling emo-
tional responses, evaluating their precipitants, and reducing the onset and
duration of negative emotions. Typically, binge eating reduces negative emo-
tions. Hence, it was explained that the primary goal of treatment is to learn
and practice new, more skillful ways to regulate strong emotions, enabling
them to stop binge eating. Participants were also taught how to conduct a
chain analysis of problem behavior, describing the antecedents and conse-
quences of such behaviors as well as the moment-to-moment series of linking
events, thoughts, emotions, and actions in between, with a focus on the
evoked emotions and identifying skills used, or that might have been used, to
break the chain of events and stop binge eating. A chain analysis is completed
each week and reviewed in the group, providing information on the use of
adaptive coping skills, and an opportunity to suggest the use of new and more
adaptive skills. Participants were also taught to monitor their skills practice,
binge eating, and mood each day to assess progress and adherence to skills
training. If sessions were missed, the participant was expected to listen to the
tape recording of the missed session before the next session. Handouts describ-
ing self-monitoring procedures and specific skills were provided throughout
treatment.
The teaching of mindfulness skills was centered on exercises aimed at
helping participants increase their awareness of moment-to-moment experi-
encing, particularly the experience of the transitory ebb and flow of emo-
tional experiencing. For example, participants were taught to observe their
emotional experiences, thoughts, and action urges, to describe them accu-
rately, allowing them to pass through their minds, fully experiencing them,
not suppressing them or attempting to keep them going, and not labeling
them as good or bad. This counteracts the tendency of the binge eater to avoid
strong emotional states by binge eating.
Emotion-regulation training built on the skills taught in the previous ses-
sions. This included identifying emotional triggers of urges to eat and binge
eating, investigating the relationship between the participants' interpretation
of events and their emotional responses, and becoming aware of the bodily
responses that accompany emotions. Participants also learned about the
action impulses that accompany strong emotions, how to label emotions
clearly, and to understand the adaptive function of emotions. They were also
taught how to decrease emotional vulnerability (e.g., by reducing the use of
drugs or alcohol, exercising, and getting adequate sleep). In addition, partici-
pants were taught how to change emotional states by opposite reaction (e.g.,
576 TELCH ET AL.

approach rather than avoidance when afraid; public disclosure rather than
hiding when ashamed).
Distress-tolerance training continued to build on the skills taught in the
previous sessions. The aim of this module was to teach participants how to
endure distressing situations that cannot be changed, without worsening the
situation by binge eating. These skills include distraction techniques (e.g.,
visiting with friends or taking walks); self-soothing procedures (e.g., listen-
ing to tapes of nature sounds or taking a warm bath); and realistically evaluat-
ing the pros and cons of tolerating and not tolerating distress. A series of
acceptance strategies was also taught, encouraging participants to replace
their natural impulse to fight against inescapable situations, to accept the situ-
ation as is, and willingness to do what is needed. The final two sessions con-
centrated on a review of the skills that had proved most useful to each partic-
ipant, strengthening skills that participants felt "weak" in. In addition, an
individualized plan was developed by each group member as to how to cope
with future problems and to plan for continued skills practice.

Results
O u t c o m e at Treatment End
All 11 women completed treatment and the posttreatment assessments.
Ninety-one percent of the women attended 17 or more of the 20 group sessions
(85% of sessions). All of those who missed sessions listened to the session
tape prior to the next session.
Because this was an observational study, the analytic approach used is
descriptive rather than hypothesis testing; hence, effect sizes rather than sta-
tistical testing were used to determine the efficacy of treatment. Although
there are no absolute standards as to what constitutes a small, medium, or
large effect size (ES), generally 0.2 (Odds Ratio = 1.2) might be considered
small, 0.5 (Odds Ratio = 1.6) might be considered moderate, and 0.8 (Odds
Ratio = 2.2) might be considered large. The means, standard deviations, and
effect sizes for the variables of interest are reported in Table 1.
The frequencies of objective binge episodes and binge days over the past 4
weeks were obtained from the EDE. As can be seen in Table 1, both the num-
bers of binge episodes (ES = 1.2) and binge days (ES = 1.9) decreased from
baseline to posttreatment. Nine of the 11 women (82%) reported no binge
eating over the prior 4 weeks at the end of treatment and, in addition, no
longer met diagnostic criteria for BED. The mean reduction in binge episodes
was 95% (range: 52% to 100%). Consistent with these findings, participants'
scores on the BES were reduced at posttreatment (ES = 1.7) and were within
the range that indicates no binge eating problems.
Measures of urges to eat when experiencing negative affect and emotion
regulation revealed encouraging findings. Participants' scores on the NMR
scale increased from pre- to posttreatment (ES = - 0 . 9 ) , indicating improve-
 DBT FOR B I N G E - E A T I N G D I S O R D E R 577

TABLE 1
PRE- AND POSTTREATMENT VALUES FOR THE OUTCOME MEASURES

Pretreatment Posttreatment
Variable Mean (SD) Mean (SD) Effect Size
No. of binge episodes
(past 28 days) 15.2 (12.3) 3.2 (7.6) 1.2
No. of binge days
(past 28 days) 11.8 (6.0) 1.8 (4.7) 1.9
Weight in pounds 226.8 (56.5) 219.9 (59.7) 0.1
Body Mass Index 37.3 (8.9) 36.1 (9.4) 0.4
EDE Weight 3.8 (1.2) 2.5 (0.8) 1.3
Concern
EDE Shape Concern 3.9 (1.0) 2.3 (1.5) 1.3
EDE Eat Concern 1.8 (1.5) 0.6 (.75) 1.1
EDE Restraint 1.9 (1.3) 1.6 (1.1) 0.3
Binge Eating Scale 32.4 (8.5) 17.2 (9.6) 1.7
NMR 99.5 (15.6) 112.6 (13.3) -0.9
EES-Anger 2.3 (0.7) 1.9 (0.8) 0.7
EES-Anxiety 1.9 (0.6) 1.5 (0.5) 0.9
EES-Depression 2.6 (0.9) 2.3 (0.7) 0.4
PANAS-Positive 25.4 (7.3) 30.8 (7.5) -0.7
PANAS-Negative 19.4 (5.5) 18.2 (5.3) 0.2
BDI 11.5 (6.4) 7.0 (5.1) 0.8
RSE 28.1 (7.3) 30.2 (6.9) -0.3

m e n t in their expectancies for self-regulation o f negative m o o d s . Consistent

with this finding, there was a reduction in the urge to eat w h e n e x p e r i e n c i n g
negative m o o d s as evidenced on both the A n g e r (ES = 0.7) and A n x i e t y (ES =
0.9) subscales o f the E E S .
Participants' scores on the E D E subscales o f Eating C o n c e r n (ES = 1.1),
S h a p e C o n c e r n (ES = 1.3), and W e i g h t C o n c e r n (ES = 1.3) w e r e also
reduced. H o w e v e r , the E D E Restraint subscale was o n l y slightly c h a n g e d
(ES = 0.3). Participants lost 6.9 lbs (3.0%) on average f r o m pre- to posttreat-
m e n t (ES = 0.1).
A n a l y s e s o f affect m e a s u r e s revealed positive trends as follows: Positive
Affect P A N A S subscale (ES = - 0 . 7 ) and B D I (ES = 0.8). The Negative Affect
P A N A S subscale c h a n g e d little f r o m pre- to posttreatment (ES = 0.2), as d i d
the D e p r e s s i o n subscale o f the E E S (ES = 0.4).

Posttreatment Follow-up
Ten o f the 11 w o m e n participated in the 3 - m o n t h and 6 - m o n t h f o l l o w - u p
telephone interviews. Eight o f the 10 w o m e n (80%) c o n t i n u e d abstinence
f r o m b i n g e eating at the 3-month f o l l o w - u p a s s e s s m e n t and no l o n g e r m e t
criteria for B E D . O n e o f the 2 w o m e n w h o c o n t i n u e d to have b i n g e e p i s o d e s
578 TELCH ET AL.

reported only four binge episodes during the previous 4 weeks and therefore
did not meet the binge frequency criterion for a diagnosis of BED. Seven
women (70%) remained abstinent at the 6-month follow-up, and none of the
3 women who reported binge episodes met full criteria for BED. Mean
weight losses from baseline to 3-month follow-up were 11.5 lbs, and to the
6-month follow-up were 8.6 lbs. Nine women reported continued practice of
the skills over the 3 months posttreatment and 8 women maintained skills
practice at 6-month follow-up. Participants reported practicing skills an aver-
age of 4.6 days per week at 3-month follow-up and 3.9 days per week at the
6-month follow-up. The women reported practicing an average of 6.4 dif-
ferent skills each week at 3-month follow-up and 6.9 different skills at
6 months. None of the 10 women received additional psychological or phar-
macological treatment during the follow-up period. One woman attended
three sessions of Weight Watchers over the 6-month follow-up period.

Discussion
To date, treatments for BED have not directly addressed a key factor, nega-
tive affect, which has been demonstrated to play a central role in the mainte-
nance of binge eating. Based on the theoretical model that binge eating serves
an affect-regulation function, the purpose of the current study was to provide an
initial test of a treatment for BED that focuses on teaching adaptive emotion-
regulation skills. Although this research is preliminary, the first step in treat-
ment development is to conduct an uncontrolled trial to determine if the new
treatment is promising before moving to a more expensive controlled study.
Caution must be exercised in drawing conclusions from this uncontrolled
trial, although the results were promising.
Eighty-two percent of the participants had stopped binge eating by treat-
ment end. This compares favorably with reviews that report on average about
50% of BED participants are abstinent at the end of CBT (Castonguay et al.,
1995; Wilfley & Cohen, 1997). Moreover, many of the past studies based
abstinence rates on a 1- or 2-week recall of binge eating at treatment end
while the abstinence rate in our study is based on the EDE structured inter-
view, which measures binge eating over the past 28 days. Importantly, the
reductions in binge eating and abstinence were maintained reasonably well
over the 6-month follow-up period. It is not possible to state definitively that
these changes were due to the treatment without the presence of a control
group. Small reductions in weight were evidenced at posttreatment, and these
weight losses were maintained over the follow-up period. There were also
improvements with large effect sizes pre- to posttreatment on the EDE sub-
scales measuring eating, weight, and shape concerns.
The findings on the emotion and emotion-regulation measures are interest-
ing to consider. Following treatment, participants' scores on the NMR dem-
onstrated a higher expectancy that they could actively and constructively
influence negative mood regulation. Additionally, participants' scores on the
 DBT FOR B I N G E - E A T I N G D I S O R D E R 579

EES evidenced a significantly reduced urge to eat when experiencing anger

and anxiety, but not depression. Therefore, it appears that the DBT skills
treatment may have enhanced these women's general emotion-regulation
abilities as well as specifically targeted the maladaptive urges to eat, overeat,
and binge eat in response to negative emotional states. There were also
changes with medium effect sizes on the measures of positive affect and the
BDI, but not on the experience of negative affect. It appears that the DBT
skills treatment affected participants' emotion-regulation abilities (measured
by the NMR and EES scales) independent of changes in the experience of
negative emotion (measured by the PANAS Negative Emotion scale and the
EES Depression scale). The aim of treatment was not simply to eliminate
negative feelings (although decreasing negative affect was a goal). Rather, the
skills treatment was aimed at eliminating maladaptive emotion-regulation
behaviors (i.e., binge eating) that offer temporary relief but maintain and
probably worsen negative affect in the long term and replacing the maladap-
tive binge eating with adaptive means of regulating affect. Our results suggest
that, armed with these skills, participants were better able to adaptively regu-
late negative emotions despite continuing to experience negative emotional
states.
One important question in testing a new treatment is the acceptance of
such treatment. Given that all 11 participants completed the 20-week DBT
skills treatment and that attendance was quite good over the treatment course,
it appears that the treatment was well received. Another important issue
involves whether or not some participants worsen during treatment. Our data
indicate that the frequency of binge-eating episodes improved in all partici-
pants, and that the woman who responded least well to treatment evidenced a
52% reduction in objective binge-eating episodes. Anecdotally, virtually
every participant reported that this treatment "hit the mark" by addressing the
emotion-regulation dysfunction. Many reported that acquiring the mindful-
ness, emotion-regulation, and distress-tolerance skills had positively impacted
not only their binge eating but also many other areas of their lives, such as
their work and relationships.
The limitations of this study warrant reemphasis. This study's purpose was
to provide the first step in the development of a new treatment for BED by
conducting an uncontrolled trial using a newly developed treatment manual.
Because this was not an experimental design with random assignment to a
control condition, we cannot definitively state that the changes evidenced
were due to the treatment. However, the changes in binge eating and weight
endured at the 6-month follow-up. It is recognized that the follow-up period
was relatively brief and that demonstrating maintenance of treatment gains
over a longer period is needed, especially given the chronicity of binge-eating
problems. Finally, our sample size was small and consisted exclusively of
women.
In summary, it appears that DBT skills training adapted for women with
BED is a promising new treatment. The results of this preliminary study sup-
580 TELCH ET AL.

port going forward with the next step in treatment development, namely, con-
ducting a controlled trial. We are currently in the process of conducting a
controlled trial using a treatment versus wait-list control design. This next
step is necessary before undertaking a more expensive comparative trial that
would require a substantially larger sample. If the results of our controlled
trial demonstrate significant improvement in the treated group, then subse-
quent research should focus on a comparative outcome study that would also
permit the identification of mediators and moderators of outcome and deter-
mination of which patients respond best to which treatment.

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RECEIVED: March 29, 1999

ACCEPTED: February 8, 2000