





































Microsoft Word - Vol10_TraciStein_AVK#2AF73E.doc


23

Graduate Student Journal of Psychology                                                                            Copyright 2008 by the Department of Counseling & Clinical Psychology

2008, Vol. 10                                                                                                                        Teachers College, Columbia University                         ISSN 1088-4661

Dialectical Behavior Therapy: An Effective Treatment for Individuals with

Comorbid Borderline Personality and Eating Disorders?

Traci R. Stein
Teachers College, Columbia University

Patients with either or both Borderline Personality Disorder (BPD) and an eating disorder face a

number of intrapsychic and interpersonal difficulties that have been historically treatment resistant.

Dialectical Behavior Therapy, which combines elements of cognitive behavioral therapy and Zen

practices, has shown some promise as a potential treatment for patients with comorbid personality

and eating disorders. Criticisms of DBT include the limited number of randomized, controlled tri-

als examining the efficacy of the treatment, small sample sizes, and as of yet no clear understand-

ing of the specific mechanisms of action. These limitations aside, DBT is the only treatment con-

sidered empirically supported for use with patients who have BPD. The focus on acceptance in the

present moment may be particularly beneficial for patients with eating disorders, especially in light

of their characteristic lack of acceptance of their bodies. Given the promising results in reducing

self-harming behaviors among patients with BPD, further study of this therapy for those with both

personality and eating disorders is warranted.

Borderline Personality Disorder (BPD) is characterized

by a pervasive pattern of emotional and interpersonal insta-

bility, impulsivity, and fears of abandonment (American

Psychiatric Association, 2000). Borderline individuals tend

to engage in behaviors that are potentially self-damaging,

which can include binge eating, substance abuse, reckless

driving or unsafe sex, as well as self-mutilating or suicidal

behavior. Most (75%) of patients with BPD are female, and

the prevalence of the disorder is estimated to be about 2%

of the general population, 10% of psychiatric outpatients,

and up to 20% of psychiatric inpatients. Between 30 and

60% of patients with personality disorders meet criteria for

BPD (American Psychiatric Association, 2000).

Linehan (2000) describes BPD as a persistent and se-

vere mental disorder with poor outcomes following the use

of traditional treatments, and hypothesizes that the disorder

arises from a tendency toward emotionality that is shaped

by an invalidating environment (Linehan, 1993a). BPD is

characterized by high rates of psychiatric hospitalization

and serious risk of suicide. Between 60 and 80% of patients

with BPD engage in parasuicidal or self-injurious behavior

at some point in their lives and there is often little change in

level of functioning or rates of psychiatric hospitalization

up to 5 years after treatment (Linehan & Heard, 1999).

Patients with BPD present unique challenges to thera-

pists. These include high rates of noncompliance with

treatment, the tendency to misuse medications, poor

Correspondence concerning this article should be addressed to

Traci R. stein, email ts2007@columbia.edu.

outcomes  with  even  intensive  psychotherapy,  high  rates

of parasuicidal behavior, high rates of psychological co-

morbidity, and tendencies to engage in hostile behaviors

toward their therapists (Linehan, 2000). BPD is considered

substantially comorbid with both Axis II (e.g., histrionic

personality disorder), and Axis I disorders (e.g., mood dis-

orders, substance related disorders), including eating disor-

ders, and is less responsive to pharmacotherapy than many

other psychological illnesses (American Psychiatric Asso-

ciation, 2000; Clarkin, Levy, Lenzenweger, & Kernberg,

2004). For those borderline patients who have comorbid

eating disorders, treatment is often more difficult and prog-

nosis poorer than for those patients with BPD or an eating

disorder alone (Palmer, Birchall, Damani, Gatward,

McGrain, & Parker, 2003). Thus, it is essential to find a

treatment that will address adequately the specific needs

and challenges of these patients. This paper will review and

summarize the research findings and limitations related to a

Dialectical Behavior Therapy (DBT) as a potential treat-

ment for those with this comorbid BPD and eating disor-

ders.

Comorbidity of Eating Disorders and BPD

Both clinical observations and empirical research sug-

gest that personality disorders (PD) are more common

among patients who have eating disorders than those who

do not have an eating disorder diagnosis (Livesley, Jang, &

Thordarson, 2005; Sansone, Levitt, & Sansone, 2005).

Conversely, eating disorders also appear to be more preva-

lent in patients with personality disorders, and are more

common in patients with BPD than in patients diagnosed

with other personality disorders. Reported prevalence rates



STEIN

24

of co-occurrence vary widely, ranging from 27 to 93%,

with bulimia and the binge-eating/purging subtype of ano-

rexia being the eating disorders most commonly comorbid

with BPD (Livesley et al., 2005; Sansone et al., 2005). Re-

lated to the above, BPD is the most frequent Axis II disor-

der diagnosed in patients with bulimia nervosa, with a

prevalence rate of over 28%, and it is also the most frequent

personality disorder diagnosed among those with the binge-

eating/purging subtype of anorexia at a rate of 25% (San-

sone et al., 2005). In these two types of eating disorders,

impulsivity is expressed via the behaviors of binge eating

and purging. In addition, though obsessive-compulsive per-

sonality disorder is the most common Axis II diagnosis in

individuals with binge eating disorder, BPD makes up ap-

proximately 12% of the Axis II diagnoses in those with this

type of eating disorder (Sansone et al., 2005).

Outcomes in Patients with Dual Diagnoses

Patients who have both an eating disorder and a co-

morbid personality disorder tend to have poorer overall

psychotherapy treatment outcomes and prognoses (Palmer

et al., 2003), though it is unclear whether this relates to

eating disorder symptomatology or other psychiatric

symptoms found in individuals with both diagnoses (San-

sone et al., 2005). In addition, the variety of self-defeating

and self-damaging behaviors exhibited by those with BPD

and comorbid eating disorders, including impulsivity and

engaging in self-harming behaviors, can reduce the likeli-

hood of patients benefiting from most therapies (Palmer et

al., 2003).

Etiology and Common Mechanisms – BPD and Eating Dis-

orders

Although several studies have described eating disor-

ders as being more prevalent among patients with personal-

ity disorders, this finding was contradicted in one fairly

recent, large-scale trial. In this study, researchers examined

the prevalence of eating disorders among 668 patients who

were diagnosed with schizotypal, borderline, obsessive-

compulsive, or avoidant personality disorder, or major de-

pressive disorder (MDD). The results indicated that person-

ality disordered patients were not significantly more likely

to have an eating disorder than those patients with MDD

(Grilo, Sanislow, Skodol, Gunderson, Stout, & Shea et al.,

2003). It is unclear whether this is due to a common

mechanism or mechanisms shared by patients with major

depression, eating disorders, and personality disorders

(Livesley et al., 2005). It is possible that factors common to

BPD, eating disorders, and major depression may include

genetic and environmental influences on the development

of these disorders; however, the trial was not designed to

explore this hypothesis.

In another trial, however, researchers sought to eluci-

date etiological factors that may be common to the devel-

opment of PDs and eating disorders. In their recent study of

221 pairs of monozygotic (121 pairs) and dizygotic (100

pairs) twins, Livesley and colleagues (2005) explored the

relationship between Axis II symptoms and a measure of

eating disorder symptoms. They estimated the extent to

which genetic and environmental influences on symptoms

were shared with specific personality characteristics by

exploring correlations between scales assessing personality

disorder and eating disorder traits. Genetic correlations

between variables were estimated using a method similar to

estimating the heritability (proportion of the total variance)

of a single variable. Heritability was estimated by compar-

ing the similarity (in terms of endorsement of symptoms) of

monozygotic and dizygotic twins. A higher within-pair cor-

relation for monozygotic than dizygotic twins was indica-

tive of genetic influence.

The team’s findings suggested that, while there were

genetic influences in the development of the disorders, the

relationship between personality disorder traits and eating

disorders was relatively modest, and there were small but

significant phenotypic relationships. Specifically, the in-

vestigators found dimensions of “concern with overeating”

to share a genetic etiology with the construct of “emotion

dysregulation.” Affective lability was phenotypically and

etiologically related to purging, and the strongest associa-

tion was between purging and the tendency to self-harm.

These findings suggest that personality characteristics are

related to eating disorders, but that the degree to which they

are expressed may vary according to environmental experi-

ences. The authors postulated that purging may be related to

the spectrum of self-harming behaviors in BPD, and this

may account, at least in part, for the relationship between

bulimia and BPD. Though this study was comprised of in-

dividuals from a general population sample, rather than

those with a diagnosable eating disorder, it suggests hy-

potheses linking BPD and eating disorders are worthy of

further study.

Dialectical Behavior Therapy for BPD

There are few randomized controlled trials of specific

treatments for personality disorders (see Bateman &

Fonagy, 2000, for a review). However, psychotherapy is the

most commonly applied treatment for personality disorders,

and, despite Linehan’s (2000) observation of poor outcomes

associated with patients with a personality disorder, psy-

chotherapy has been associated with an up to seven-fold

faster rate of recovery as compared to no treatment at all

(Clarkin et al., 2004).

Dialectical Behavior Therapy (DBT; Linehan, 1993a)

is a treatment that blends cognitive-behavioral and Zen-

inspired practices, and was specifically developed to ad-

dress the problems of affect dysregulation that are at the

core of BPD. DBT, which combines individual psychother-

apy with group skills training, was the first psychotherapy

intervention that was shown via controlled trials to be ef-

fective for the treatment of BPD (Linehan, Armstrong, Su-

arez, Allmon, & Heard, 1991; Linehan, Heard, & Arm-



DIALECTICAL BEHAVIOR THERAPY FOR BPD AND ED

25

strong, 1993). Dialectical philosophy, which stresses the

importance of understanding and incorporating the natural

tensions between acceptance of one’s emotions at the pre-

sent moment and the simultaneous need for change, is at the

heart of DBT. DBT is highly structured, particularly during

the initial stage of treatment. Prior to the initial stage, the

therapist must secure the client’s agreement to the require-

ments of DBT. These include a year-long commitment to

treatment and up to 4 hours per week for the individual,

group, and consultation sessions.

During the first stage, the therapist facilitates decreas-

ing both the patient’s life-threatening and therapy-

interfering behaviors (e.g., missing appointments without

calling, hostility toward the therapist), and targets those

behaviors that interfere with the patient’s quality of life. At

this stage, DBT focuses on four concurrent modes of treat-

ment: weekly individual psychotherapy; group skills train-

ing sessions, which emphasize acquiring and strengthening

interpersonal and coping skills; telephone consultation with

the therapist (as needed); and weekly consultation team

meetings for therapists. The manualized skills training ses-

sions are structured and include the assignment of home-

work (Linehan, 1993a; Linehan, 1993b). The team meetings

are aimed at helping therapists process and receive feed-

back regarding treatment concerns and enhance their capa-

bility for effectively working with patients (McMain, Kor-

man, & Dimeff, 2001).

During stage two, the emphasis is on using a cognitive-

behavioral therapy approach to reduce the symptoms of

posttraumatic stress that are common to most patients with

BPD (Smith & Peck, 2004). For example, key techniques

include keeping a thought diary, behavioral analyses, expo-

sure techniques, flooding, and contingency management

(although these can be applied during any stage of treat-

ment). During stage three, the client with BPD begins to

apply the newly acquired skills to every area of life. This

includes planning for the future, asking the therapist for

help in an appropriate way, focusing on reducing shame and

self-hate, accepting reality as it is, and integrating the self

with the past, present, and future (Linehan, 1993a).

Studies of DBT for Patients with BPD

While an exhaustive review of the literature on DBT is

not within the scope of this paper, a brief overview of the

support for DBT for BPD is presented below. Several stud-

ies have examined the use of DBT compared to standard

care, or Treatment as Usual (TAU), for patients with BPD,

usually for those with a history of self-harm or parasuicidal

behavior (Smith & Peck, 2004). In their 1991 study, Line-

han and colleagues conducted a randomized clinical trial to

evaluate the effectiveness of DBT for the treatment of

chronically parasuicidal women who met criteria for BPD.

The treatment lasted 1 year, with assessments every 4

months. The control condition was TAU. Prior to randomi-

zation, subjects were matched regarding the number of past

parasuicidal events, psychiatric hospitalizations, age, and

prognosis. However, almost one third of potential subjects

across both groups either dropped out or were excluded

from the sample because they did not meet inclusion crite-

ria. Twenty-two subjects were left in the DBT group, 20 of

whom remained in DBT for the required year. The control

subjects (n = 20) received referrals for therapy in the com-

munity. TAU subjects reported significantly fewer hours of

individual or group therapy, but reported more day treat-

ment than the DBT group. At most assessment time points,

subjects who received DBT had fewer incidences of para-

suicide and less medically severe parasuicides, were more

likely to stay in individual therapy, and had fewer inpatient

psychiatric days. There were no between-group differences

on measures of depression, hopelessness, suicidal ideation,

or reasons for living, and scores on all four measures de-

creased throughout the year.

There were several limitations associated with this

study. Among them were the high pretreatment attrition rate

and the somewhat sparse information regarding the specif-

ics of the treatment received by those in the TAU group. In

addition, the DBT subjects received treatment for free,

whereas the TAU subjects were charged for services ob-

tained in the community, resulting in their seeking treat-

ment in low-fee settings. This last limitation likely ac-

counted to some extent for the fact that subjects in the DBT

condition were significantly more likely to begin and re-

main in therapy than the TAU subjects (Scheel, 2000).

In another trial by Barley, Buie, Peterson, and

Hollingsworth (1993), DBT was adapted for use with 130

BPD patients (almost 80% of whom were women) who

were discharged from an inpatient psychiatric unit after an

approximately 100-day length of stay. The patients received

individual therapy, group skills training and other activities,

including DBT homework. Average rates of parasuicidal

behavior were compared for the 19 months prior to the in-

troduction of DBT, the 10 months of the initial phase of the

program, and the subsequent 14 months of DBT. This ap-

proach resulted in a significant reduction in parasuicide

under the full DBT program as compared to the pre-DBT

and phase I DBT periods. Rates were also significantly

lower than the average rates of parasuicide within a general

psychiatric unit offering treatment as usual (Scheel, 2000).

The primary strength of this study may be its reasona-

bly large sample size (N = 130) as compared to other trials

of DBT. However, without a true control group or random

assignment to either DBT or another therapeutic interven-

tion, definitive conclusions cannot be made attributing ob-

served benefits to DBT alone. Yet, reduction of parasuicidal

behaviors seems to be a consistent finding across DBT

studies (see Scheel, 2000, for a review). In addition, Barley

and colleagues (1993) reported that DBT was readily ac-

cepted and understood by both patients and hospital staff

alike, presumably adding to the observed effectiveness of

this approach.



STEIN

26

DBT for Binge Eating Disorder

Although most studies of DBT have been with patients

who have an Axis II diagnosis, a 2001 study by Telch, Ar-

gas, and Linehan evaluated DBT for patients with binge

eating disorder (BED). The investigators adapted DBT for

use with this population in a randomized, controlled trial.

This study followed an uncontrolled pilot study during

which 11 women with BED received the group skills train-

ing portion of DBT, which was adapted from Linehan’s

(1993b) treatment manual but was not accompanied by the

other aspects of standard DBT. The original pilot skills

training program took place over 20 sessions. In the RCT,

however, the treatment was adapted from the DBT manual

as follows: participants were taught mindfulness, distress

tolerance, and the emotion regulation skills that are nor-

mally part of DBT, but the interpersonal effectiveness com-

ponents of DBT were not included. Furthermore, standard

DBT includes both weekly group therapy skills training and

weekly individual therapy. The adaptation of DBT in this

study combined skills training and skills-to-daily-life com-

ponents in a weekly group therapy format. The intervention

was structured in this way both to decrease the amount of

time spent in therapy, and to allow for comparisons of this

affect regulation treatment with other interpersonally fo-

cused therapies for eating dysfunction. There were no drop-

outs in the pilot, and 82% of women were abstinent from

binge eating at the end of treatment as well as at 3 and 6

months post-treatment (Telch, Agras, & Linehan, 2000;

Wise & Telch, 1999). Thus, despite the elimination of por-

tions of the DBT protocol, these patients experienced re-

duction in a key symptom that was maintained after the

cessation of the intervention.

DBT for BPD Patients with Comorbid Eating Disorders

A review of the literature revealed only one published

study on the use of DBT for patients diagnosed with both

BPD and a comorbid eating disorder (Palmer et al., 2003).

The trial adapted a full program of DBT for use with pa-

tients in a specialized eating disorder service who met

DSM-IV (American Psychiatric Association, 2000) criteria

for both BPD and an eating disorder (binge eating disorder,

n = 1; bulimia, n = 5; eating disorder NOS, n = 1; two of the

subjects also met criteria for anorexia nervosa prior to, but

not at the time of enrollment in the study). The team was

comprised of experienced clinicians who had undergone

intensive training in DBT prior to the study. Subjects re-

ceived weekly individual therapy sessions, weekly skills

training in a group format, and phone contact with thera-

pists outside of the formal sessions. In addition, the thera-

peutic team met for a weekly consultation group as per

standard DBT. The adaptation consisted of the addition of a

skills training module that focused on problems of weight

and eating.

The all-female study sample was small, however (N =

7), and began with three patients, with three more being

enrolled at 6 months into the intervention, and a seventh

being enrolled at 1 year. The length of time patients were

enrolled in the program thus varied from a minimum of 6

months to 18 months, rather than adhering to the normal

minimum requirement of remaining in DBT for 1 year. All

of the women in the sample had engaged in prior acts of

self-harm and most had been patients on the service for

some time prior to the intervention, though this range was

not specified in the article. Five of the patients had received

inpatient treatment prior to the study.

As several of the patients were “uncooperative” (p.

283) with respect to filling out questionnaires during the

study, data for pre-post comparisons were limited, leaving

only two variables available for all patients. These were the

total number of days spent in the hospital and the number of

acts of self-harm that either did receive, or should have re-

ceived medical attention. Acts such as self-cutting not re-

quiring stitches were not counted. Self-harm episodes were

obtained via documentation by the clinical staff and from

diary cards patients filled out during the program. These

endpoints were also available for the 18 months prior to and

the 18 months after the completion of the program, as well

as for the duration of the program.

Due to the small sample size and variability of the data

available for each patient, the research team deemed it in-

appropriate to attempt to perform statistical analyses and

instead provided results descriptively. All patients survived

and remained in treatment throughout the duration of the

program. There was a reduction in both inpatient days and

self-harm requiring medical attention for the group as a

whole. However, one patient was assaulted during the fi-

nalthird of her treatment, and this was followed by a major

relapse necessitating prolonged hospital admission.

The investigators reported marked reduction in minor

self-harm (that not requiring medical attention) in all pa-

tients, and eating disorder symptoms also decreased in the

group such that by the end of follow-up, none of the pa-

tients still had a full syndrome eating disorder, although

four had partial syndromes diagnosable as eating disorder

NOS. All participants retained some concerns regarding

weight and eating behaviors; however, in the post-treatment

months all were described as making “significant progress

in their lives” (p. 284), including marriages, having a baby,

a graduation, and progress in employment (Palmer et al.,

2003). Also, none continued to present the behav-

ioral/interpersonal difficulties in therapy that had been

characteristic prior to the DBT program.

The limitations to this study are many. First, the small

sample size, lack of a control group or randomization, great

variation in total time subjects spent in the study, and in-

complete baseline and other data make it impossible to con-

clude that the DBT program was effective above and be-

yond the effects of internal validity confounds. However,

the results of this program are promising and suggestive of

significant benefits for patients who are at high-risk, tend to

be difficult and demanding, and who remain treatment-

resistant even after extensive therapy. Additional trials of



DIALECTICAL BEHAVIOR THERAPY FOR BPD AND ED

27

DBT for patients diagnosed with BPD and comorbid eating

disorders are warranted to further explore the utility of this

approach with this challenging population.

In a follow up to the aforementioned study of patients

with BED by Telch and colleagues (2001), the team con-

ducted a controlled trial of 44 women meeting diagnostic

criteria for BED, (27% of whom had a current, but unspeci-

fied, personality disorder) that were randomized to either

DBT skills training (n = 22) or a wait-list control condition

(n = 22). Following randomization, 10 participants dropped

out of the study (four in the treatment group and six in the

waitlist control). Participants were assessed at baseline and

after completing 20 weeks of treatment using the SCID I

and II, the Binge Eating Scale, the Emotional Eating Scale

(EES), the Beck Depression Inventory, the Positive and

Negative Affect Schedule (PANAS), and the Negative

Mood Regulation Scale. Those in the treatment group also

completed abbreviated assessments of binge frequency and

skills usage at 3 and 6 months post-intervention. Assess-

ments were performed via structured clinical interview by

trained interviewers. Though the original design specified

having interviewers unaware of group assignment, the blind

was often broken by the patient.

There was a great deal of psychiatric comorbidity in

the sample, and over 75% of participants had received psy-

chiatric treatment in the past, though they did not receive

other types of psychotherapy during the trial. Analyses

were limited to those who completed treatment (n = 34).

There were no significant differences between groups on

any of the baseline measures, but significant effects were

found at the end of the treatment for binge days and epi-

sodes. Eighty-nine percent of the treatment group were con-

sidered abstinent (no binges in the previous 4 weeks) com-

pared with 12.5% of the control group. Those in the treat-

ment group also had significantly lower scores on measures

of weight concerns, shape concerns, and eating concerns,

though there were no significant differences in dietary re-

straint. Patients in the treatment group reported significantly

lower scores on a scale measuring the urge to eat when ex-

periencing anger. Changes were maintained among many of

the women in the post-treatment months, with 67% and

56% being abstinent at 3 and 6 months, respectively. The

majority of participants (89%) continued to practice skills

taught during treatment.

Of those in the waitlist control group, 14 women ac-

cepted the invitation to participate in treatment. For those

who completed the intervention, 90% were abstinent at the

end of treatment and 80% and 67% were abstinent at the 3-

and 6-month follow ups, respectively.

The study was limited by its small sample size and

relatively high dropout rate. The authors were also unable

to conclude how DBT worked to reduce binge eating, and

the results of the study offered no support for the hypothesis

that the treatment worked by reducing negative affect or by

improving expectancies for mood regulation (Telch et al.,

2001). However, treated women reported significantly

lower scores on the anger subscale, but not the anxiety and

depression subscales, of the EES at posttest. These findings

suggest, but do not conclusively demonstrate, that the modi-

fied DBT program used in this study may work by reducing

the urge to eat when experiencing negative emotions rather

than by changing affect directly.

Summary and Future Directions

Personality disorders and eating disorders appear to be

frequently comorbid, and patients with either or both Bor-

derline Personality Disorder and an eating disorder face a

number of difficulties that have been historically treatment

resistant. Dialectical Behavior Therapy, which combines

elements of cognitive behavioral therapy and Zen practices,

addresses many of the specific challenges of BPD via indi-

vidual psychotherapy and group skills training, as well as a

focus on self-acceptance. At present, DBT is the only

treatment that is considered empirically supported for pa-

tients with BPD, and has been shown to reduce self-

harming behaviors and improve interpersonal functioning in

this population. As BPD and eating disorders appear to

share some common features, including the tendency to

engage in self-harming behaviors, it has been hypothesized

that DBT may be a useful treatment option for those with

this type of comorbidity. DBT has shown some initial

promise as a potential treatment for patients with binge

eating disorder, and preliminary research suggests it may be

of benefit to those with BPD and comorbid eating disorders.

Criticisms of DBT include the limited number of random-

ized, controlled trials examining the efficacy of the treat-

ment, small sample sizes, and as of yet no clear under-

standing of the specific mechanisms of action. Also, attri-

tion rates are high in many studies of BPD due to the im-

pulsivity and instability of patients with this disorder. Fur-

thermore, DBT frequently does not result in significant re-

ductions in the depression or hopelessness characteristic of

BPD. Outcomes of interest vary from study to study, as do

the measures used to assess them. Both of these issues

make it difficult to compare the results of trials even when

conducted with comparable patient populations. In a related

vein, DBT is often adapted for use in different settings and

for patients who meet different diagnostic criteria, resulting

in treatments that are similar but not quite the same. This

too makes comparison across trials difficult.

Comorbidity presents additional and significant chal-

lenges to treating and conducting rigorous research with

those who have personality disorders. Many individuals are

diagnosed with more than one Axis II disorder, and the in-

teraction between Axis II and Axis I disorders may obscure

treatment effects. Studies may also confound personality

change with improvement in symptoms. Additionally, since

most patients with either BPD or an eating disorder are

women, it is unclear whether and to what extent DBT

would have similar effects for men with either or both dis-

orders. Last, DBT is a time-intensive and thus, potentially

costly treatment. This presents probable barriers to those

with limited incomes or whose work schedules would not



STEIN

28

allow for the up to 4 hours per week required for standard

DBT.

Nevertheless, these limitations aside, DBT is the only

treatment considered empirically supported for use with

patients who have BPD. The focus on acceptance in the

present moment may be particularly beneficial for patients

with eating disorders, especially in light of their character-

istic lack of acceptance of their bodies. Given the promising

results in reducing self-harming behaviors among patients

with BPD, the preliminary results showing similar benefits

for those with both BPD and a comorbid eating disorder,

and benefits, including decreased weight and eating con-

cerns for those with binge eating disorder, further study of

this therapy for those with both disorders is warranted.

References

American Psychiatric Association. (2000). Diagnostic and

statistical manual of mental disorders (4
th

 ed., text rev.).

Washington, DC: Author.

Barley, W. D., Buie, S. E., Peterson, E. W., Hollingsworth,

A. S., Griva, M., Hickerson, S. C., Lawson, J. E., & Bai-

ley, B. J. (1993). Development of an inpatient cognitive-

behavioral treatment program for borderline personality

disorder. Journal of Personality Disorders, 7, 232-240.

Bateman, A. W., & Fonagy, P. (2000). Effectiveness of

psychotherapeutic treatment of personality disorder. Brit-

ish Journal of Psychiatry, 177, 138-143.

Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kern-

berg, O. F. (2004). The Personality Disorders Insti-

tute/Borderline Personality Disorder Research Foundation

randomized control trial for borderline personality disor-

der: rationale, methods, and patient characteristics. Jour-

nal of Personality Disorders, 18(1), 52-72.

Grilo, C. M., Sanislow, C. A., Skodol, A. E., Gunderson, J.

G., Stout, R. L., Shea, M. T., Zanarini, M. C., Bender, D.

S., Morey, L. C., Dyck, I. R., & McGlashn, T. H. (2003).

Do eating disorders co-occur with personality disorders?

Comparison groups matter. International Journal of Eat-

ing Disorders, 33(2), 155-164.

Linehan, M. M. (1993a). Cognitive behavioral treatment of

borderline personality disorder. New York: Guilford

Press.

Linehan, M. M. (1993b). Skills training manual for treating

borderline personality disorder. New York: Guilford

Press.

Linehan, M. M. (2000). The empirical basis of dialectical

behavior therapy: development of new treatments versus

evaluation of existing treatments. Clinical Psychology

Science and Practice, 7(1), 113-119.

Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D.,

& Heard, H. L. (1991). Cognitive-behavioral treatment of

chronically parasuicidal borderline patients. Archives of

General Psychiatry, 48(12), 1060-1064.

Linehan, M. M., Heard, H. L., & Armstrong, H. E. (1993).

Naturalistic follow-up of a behavioral treatment for

chronically parasuicidal borderline patients. Archives of

General Psychiatry, 50, 971-974.

Linehan, M. M., & Heard, H. (1999). Borderline personality

disorder: costs, course, and treatment outcomes. In N.

Miller & K. Magruder (Eds.), The cost-effectiveness of

psychotherapy: A guide for practitioners, researchers,

and policy-makers (pp.291-305). New York: Oxford Uni-

versity Press.

Livesley, W. J., Jang, K. L., & Thordarson, D. S. (2005).

Etiological relationships between eating disorder symp-

toms and dimensions of personality disorder. Eating Dis-

orders, 13, 23-35.

McMain, S., Korman, L. M., & Dimeff, L. (2001). Dialecti-

cal behavior therapy and the treatment of emotion dys-

regulation. JCLP/In Session: Psychotherapy in Practice,

57(2), 183-196.

Palmer, R. L., Birchall, H., Damani, S., Gatward, N.,

McGrain, L., & Parker, L. (2003). A dialectical behavior

therapy program for people with an eating disorder and

borderline personality disorder – description and out-

comes. International Journal of Eating Disorders, 33(3),

281-286.

Sansone, R. A., Levitt, J. L., & Sansone, L. A. (2005). The

prevalence of personality disorders among those with

eating disorders. Eating Disorders, 13, 7-21.

Scheel, K. R. (2000). The empirical basis of dialectical be-

havior therapy: summary, critique, and implications.

Clinical Psychology Science and Practice, 7, 68-86.

Smith, L. D., & Peck, P. L. (2004). Dialectical behavior

therapy: A review and call to research. Journal of Mental

Health Counseling, 26(1), 25-38.

Telch, C. F., Agras, W. S., & Linehan, M. M. (2000). Group

dialectical behavior therapy for binge eating disorder. A

preliminary uncontrolled trial. Behavior Therapy, 31, 569-

582.

Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dia-

lectical behavior therapy for binge eating disorder. Jour-

nal of Consulting and Clinical Psychology, 69(6), 1061-

1065.

Wiser, S., & Telch, C. F. (1999). Dialectical behavior ther-

apy for binge eating disorder. Journal of Clinical Psy-

chology, 55, 755-768.


