Symptoms of Bulimia Nervosa 

Bulimia Nervosa is a type of eating disorder characterized by a pattern of binge and purge behaviors. Individuals with bulimia experience episodes of binge eating and engage in compensatory behaviors in order to prevent weight gain.

The American Psychiatric Association defines an episode of binge eating as a discrete amount of time in which an individual eats an amount of food that is significantly above average (for said timeframe) and feels out of control while doing so. Individuals with bulimia also engage in purging behaviors such as self-induced vomiting, laxative or diuretic abuse, fasting or excessive exercise in an effort to maintain their weight.

Individuals with bulimia are at greater risk of psychological comorbidities such as depression and anxiety and are at heightened risk of negative physical health outcomes. Repeated purging behaviors such as vomiting or laxative abuse can lead to serious dental, cardiovascular and gastroenterological problems (Westmoreland et al., 2016).

Data collected in 2003 found that 1.5% of people in the United States will experience bulimia in their lifetime, but experts believe that these numbers have only grown in the past twenty years. Research also found that women were five times more likely to experience bulimia than men (Hudson et al., 2012). 

Can Bulimia Nervosa be cured or treated?

While bulimia cannot be “cured,” recovery from bulimia nervosa is possible. A recent study showed that over two thirds of women with bulimia recovered (Eddy et al., 2017). Cognitive Behavioral Therapy (CBT) has been proven to be effective at treating bulimia and research has also found that CBT for bulimia can create significant improvements in as few as six sessions (Wilson et al., 2002).

Interpersonal psychotherapy is also an effective treatment for bulimia. Studies have found that while it does not work as quickly as CBT, success rates are equivalent in the longer-term (Murphy et al., 2012; Agras et al., 2000). More recent research, however, has shown that dialectical behavioral therapy (DBT) is also incredibly effective at treating bulimia nervosa (Safer et al., 2001).

What is DBT?

Dialectical Behavioral Therapy (DBT) is a type of therapy which was developed by Marsha Linehan. DBT was created as a means of treating self-harm and suicidal behaviors, but is now used to treat a variety of psychological concerns, most popularly, Borderline Personality Disorder (BPD). DBT combines techniques used in traditional Zen practices with traditional behavioral therapy in order to create a therapeutic modality that prioritizes both acceptance and change.

This seemingly paradoxical relationship of acceptance and change that is central to DBT is based upon the philosophy of dialectics. The philosophy of dialectics is the idea that two contradictory ideas can be true at the same time, and often are. The dialectic, central to DBT, is that of acceptance and change.

Traditional DBT was designed for outpatient care and includes individual therapy, skills training, phone communication between client and therapist as needed and clinician consultation groups. Skills training can be done individually or in a group setting, and consists of four main components: mindfulness, interpersonal effectiveness, distress tolerance, and emotion regulation (Chapman and Dixon-Gordon, 2020).

Is DBT effective at treating Bulimia Nervosa?

DBT has been proven to be incredibly effective at treating Bulimia Nervosa. Within a DBT framework, eating disorders are conceptualized as an individual’s attempt to regulate their emotions by engaging in binging, restricting or purging behaviors. Therefore, DBT helps to treat eating disorders such as bulimia by helping individuals improve their emotion regulation skills (Bankoff et al., 2012). 

Many scientific studies have found that DBT is effective at treating bulimia nervosa. A study published in the American Journal of Psychiatry in 2001 found that DBT was incredibly effective at treating bulimia nervosa (Safer et al., 2001). In 2015, research found that even brief DBT interventions resulted in significant improvement in symptoms of bulimia nervosa (Hall, 2015).

Research also suggests that DBT is effective in improving eating disorder psychopathology, BMI, and emotion regulation in eating disorder patients (Journal of Personalized Medicine, 2021). Studies have also found that patients are less likely to drop out of DBT treatment for bulimia compared to other types of therapy, such as cognitive behavioral therapy (CBT) (Safer et al., 2001).

How to find DBT therapy for Bulimia in NYC?

Finding therapy in NYC, specifically eating disorder treatment, can be difficult. The first thing to consider when looking for treatment for bulimia is what level of treatment is appropriate for you. The level of treatment required depends on the severity of illness. Options include inpatient, residential, intensive outpatient or outpatient treatment. If you determine that inpatient, residential or intensive-outpatient treatment is right for you, there are many options in and around NYC.

When looking at programs, ask questions about what types of therapy are utilized as many of these treatment centers do use DBT but in various capacities. If you decide to pursue outpatient individual psychotherapy, a good place to start is online. There are many sites which allow you to search for therapists in your area and filter based on insurance plan, clinician’s area of expertise and type of therapy. It is important to look out for therapists who specialize in the treatment of eating disorders, and who utilize DBT in their practice.

Finding a therapist who’s the right fit can be challenging, but many therapists offer free phone consultations to help you decide whether or not you may be a good fit. If you are struggling with an eating disorder such as bulimia it is also very important to be in touch with a medical doctor. They are not only able to help support your physical health throughout your recovery, but also will likely be able to refer you to mental health professionals in your area who specialize in treating eating disorders.

What techniques from DBT are used at New York Behavioral Health

New York Behavioral Health does not offer an “intensive” DBT program, e.g., there is not a formal weekly DBT consultation group. Some NYBH therapists are intensively trained and all of our staff utilize DBT as a part of their practice, especially when working with clients struggling with bulimia.

NYBH clinicians utilize a variety of DBT skills when treating eating disorders, specifically distress tolerance skills. One example of a specific set of distress tolerance skills your therapist may teach you are called TIP skills. TIP stands for Temperature, Intense exercise, Paced breathing and Paired muscle relaxation. The temperature skill, for example, asks you to significantly reduce the temperature of your face by soaking your face in ice water or holding an ice pack on your face.

These skills are designed to help you decrease your level of acute distress and are intended to be used in moments of severe emotional arousal when using other DBT skills may seem too difficult (Linehan, 2014). These skills that can be used when you are having the urge to binge or purge and feel overwhelmed by emotions such as guilt, shame or anxiety. Therapists at NYBH also incorporate interpersonal effectiveness skills into bulimia treatment.

Your therapist may help you develop assertiveness skills to help you set boundaries around food and weight with people in your life. For example, many people with eating disorders do not benefit from friends or family making comments about food consumption or body weight, but struggle to express this to those around them.

One specific set of skills your therapist may help you learn in order to help you have these difficult conversations are the DEAR MAN skills. DEAR MAN is an acronym that stands for Describe, Express, Assert, (stay) Mindful, Appear confident and Negotiate. The goal of DEAR MAN is to help you be assertive in asking for what you want or maintaining a boundary, and your therapist may also lead you in role play exercises to practice using these skills (Linehan, 2014). DBT skills such as TIP and DEAR MAN take time to learn, but with practice and support from your therapist, they can be incredibly useful in helping you recover from bulimia.

References

Agras WS, Walsh BT, Fairburn CG, Wilson GT, Kraemer HC. A Multicenter Comparison of Cognitive-Behavioral Therapy and Interpersonal Psychotherapy for Bulimia Nervosa. Arch Gen Psychiatry. 2000;57(5):459–466. doi:10.1001/archpsyc.57.5.459

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) 

Bankoff, S., Karpel, M., Forbes, H., & Pantalone, D. (2012). A Systematic Review of Dialectical Behavior Therapy for the Treatment of Eating Disorders. Eating Disorders, 20(3), 196–215. https://doi-org.ezproxy.cul.columbia.edu/10.1080/10640266.2012.668478

Chapman, A. L., & Dixon-Gordon, K. L. (2020). Dialectical behavior therapy. American Psychological Association. https://doi-org.ezproxy.cul.columbia.edu/10.1037/0000188-000

Eddy, K. T., Tabri, N., Thomas, J. J., Murray, H. B., Keshaviah, A., Hastings, E., Edkins, K., Krishna, M., Herzog, D. B., Keel, P. K., & Franko, D. L. (2017). Recovery From Anorexia Nervosa and Bulimia Nervosa at 22-Year Follow-Up. The Journal of clinical psychiatry, 78(2), 184–189. https://doi.org/10.4088/JCP.15m10393

Hall, A. R. (2015). A brief DBT skills group for bulimia nervosa : A feasibility study (Order No. 27823921). Available from ProQuest Dissertations & Theses Global. (2351347452). Retrieved from http://ezproxy.cul.columbia.edu/login

Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007 Feb 1;61(3):348-58. PMID: 16815322

Linehan, M. M. (2014). Dbt skills training manual, second edition. Guilford Publications.

Murphy, R., Straebler, S., Basden, S., Cooper, Z., & Fairburn, C. G. (2012). Interpersonal psychotherapy for eating disorders. Clinical psychology & psychotherapy, 19(2), 150–158. https://doi.org/10.1002/cpp.1780

Rozakou-Soumalia, N., Dârvariu, Ş., & Sjögren, J. M. (2021). Dialectical Behaviour Therapy Improves Emotion Dysregulation Mainly in Binge Eating Disorder and Bulimia Nervosa: A Systematic Review and Meta-Analysis. Journal of personalized medicine, 11(9), 931. https://doi.org/10.3390/jpm11090931

Safer, D. L., Telch, C. F., & Agras, W. S. (2001). Dialectical behavior therapy for bulimia nervosa. American Journal of Psychiatry, 158(4). https://doi.org/10.1176/appi.ajp.158.4.632 

Westmoreland, P., Krantz, M. J., & Mehler, P. S. (2016). Medical complications of anorexia nervosa and bulimia nervosa. American Journal of Medicine, 129(1), 30–37. https://doi.org/10.1093/oxfordhb/9780190620998.013.29 

Wilson, G. T., & Fairburn, C. G. (2002). Treatments for eating disorders. In P. E. Nathan & J. M. Gorman (Eds.), A guide to treatments that work (pp. 559–592). Oxford University Press.