RO-DBT: A Groundbreaking Treatment for Anorexia Nervosa
I recently had the pleasure of attending the Eating Recovery Center Foundation Eating Disorders Conference in Denver, CO. As a self-described nerd, I relished the chance to learn about the latest advancements in understanding and interventions for eating disorders, and the conference did not disappoint. Out of all of the offerings, however, I was most excited to learn about RO-DBT, a new treatment for patients who suffer from emotional over-control – a hallmark for many sufferers of anorexia, obsessive-compulsive personality disorder, anxiety disorders, and chronic depression.
Many eating disorder programs have adopted Dialectical Behavior Therapy (DBT) as a foundation for treatment, including our Pathway to Eating Disorders Treatment program at Brookhaven Hospital. DBT was primarily developed to address disorders involving emotion disregulation, such as binge/purging eating disorders, borderline personality disorder, bipolar disorder, and chronic self-injury by applying both behavioral skills training and mindfulness training to improve relationships, ability to choose effective responses to emotions, and ability to tolerate overwhelming emotions in the pursuit of “a life worth living.” As a DBT facilitator, I have witnessed the improvement the use of these skills makes in eating disorder recovery. As a practitioner of DBT principles, I have found these skills incredibly useful in my own life. However, I have also noticed patients who didn’t seem to respond as well. They had a few things in common. For example, they didn’t seem to relate to many of the anecdotal examples used to illustrate when and how to use DBT skills. They diligently completed any assigned homework, but it would lack depth of insight. They were often under-expressive of emotions and even had difficulty identifying their emotions. This was in contrast to the over-the-top expression of emotion often seen in more disregulated patients.
Developed by Thomas Lynch, Radically Open Dialectical Behavior Therapy (RO-DBT) is a new treatment for patients who suffer from emotional over-control. While self-control is a generally desirable trait, excessive self-control is associated with social isolation, poor interpersonal relations, and contributes to conditions like anorexia nervosa and chronic depression. What I realized as I listened to the description of the OC, or over-controlled, patient is that this is what the outliers had in common. These OC patients have a genetic predisposition to view conflict and displeasing others as a threat to safety. They are often also sensitive to sensory stimulation and overly sensitive to others’ emotions. Over-control then emerges as the environment of upbringing punishes mistakes; self-initiated, creative, or silly behavior; displays of emotion; and requests for nurturance, while it rewards appearing perfect; following the rules; and tolerance for pain. The OC person then learns “If I inhibit my emotional signaling, then good things may happen.” Unfortunately, extreme over-control is also associated with social difficulties due to impaired emotional signaling, as well as disorders associated with rigidity, like anorexia nervosa, anxiety, obsessive-compulsive disorders, and chronic depression.
If control over reactions to emotions is considered on a continuum, it makes sense that some eating disorder patients lack emotional control and need interventions designed to enhance constraint or inhibitory control, while others require interventions designed to relax rigid or inflexible inhibitory control. RO-DBT fills the void for the latter patients. RO-DBT addresses skills deficits to increase mental flexibility and reduce rigidness by learning openness to feedback, flexibility in responses to changing environmental demands, and communication of emotions as crucial to forming close interpersonal bonds.
The benefits of this approach have been verified in several studies. RO-DBT with anorexic patients has been associated with significant improvements in weight gain, reductions in eating disorder symptoms, decreases in eating disorder-related psychopathology, and increases in eating disorder-related quality of life in a severely underweight sample.
Pathway to Eating Disorders Treatment at Brookhaven Hospital is aptly named, as it acknowledges that there is more than one path to recovery from eating disorders. As such, I am excited to continue learning and applying interventions from RO-DBT to be better able to meet the unique recovery needs of each patient that comes to Brookhaven Hospital for help.