Journal of Behavior Therapy and Experimental Psychiatry 71 (2021) 101637

Contents lists available at ScienceDirect

Journal of Behavior Therapy and Experimental Psychiatry

journal homepage: www.elsevier.com/locate/jbtep

Radically open dialectical behavior therapy for anorexia nervosa: A

multiple baseline single-case experimental design study across 13 cases☆
Martina Isaksson a, *, Ata Ghaderi b, 1, Mia Ramklint a, Martina Wolf-Arehult a, 2
a
Department of Neuroscience, Psychiatry, Uppsala University, Entrance 10, Floor 3B, 751 85, Uppsala, Sweden
b
Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, SE-171 77, Stockholm, Sweden

A R T I C L E I N F O A B S T R A C T

Keywords: Background and objectives: No treatment for adult anorexia nervosa (AN) has shown sufficient effectiveness or
Anorexia nervosa superiority to other treatments. Overcontrol has been suggested as a viable mechanism to target in the treatment
Eating disorders of patients with AN. Radically open dialectical behavior therapy (RO DBT) is developed for disorders related to
Overcontrol
maladaptive overcontrol. Our objective was to evaluate the outcome of RO DBT for AN in a clinical outpatient
Radically open dialectical behavior therapy
Single-case experimental design
setting.
Methods: Thirteen adult female patients with mild to moderate AN provided written consent and entered a
multiple baseline single-case experimental design study. Median age at eating disorder (ED) onset was 15 years
and the median duration of the ED was 10 years. Individual changes were assessed weekly during a baseline
phase (A) of four to six weeks, and during the subsequent 40-week RO DBT phase (B). Additional assessments
were conducted before and after treatment, and at a six-month follow-up. Primary outcome was ED psychopa­
thology. Secondary outcomes were psychosocial impairment, quality of life, social connectedness, and adaptive
control strategies.
Results: Eight patients (62%) completed treatment. All completers were in full remission after treatment, with
BMI ≥18.5 kg/m2 and ED psychopathology within one standard deviation of the community mean. Improve­
ments occurred after introducing RO DBT, not during baseline.
Limitations: Participants were female with mild to moderate AN, limiting generalizability to severe AN or males.
Conclusions: The study provides preliminary support for using RO DBT in adult outpatients with AN and over­
control. Further studies should replicate these findings.

1. Introduction Lynch, 2018; Westen and Harnden-Fisher, 2001). Overcontrol, or

self-control, is defined as the ability to inhibit emotional urges, impulses,
Despite research and availability of several treatments for anorexia and behaviors in order to pursue long-term goals (Letzring, Block, &
nervosa (AN) in adults, no treatment is supported by robust evidence or Funder, 2005; Lynch, Hempel, & Dunkley, 2015). Individuals with
outperforms any other (Byrne et al., 2017; Murray, Quintana, Loeb, excessive overcontrol often exhibit maladaptive perfectionism, rigidity,
Griffiths, & Le Grange, 2019; National Institute for Health and Care and emotional inhibition, with difficulties in forming warm and intimate
Excellence, 2017). The treatments most frequently offered have been relationships. Excessive overcontrol in AN has been found, primarily in
criticized for focusing too much on symptom reduction, while failing to the restricting subtype but also for patients with binge eating/purging
address the core psychopathology of AN (Watson & Bulik, 2013). behaviors (Isaksson, Ghaderi, Wolf-Arehult., & Ramklint, 2020; Westen
Overcontrol has been suggested as one of the mechanisms contrib­ and Harnden-Fisher, 2001). However, it is rarely targeted as a key
uting to development and maintenance of AN (Hempel, Vanderbleek, & element in treatment of the disorder (Lynch et al., 2013; Martinez &

The study was preregistered in the ISRCTN registry, no: ISRCTN47156042, URL: https://www.isrctn.com/ISRCTN47156042.
☆

* Corresponding author.
E-mail addresses: martina.isaksson@neuro.uu.se (M. Isaksson), ata.ghaderi@ki.se (A. Ghaderi), mia.ramklint@neuro.uu.se (M. Ramklint), martina.wolf@neuro.
uu.se (M. Wolf-Arehult).
1
Stockholm Centre for Eating Disorders, Stockholm Health Care Services, Stockholm County Council, SE-171 77 Stockholm, Sweden.
2
Psychiatry Northwest, Region Stockholm, Clinic Management, PO Box 98, SE-191 22 Sollentuna, Sweden.

https://doi.org/10.1016/j.jbtep.2021.101637
Received 14 September 2020; Received in revised form 23 November 2020; Accepted 7 January 2021
Available online 12 January 2021
0005-7916/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
M. Isaksson et al. Journal of Behavior Therapy and Experimental Psychiatry 71 (2021) 101637

Craighead, 2015). interview (EDE; Cooper & Fairburn, 1987). Because patients with severe
Radically Open Dialectical Behavior Therapy (RO DBT) was devel­ AN are treated with inpatient care or with extensive meal support in a
oped for mental health problems related to maladaptive overcontrol in day programme, only patients with a BMI ≥16 were included. In addi­
conditions like chronic depression and AN (Lynch, 2018a, 2018b). The tion, because RO DBT is only relevant for patients with overcontrol
main goals of RO DBT are to enhance openness, flexibility, and social tendencies, a patient’s personality style was identified according to the
connectedness by targeting maladaptive overcontrol and social prototype rating by Lynch (2018a, p. 81–82). Patients with a cutoff
signaling. Initial studies investigating RO DBT show promising results below 17 were excluded, representing patients that did not endorse rigid
for treatment-resistant depression (Lynch et al, 2020; Lynch, Morse, and rule-governed behaviors, emotion inhibition, or distanced re­
Mendelson, & Robins, 2003) and AN – both as inpatient treatment lationships in their life (i.e. no overcontrol). Excluded were also patients
evaluating the full RO DBT program (Lynch et al., 2013), as outpatient in need of intensive treatment for ED (e.g., inpatient care or day pro­
treatment when standard DBT was evaluated in combination with RO gramme), patients in immediate need of treatment for other psychiatric
DBT skills training (Chen et al., 2015), and as RO DBT skills training as or somatic conditions, patients who had participated in any psycho­
ad-on to a day treatment program for adolescents (Baudinet et al., logical treatment for ED during the last three months, and patients with
2020). However, RO DBT has never been evaluated as a full-scale insufficient cognitive capacity or knowledge of Swedish (if the patient
treatment program, including all four parts of treatment (skills could not independently fill out questionnaires or answer questions
training, individual therapy, consultation teams, and telephone coach­ during the interviews). In total, 12 female patients with AN and one
ing), in an outpatient setting for AN. patient with AAN were included in the study (mean BMI 17.5, SD =
Treatment studies of AN tend to be underpowered and methodo­ 0.84). Full criteria for AN and AAN diagnoses were met at the start of
logically unsatisfactory due to low prevalence of AN, high dropout rates treatment. Participant characteristics are presented in Table 1. The
(30–70%), and ethical issues that make it basically impossible to use median age at ED onset was 15 years (range 12–20), the median dura­
placebo as a comparison condition (Fassino, Pierò, Tomba, & tion living with an ED was 10 years (range 1–27), and number of current
Abbate-Daga, 2009; Hay, 2013; Linardon, Wade, De La Piedad Garcia, & comorbid diagnoses ranged between one to three. Comparing com­
Brennan, 2017). The Single-Case Experimental Design (SCED) has been pleters and non-completers, non-completers were generally older, had
suggested as a rigorous alternative to group designs. In a SCED, each more severe symptoms before treatment, and had a longer duration of
individual provides their own control data for a within-subject com­ the ED. Completers had suffered from an ED at a median of 7.5 years
parison, enabling inferences about causality without large samples and (range 1–13), the median for non-completers was 14 years (range
randomized controlled trials (Smith, 2012). The method is underused in 10–27). Age at ED onset, BMI at study start, and number of comorbid
the eating disorder (ED) field and has been recommended for investi­ diagnoses did not differ between the groups.
gating intervention effects in ED patients (De Young & Bottera, 2018;
Martinez & Craighead, 2015). To enhance internal and external validity, 2.3. Treatment and therapists
and enabling inferences about causality, multiple baselines and repli­
cation across several cases are recommended (Krasny-Pacini & Evans, The RO DBT encompassed a 40-week full-scale intervention pro­
2018). There is no gold standard in how many replications are needed, gram, including individual therapy, skills training in class, telephone
however, a minimum of three have been recommended, and more rep­ coaching (when necessary), and weekly consultation team meetings for
lications further increase confidence of causal inference (Kratochwill therapists, as described by Lynch (2018a, 2018b). As for all in­
et al., 2013). terventions treating patients with AN, support to target key elements of
The aim of this study was to evaluate the outcome of full-scale RO AN (e.g., underweight and starvation) was included. This is in line with
DBT for treating AN among adults in an outpatient setting. We hy­ evidence and international recommendations by the National Institute
pothesized that participants would reduce their ED symptoms (primary for Health and Care Excellence (2017), and recommendations for
outcome). In addition, we hypothesized that psychosocial impairment, treating AN with RO DBT (Ben-Porath et al., 2020; Gilbert, Hall, & Codd,
quality of life, social connectedness, and adaptive control strategies 2020). RO DBT skills such as self-enquiry, open expression of emotion,
would improve (secondary outcomes). We also hypothesized that im­ and learning from feedback, in combination with a matter-of-fact ther­
provements in weekly measures of ED behaviors would be evident apeutic stance emphasizing the patient’s own valued goals, were used to
within the first six weeks after introducing the intervention for such target ED difficulties throughout the treatment. Individual therapy
behaviors, while changes for overcontrolled behaviors would be seen consisted of a six-week engagement phase, encompassing two sessions
within four weeks after the introduction of specific adaptive control (one per week for two weeks) that served to orient the individual to RO
strategies. DBT, and eight sessions (two per week for four weeks) that focused on
taking the first steps towards normal eating habits and weight. The
2. Material and methods engagement phase was followed by phase two, including 30 individual
sessions and 30 skills training sessions, during which the primary focus
2.1. Research design was on enhancing openness, flexibility, and social connectedness, to
continue weight restoration, minimize loneliness, and create a life worth
The study was an AB (N = 13) SCED with multiple baselines, where sharing with others (Hempel et al., 2018; National Institute for Health
patients were randomized to baseline length. A baseline of four, five, or and Care Excellence, 2017). Outpatient meal support was not offered as
six weeks (A) was followed by an intervention of 40 weeks (B). Multiple default, but could be offered for three meals per day at a maximum of 16
baselines across individuals were used to control for threats to internal days if a patient was unable to make changes to their eating habits. This
validity. was the case for three of the 13 patients, all of whom later dropped out
from the study. During the final eight weeks, sessions were held once
2.2. Participants and setting every two weeks to enhance independence. The treatment ranged from
38 to 43 calendar weeks for completers and from 10 to 33 calendar
The ED clinic at the Uppsala University Hospital treats patients in weeks for non-completers, with individual session time of 68 min on
need of specialized ED care. We included patients consenting to diag­ average. Skills class attendance was between 24 and 30 sessions for
nostic assessment and treatment evaluation who were ≥18 years with completers and between 4 and 23 sessions for non-completers. Partici­
AN or atypical AN (AAN; i.e., fulfilling criteria for AN, including sig­ pants did not receive any additional ED treatment between treatment
nificant weight loss, but weight still in normal range) according to DSM- and follow-up measurements.
5. Diagnosis was assessed with the Eating Disorder Examination Five clinical psychologists conducted the treatment, all of whom

2
M. Isaksson et al. Journal of Behavior Therapy and Experimental Psychiatry 71 (2021) 101637

Table 1
Summary of participant characteristics.
Participant Age interval (years) Diagnosis OC-PRS Marital status Highest level of education Occupation

1 18–25 AN 21 Single University Unemployed

2 26–35 AAN 19 Relationship University Studying
3 18–25 AN 20 Single High school Studying
4 18–25 AN 17 Single High school Studying
5 18–25 AN 20 Single High school Studying
6 18–25 AN 18 Single University Studying
7 18–25 AN 20 Single High school Studying
8 18–25 AN 18 Single High school Working
9 36–45 AN 17 Relationship University Sick leave
10 26–35 AN 21 Relationship University Working
11 36–45 AN 29 Relationship High school Working
12 26–35 AN 25 Single High school Studying
13 18–25 AN 20 Relationship High school Studying

Note. Participants 1–8 completed treatment, participants 10–13 did not. AN, Anorexia nervosa; AAN, Atypical AN; OC-PRS, Overcontrolled Global Prototype Rating Scale.

underwent extensive training in RO DBT. During the study, team severe ED difficulties.
meetings were held weekly and the team was supervised by an approved The Visual Analogue Scales for measuring Flexible Control (VAS-FC)
RO DBT supervisor to improve therapeutic skills and adherence. were four visual analogue scales (VAS) created specifically for this study
to assess patient experiences of adaptive control strategies for managing
2.4. Assessment measurements their maladaptive overcontrol tendencies. Endpoints were “a very low
degree” and “a very high degree” on a 10-centimeter line. Two VAS
2.4.1. Measurements at admission (social skills and flexibility) were the same for all participants; the other
The EDE is a clinically administered semi-structured interview for two were created in collaboration with each patient at the beginning of
assessing ED psychopathology (Cooper & Fairburn, 1987). The inter­ the treatment, to target two prosocial behaviors that were important for
view has shown satisfactory reliability and there is support for using it to the patient. High scores indicate adaptive control strategies.
differentiate between cases and non-cases (Berg, Peterson, Frazier, &
Crow, 2012). 2.4.3. Measurements before and after intervention, and at follow-up
The Overcontrolled Global Prototype Rating Scale (OC-PRS) is a The Brunnsviken Brief Quality of life scale (BBQ) is a 12-item self-
clinician-rated assessment form for evaluating core deficits commonly rating questionnaire administered to assess self-experienced quality of
identified in individuals with overcontrol, as regards receptivity and life in six different life areas: leisure time, view of life, creativity,
openness, flexible responding, emotional awareness and expression, and learning, friends and friendship, and view of self (Lindner et al., 2016).
forming warm and intimate interpersonal relationships (Lynch, 2018, p. Responses are given on a five-point Likert scale ranging from 0 (strongly
81–82 & appendix 3). The scale is based on prototype models of per­ disagree) to 4 (strongly agree). The BBQ has shown satisfactory internal
sonality assessments where the individual is compared to prototype consistency of 0.76 and reliability in a Swedish sample (Lindner et al.,
descriptions of personality characteristics (Lynch, 2018a; Westen, 2016). High scores indicate high quality of life.
DeFife, Bradley, & Hilsenroth, 2010). The patient is given a summarized The Clinical Impairment Assessment (CIA) is a 16-item self-rating
score in the range 0–32; scores over 16 indicate a good match for questionnaire developed to assess psychosocial impairment related to
overcontrol. In general, use of prototype ratings has shown acceptable an ED (Bohn et al., 2008). Respondents indicate, on a four-point Likert
interrater reliability (Westen et al., 2010). scale ranging from 0 (not at all) to 3 (a lot), the extent to which their ED
symptoms have affected their social, personal, and cognitive functioning
2.4.2. Weekly measurements during the preceding month. The scale has high internal consistency
Body Mass Index (BMI) was calculated to evaluate nutrition status in (0.97) and validity (Bohn et al., 2008). Swedish norms are available
adults (World Health Organization, n. d.). BMI is interpreted as follows: (Welch, Birgegård, Parling, & Ghaderi, 2011). High scores indicate se­
≤ 18.5 kg/m2 = underweight; 18.5–24.9 kg/m2 = normal weight; vere impairment.
25.0–29.9 kg/m2 = pre-obesity; ≥ 30 kg/m2 = obesity. Height and The EDE-Q is a 36-item self-rating questionnaire designed to assess
weight were assessed using calibrated instruments. ED symptoms on four different subscales: restraint, eating concern,
The Eating Disorder Symptom List (EDSL) is an eight-item self-rating weight concern, and shape concern (Fairburn & Beglin, 1994). Partici­
questionnaire designed to assess eating disorder symptoms important pants indicate, on a seven-point Likert scale ranging from 0 (no days or
for diagnosis. The scale was developed to detect change, or lack of not at all) to 7 (every day or markedly), the extent to which they have
change, during treatment (Isaksson, Ghaderi, Wolf-Arehult, & Ramklint, engaged in a specific ED behavior during the preceding 28 days. The
2020a). Participants are asked on how many days during the preceding scale has acceptable internal consistency (ranging from 0.70 to 0.93)
week they: restricted the amount of food, restricted the type of food, and validity (Berg et al., 2012). Swedish norms are available (Welch
binged, vomited, used laxatives/diuretics, exercised excessively, expe­ et al., 2011). High scores indicate a higher presence of ED symptoms.
rienced fear of gaining weight, or had thoughts about weight and shape The Social Safeness and Pleasure Scale (SSPS) is an 11-item self-rating
that affected their self-image. Responses are given on an eight-point questionnaire designed to assess how warm, soothing, and safe people
Likert scale ranging from 0 (no days) to 7 (seven days). Psychometric perceive their social life to be (P. Gilbert et al., 2009). This scale was
properties have been evaluated in a Swedish clinical and non-clinical chosen since these factors may be important for social connectedness. In
sample in a study that has not yet been published (Isaksson, Ghaderi, SSPS, individuals rate their experience on a five-point Likert scale
Wolf-Arehult et al., 2020). The scale showed good psychometric prop­ ranging from 0 (almost never) to 4 (almost all the time). The original
erties with high test-retest reliability (0.88) and satisfactory internal SSPS has shown high internal consistency (Cronbach’s alpha = .91) and
validity (0.72–0.82). In a comparison with the Eating Disorder Exami­ satisfactory validity (Alavi, Ali, Moghadam, & Rahiminezhad, 2017).
nation Questionnaire (EDE-Q), correlations were moderate to strong for Preliminary data on the Swedish translation indicate similar results with
the total scale and all individual items (ρ = 0.53–0.87). The scale had a high internal consistency (α > 0.90) and validity (Holmbom Goh,
good ability to detect change after treatment. High scores indicate more Ramklint, Isaksson, & Wolf-Arehult, 2020). High scores indicate more

3
M. Isaksson et al. Journal of Behavior Therapy and Experimental Psychiatry 71 (2021) 101637

social safeness and pleasure. measurements) was counted to evaluate if there was a difference in
terms of when change occurred. We used R version 3.6.1 for all
2.5. Procedure descriptive and visual analyses. To reduce bias that may come with vi­
sual inspection, we used the non-parametric statistical method Tau-U to
After referral, patients were scheduled for a diagnostic evaluation estimate the average effect size. Tau-U combines a comparison of
using the semi-structured EDE (Cooper & Fairburn, 1987). Eleven psy­ non-overlap between phases and differences in trends within each
chologists, who were trained in performing the interview, showed phase, while controlling for non-desirable trends within each baseline
complete diagnostic agreement after co-rating six randomly selected (Parker, Vannest, Davis, & Sauber, 2011). Calculations of effect size
interviews performed by an expert. Diagnoses were initially based on the were performed using the online software calculator http://www.sin
Diagnostic and Statistical Manual of Mental Disorders, Fourth edition glecaseresearch.org.
(DSM-IV-R; American Psychiatric Association, 2000). Later, they were Measurements before and after intervention, and at follow up, were
re-coded in accordance with DSM-5, which meant including patients analyzed with clinical significance (remission) and reliable change. Full
with amenorrhea and BMI 17.5–18.5 in AN and including patients with remission was defined as no residual ED psychopathology indicated by
all criteria for AN fulfilled, except weight being in normal range, in AAN an EDE-Q value within 1 SD of the Swedish community mean, i.e., <
(American Psychiatric Association, 2013). Comorbidity was assessed 2.83 (Welch et al., 2011) for both AN and AAN, and BMI at least at
with the Mini-International Neuropsychiatric Interview (MINI) (Shee­ normal weight ≥ 18.5 kg/m2 for AN. Partial remission was defined as
han et al., 1998). residual ED psychopathology (i.e., an EDE-Q value at or above 1 SD of
Between August 2016 and March 2019, 37 patients who were the Swedish community mean, i.e., ≥ 2.83), and BMI at least at normal
eligible in terms of BMI and diagnosis and did not meet any exclusion weight ≥ 18.5 kg/m2. In addition, weight maintenance, defined as
criteria, were briefly informed about the present study by the psychol­ weight change <3% (Stevens, Truesdale, McClain, & Cai, 2006), was
ogist performing the diagnostic interview. Thirty-four patients were used as an additional criteria defining if the patient was still in remission
interested and contacted by phone to receive more information, with 25 from end of treatment to follow-up. Reliable change was calculated
being interested in proceeding to an interview involving in-depth eval­ based on data from assessment before and after treatment, as suggested
uation of overcontrol based on the Overcontrolled Global Prototype by Jacobson and Truax (1991).
Rating Scale (OC-PRS) (Lynch, 2018a). These interviews were per­ For weekly measurements data is presented visually, no imputations
formed by the first author or by a psychology student trained by the first for missing values were performed. For the measurements performed
author. The student first watched and co-rated six recordings of the first before and after treatment, and at follow-up, mean imputation was used,
author’s interviews. Ratings were discussed and the student then per­ replacing the missing value with the mean of the non-missing values.
formed interviews. New co-ratings were made for seven of these in­
terviews. The prevalence and bias adjusted kappa (PABAK) value was 2.7. Ethical considerations
0.71. Out of the 25 subjects, five were not overcontrolled, five declined
participation, and two were excluded prior to the start of the study (one The study was approved by the Regional Ethics Committee in
had deteriorated and did not fulfil inclusion criteria, one did not submit Uppsala (Ref. no. 2014/252). All participants gave informed consent.
consent). Detailed individual information is left out, so the patients cannot be
At study start, 13 patients signed informed consent. Patients were identified. Identification between patients who participated in the same
randomized to a baseline of four, five, or six weeks using an online skills class is unlikely, as RO DBT was also given to patients who did not
resource (www.randomizer.org). The person performing the randomi­ participate in the study (e.g., because they entered RO DBT after first
zation was blinded to the study participants. receiving inpatient care), and as patients only participated in the skills
Weekly measurements were conducted during baseline and inter­ class together for a limited time (since the open group format allowed
vention. Measurements not appropriate for weekly measurements (BBQ, patients to start at different timepoints).
CIA, EDE-Q, and SSPS) were administered before and after treatment
with paper and pencil, and at six month follow-up through the internet. 3. Results
For non-completers, these measurements were administered at their last
session. Weighing was performed each week during baseline, at each 3.1. Visual analysis
session, and at follow-up.
In the beginning of the study, five participants performed the weekly Eight patients completed treatment (62%) and five patients dropped
measurements with paper and pencil for a duration of 14–20 weeks out (38%). Reasons for drop-out were an inability to engage in treatment
(21% of all ratings). Six months into the study, assessment method was and need of more intense support, e.g., through inpatient care or addi­
changed and weekly measurements were administered through the tional meal support beyond the 16 days that were allowed in the study
internet to reduce missing data. By examining the weeks when the (four patients), or an unwillingness to comply with continued weight
assessment method changed for these five patients, we saw that the regain and participation in skills class (one patient). Weekly measure­
method did not affect the ratings in any meaningful way. ments of BMI, restrictive eating, and flexibility are presented in Fig. 1 for
completers and in Fig. 2 for non-completers. These measures were pre­
2.6. Data analysis sented in the manuscript for the following reasons: BMI for its objec­
tivity, restrictive eating for assessing early change in eating habits, and
Weekly data were analyzed using visual inspection, looking for flexibility for its potentially long-lasting effects on recovery. Other
changes in 1) level (mean score of data within a phase), 2) trend (slope weekly measurements are reported in the Appendix. The pattern of
of the best fitting straight line), 3) variability (fluctuation of data), and change is similar for measurements presented in the manuscript and in
4) immediacy of effect (comparing the baseline with expected change the Appendix.
within a specific timeframe) (Kratochwill et al., 2013). To analyze the When mean level of phase A versus B was investigated, all but one
multiple baselines, restrictive eating was used as outcome, as it was the participant (No. 10) showed a decrease in restrictive eating, 11 partic­
first target in treatment and therefore the outcome hypothesized to be ipants (seven completers) showed an increase in BMI, and five showed
affected first. Reduction in restriction was defined as present when an an increase in flexibility.
assessment during treatment was below any of the assessments during In terms of trend of phase A versus B, six completers and three non-
baseline. The number of weeks from start of baseline up to the first and completers showed a decrease in restrictive eating. For BMI, a positive
second week of decrease in restrictive eating (compared with baseline shift in trend was identified for seven completers and three non-

4
M. Isaksson et al. Journal of Behavior Therapy and Experimental Psychiatry 71 (2021) 101637

Fig. 1. Weekly, repeated measurements of BMI, restrictive eating, and flexibility for completers.
Note. The black vertical lines show treatment start, the black sloping lines show the trend before and after treatment start. y-axis for restrictive eating = days per week
(0–7), y-axis for flexibility = degree of the behavior present (very low to very high). BMI, Body Mass Index; Restrictive eating: item one from Eating Disorder
Symptom List; Flexibility from Visual Analogue Scale.

5
M. Isaksson et al. Journal of Behavior Therapy and Experimental Psychiatry 71 (2021) 101637

Fig. 2. Weekly, repeated measurements of BMI, restrictive eating, and flexibility for non-completers.
Note. The black vertical lines show treatment start, the black sloping lines show the trend before and after treatment start. y-axis for restrictive eating = days per week
(0–7), y-axis for flexibility = degree of the behavior present (very low to very high). BMI, Body Mass Index; Restrictive eating: item one from Eating Disorder
Symptom List, Flexibility from Visual Analogue Scale.

completers. For flexibility, three completers and one non-completer number of weeks from first assessment at baseline until change was seen
showed a trend shift in a positive direction. was 10.6 for the 4-week baseline, 11.5 for the 5-week baseline, and 13
In terms of variability, it was generally larger for the self-rating for the 6-week baseline, indicating that change was an effect of the
measurements than for BMI (where variability was low), making inter­ intervention. Results were similar when counting the weeks up to two
pretation of the intervention effect reported by self-ratings more difficult measurements below baseline, indicating stability in the decrease.
to interpret.
When estimating immediacy of effect, decrease in restrictive eating
was seen within the first six weeks, as hypothesized, for all but two 3.2. Descriptive analyses
completers (No. four, where a decrease was observed in week 10, and
No. seven, who showed no decrease compared with the lowest baseline Measurements before and after treatment and at six-month follow-up
measurement), and for participant 11 among the non-completers. BMI are presented in Table 2. Mean change in BMI before versus after
increased within six weeks after restrictive eating was reduced for all treatment was 1.7 kg/m2 for the whole group, and 2.0 kg/m2 for com­
completers except patients two and seven, and for two non-completers pleters. Mean change in BMI before treatment versus at six-month
(No. 11 and 12). Flexibility decreased for several patients at the start follow-up was 2.0 kg/m2 for completers. Weight maintenance (weight
of the treatment (for two of the completers this baseline is missing). It drop <3%) from end of treatment to follow-up was achieved by all
increased during treatment for five of the completers, but not for any of completers but patient one and four. These two also dropped to a weight
the non-completers. In analyses of the multiple baselines, two patients below 18.5.
(No. seven and 10) showed no decrease in restrictive eating when con­ Eight out of 13 patients (62%) were in full remission after treatment,
trasted to the baseline. For the other 11, we found that time to change in four were in partial remission, and one had deteriorated. Six (46%) were
restrictive eating increased as the baseline increased. The average still in full remission at follow-up. Among completers, all eight (100%)
were in full remission after treatment, while six (75%) were in full

6
M. Isaksson et al. Journal of Behavior Therapy and Experimental Psychiatry 71 (2021) 101637

Table 2
Eating disorder psychopathology, quality of life, and social safeness before (PRE) and after treatment (POST), and at follow-up (FU).
BMIa EDE-Q global CIA BBQ SSPS

PRE POST FU PRE POST FU PRE POST FU PRE POST FU PRE POST FU

1 17.0 19.2b 18.1b 4.53 2.21b 2.56b 43 26 26 24 56 50 27 30 34

2 19.5 19.5 23.2b 3.08 0.74b 0.25b 22 6 4 22 36 50 38 44 48
3 17.0 19.8b 19.7b 2.90 1.28b 1.17b 25 9 17 38 62 76 35 37 39
4 16.6 20.2b 18.4b 2.99 1.36b 0.52 19 8 4 84 92 96 55 51 55
5 17.5 18.5b 18.5b 4.50 2.22b 2.14b 35 18 18 29 49 40 18 34 39
6 17.6 18.8b 19.6b 3.46 0.88b 1.24b 21 7 8 61 63 61 47 33 44
7 17.4 19.3b 18.9b 2.95 1.46b 1.51b 22 10 14 60 69 68 39 33 41
8 17.5 20.5b 20.0b 4.21 1.52b 1.61b 23 9 11 42 50 62 39 39 42
9 18.0 18.9b NA 4.16 - NA 32 - NA 54 - NA 38 – NA
10 18.4 19.4b NA 3.03 - NA 19 - NA 41 - NA 29 – NA
11 17.4 18.5b NA 5.27 4.08b NA 36 36 NA 17 32 NA 30 38 NA
12 17.3 21.2b NA 4.91 - NA 47 - NA 10 - NA 22 – NA
13 16.2 15.2 NA 3.21 3.71 NA 31 42 NA 18 24 NA 18 27 NA

Note. BMI, Body Mass Index; EDE-Q, Eating Disorder Examination-Questionnaire; CIA, Clinical Impairment Questionnaire; BBQ, Brunnsviken Brief Quality of life scale; SSPS,
Social Safeness and Pleasure Scale; NA, Not Administered. Bold indicates healthy weight for BMI, and values within one standard deviation of the Swedish community mean for
the self-rating scales (not available for SSPS).
a
One patient was pregnant at FU, which may have affected BMI.
b
Measurements that changed reliably from PRE measurement.

remission at follow-up. and BMI occurred within the expected timeframe, while changes in
Reliable Change Index was calculated for BMI (z = 0.23), with a adaptive control strategies were generally smaller and – as expected –
reliable change for 11 out of the 12 individuals who were underweight more delayed.
at study start, and for EDE-Q (z = − 0.74), with reliable change for nine In terms of weekly, repeated measurements, the levels, trends, and
individuals. For completers, all seven with underweight at study start variability in the data indicated valid effects, in particular for ED
had a reliable change in BMI and all eight had a reliable change in EDE- symptoms. In terms of immediacy of effect, we expected a shift in trend
Q. within six weeks for ED psychopathology, and within four weeks for
overcontrol difficulties. As highlighted by De Young and Bottera (2018),
change in BMI is often somewhat delayed, as it is mediated by change in
3.3. Statistical measurements of effect
e.g., eating habits. A decreasing trend in restrictive eating was therefore
expected to start at the latest in week seven, mediating an effect of in­
The overall magnitudes of change (Tau-U) between phases and
crease in BMI. This was the case for one non-completer and all but two
during treatment, when controlling for non-desirable phase A trend
completers. In the majority of cases, ED psychopathology continued to
change, are presented in Table 3. For ED outcomes, effects were mod­
decrease after entering phase two, with much less emphasis and time
erate to large. For outcomes regarding adaptive control strategies, ef­
spent on ED behaviors. Additionally, and as has previously been shown
fects were small.
(Turner, Bryant-Waugh, & Marshall, 2015), early change seemed to be
an important predictor of successful treatment outcome.
4. Discussion For outcomes related to adaptive control, the changes in ratings were
generally smaller and results were more difficult to interpret due to the
The aim of the current study was to investigate the outcome of RO unstable baselines and the delayed effects. Because of this and because
DBT for adult patients with AN and overcontrol in an outpatient setting. adaptive control was measured using a VAS developed for this study,
For primary outcomes, main findings showed that RO DBT significantly, conclusions regarding the effects on adaptive control should be drawn
clinically, and reliably reduced ED psychopathology. For secondary with caution. Especially since the VAS-scales were not validated and
outcomes, the main findings were that quality of life was improved and hence may not have been the optimal way to measure these outcomes.
that impairment due to ED was reduced. Changes in restrictive eating Due to the complexity of the treatment, with multiple interventions
introduced simultaneously, the effect of specific interventions or
Table 3 mechanisms on specific outcomes cannot be ascertained. However, the
Averaged Tau-U scores of omnibus effect sizes for repeated measurements, based RO DBT intervention as a whole, targeting social signals of over­
on individual Tau-U scores corrected for baseline trend. controlled behaviors and the negative consequences on social connect­
Tau-U p CI 95% LL, UL edness, seems promising for treating the disorder.
BMI Completers (N = 8) 0.7437 <.0001 0.5450, 0.9423 Previous studies show that remission rates after outpatient treatment
Non-completers (N = 5) 0.4123 .0036 0.1345, 0.6900 for AN are rarely higher than one third of the whole sample (Byrne et al.,
All (N = 13) 0.6237 <.0001 0.4613, 0.7860 2017; Fairburn et al., 2013; Zipfel et al., 2014). In this study, remission
EDSL Completers (N = 8) ¡0.7408 <.0001 − 0.9503, − 0.5313 rates were 100% for completers and 62% for the entire sample
Non-completers (N = 5) − 0.2218 .0994 − 0.4856, 0.0420
All (N = 13) ¡0.5451 <.0001 − 0.7091, − 0.3810
post-treatment, with 75% of completers and 46% of the whole sample
VAS-S Completers (N = 6) 0.3366 .0075 0.0897, 0.5836 still in full remission at follow-up. However, group outcomes are to be
Non-completers (N = 5) − 0.2324 .0944 − 0.5047, 0.0399 viewed upon as preliminary. Because the present study had a small
All (N = 11) 0.0852 .3615 − 0.0978, 0.2681 sample, it is not appropriate to draw any conclusions at a group level and
VAS-F Completers (N = 6) 0.1755 .1636 − 0.0714, 0.4225
in contrast to other, larger, studies.
Non-completers (N = 5) − 0.1575 .2569 − 0.4299, 0.1148
All (N = 11) 0.0284 .7613 − 0.1546, 0.2113 Dropout rates for treatments targeting outpatients with AN vary
between around 30 to 70% (Byrne et al., 2017; Byrne, Fursland, Allen, &
Note. BMI, Body Mass Index; EDSL, Eating Disorder Symptom List; VAS-S, Visual
Watson, 2011; Fairburn et al., 2013; Fassino et al., 2009). In this study,
Analogue Scale - Social connectedness; VAS-F, Visual Analogue Scale - Flexi­
five individuals dropped out or were removed from the study (38%): one
bility; CI, confidence interval; LL, lower limit; UL, upper limit. Bold indicates
significant TAU scores at the p < .05 level.
was deteriorated with lower weight, and four fulfilled the definition of

7
M. Isaksson et al. Journal of Behavior Therapy and Experimental Psychiatry 71 (2021) 101637

partial remission. Thus, even though remission rates were relatively Methodology, Formal analysis, Writing - review & editing, Supervision.
high, 38% were not able to complete, or fully benefit from, treatment. It
is also worth mentioning that two of the patients in full remission at
Declaration of competing interest
follow-up had a weight drop of 1.1 kg and 1.4 kg respectively. Even
though these numbers are within the range of what is defined as weight
The authors declare that they have no known competing financial
maintenance (Stevens et al., 2006), a longer follow up period would
interests or personal relationships that could have appeared to influence
have been preferable to fully conclude if patients were still in remission.
the work reported in this paper.
Further, when analyzing the patients dropping out from treatment, they
were generally older, showed more severe symptoms, and had suffered
from the ED for a longer time, whereas seven out of eight that were in Acknowledgments
their young adulthood (18–25 years) completed and were in full
remission after treatment. This might indicate that the treatment, in the We would like to thank Region Uppsala for providing salary to the
outpatient form provided in this study, may be more effective for first author and Hans Arinell for advice on statistics. We also want to
younger patients with AN. It is also likely that patients with more thank research assistants Bendik Hjelm Waaler, Erica Nyström, Maria
long-lasting and severe ED symptoms could benefit from a more flexible Ziuzina and Ylva Walldén, as well as the participants and clinicians for
approach allowing for inpatient care or more extensive meal support their involvement in the study. This research did not receive any specific
prior to or in parallell with the RO DBT treatment. However, as previ­ grant from funding agencies in the public, commercial, or not-for-profit
ously mentioned it is important to not draw any firm conclusion sectors. Declarations of interest: none. Data will not be made publicly
regarding group outcomes with a small sample. available due to confidentiality, but can be made available upon
In sum, it has been suggested that treatment options with disparate reasonable request to the corresponding author. All authors provided
approaches are warranted since one size does not fit all in treatments substantially to each part of the manuscript. The study was preregistered
targeting AN (Martinez & Craighead, 2015). Patient feedback also in the ISRCTN registry, no: ISRCTN47156042, URL: https://www.isrctn.
highlights the need for individualization of treatment by addressing the com/ISRCTN47156042.
underlying mechanisms that are specific to each patient, instead of mere
focus on eating and weight gain (Rance, Moller, & Clarke, 2017). Appendix A. Supplementary data
Overcontrolled difficulties have been identified as one of these core
mechanisms for patients with AN, and interventions targeting mal­ Supplementary data to this article can be found online at https://doi.
adaptive overcontrol is a viable option for patients displaying these org/10.1016/j.jbtep.2021.101637.
difficulties (Farstad, McGeown, & von Ranson, 2016; Martinez &
Craighead, 2015). Results from the present study support these ideas. References

4.1. Limitations Alavi, K., Ali, M., Moghadam, A., & Rahiminezhad, A. (2017). Psychometric properties of
social safeness and pleasure scale (SSPS). Fundamentals of Mental Health, 19(5), 5–13.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
Several limitations need to be addressed. First, follow-up was per­ disorders (4th ed.). Washington, DC: Author: American Psychiatric Association.
formed at six months, limiting the possibility to draw conclusions about American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author: American Psychiatric Publishing.
long-term effects of RO DBT. Second, adherence was not assessed, due to Baudinet, J., Simic, M., Griffiths, H., Donnelly, C., Stewart, C., & Goddard, E. (2020).
the absence of valid RO DBT adherence rating instruments. Neverthe­ Targeting maladaptive overcontrol with radically open dialectical behaviour therapy
less, the therapists received regular supervision with review of video in a day programme for adolescents with restrictive eating disorders: An
uncontrolled case series. Journal of Eating Disorders, 8(1), 1–13. https://doi.org/
recordings, and additional consultations when needed. Third, appro­ 10.1186/s40337-020-00338-9
priate measurements for investigating weekly changes in specific RO Ben-Porath, D., Duthu, F., Luo, T., Gonidakis, F., Compte, E. J., & Wisniewski, L. (2020).
DBT targets did not exist in Swedish, for which reason we constructed Dialectical behavioral therapy: An update and review of the existing treatment
models adapted for adults with eating disorders. Eating Disorders, 28(2), 101–121.
study-specific VAS. Conclusions about secondary outcomes related to
https://doi.org/10.1080/10640266.2020.1723371
overcontrol should therefore be drawn with caution. Lastly, due to the Berg, K. C., Peterson, C. B., Frazier, P., & Crow, S. J. (2012). Psychometric evaluation of
controlled study design with multiple baselines and with the interven­ the eating disorder examination and eating disorder examination-questionnaire: A
tion replicated over several cases, it is reasonable to conclude that our systematic review of the literature. International Journal of Eating Disorders, 45(3),
428–438. https://doi.org/10.1002/eat.20931
results can be generalized to female patients with overcontrol and mild Bohn, K., Doll, H. a, Cooper, Z., O’Connor, M., Palmer, R. L., & Fairburn, C. G. (2008).
to moderate AN. However, neither males nor individuals with severe The measurement of impairment due to eating disorder psychopathology. Behaviour
underweight receiving stepwise treatment with inpatient care as the first Research and Therapy, 46(10), 1–15. https://doi.org/10.1016/j.brat.2008.06.012
Byrne, S., Fursland, A., Allen, K. L., & Watson, H. (2011). The effectiveness of enhanced
intervention have been evaluated in this study. cognitive behavioural therapy for eating disorders: An open trial. Behaviour Research
and Therapy, 49(4), 219–226. https://doi.org/10.1016/j.brat.2011.01.006
4.2. Conclusion Byrne, S., Wade, T., Hay, P., Touyz, S., Fairburn, C. G., Treasure, J., et al. (2017).
A randomised controlled trial of three psychological treatments for anorexia nervosa,
2823–2833. https://doi.org/10.1017/S0033291717001349
The current study provides preliminary support for the use of RO Chen, E. Y., Segal, K., Weissman, J., Zeffiro, T. A., Gallop, R., Linehan, M. M., et al.
DBT as outpatient treatment for mild to moderate adult AN with over­ (2015). Adapting dialectical behavior therapy for outpatient adult anorexia nervosa-
A pilot study. International Journal of Eating Disorders, 48(1), 123–132. https://doi.
control. Further studies should replicate these findings, and investigate org/10.1002/eat.22360
if targeting dysfunctional overcontrol can decrease long-term risks for Cooper, Z., & Fairburn, C. G. (1987). The eating disorder examination: A semi-structured
relapse and social ostracism. interview for the assessment of the specific psychopathology of eating disorders.
International Journal of Eating Disorders, 6(1), 1–8. https://doi.org/10.1002/1098-
108X(198701)6:1<1::AID-EAT2260060102>3.0.CO;2-9
CRediT authorship contribution statement De Young, K. P., & Bottera, A. R. (2018). A summary of reporting guidelines and
evaluation domains for using single-case experimental designs and
recommendations for the study of eating disorders. International Journal of Eating
Martina Isaksson: Conceptualization, Methodology, Formal anal­
Disorders, 51(7), 617–628. https://doi.org/10.1002/eat.22887
ysis, Investigation, Data curation, Writing - original draft, Visualization, Fairburn, C. G., & Beglin, S. J. (1994). Assessment of eating disorders: Interview or self-
Project administration. Ata Ghaderi: Conceptualization, Methodology, report questionnaire? International Journal of Eating Disorders, 16(4), 363–370.
Formal analysis, Writing - review & editing, Supervision. Mia Ram­ Fairburn, C. G., Cooper, Z., Doll, H. A., Connor, M. E. O., Palmer, R. L., & Dalle, R.
(2013). Enhanced cognitive behaviour therapy for adults with anorexia nervosa : A
klint: Conceptualization, Methodology, Formal analysis, Writing - re­ UK–Italy study. Behaviour Research and Therapy, 51(1), R2–R8. https://doi.org/
view & editing, Supervision. Martina Wolf-Arehult: Conceptualization, 10.1016/j.brat.2012.09.010

8
M. Isaksson et al. Journal of Behavior Therapy and Experimental Psychiatry 71 (2021) 101637

Farstad, S. M., McGeown, L. M., & von Ranson, K. M. (2016). Eating disorders and Lynch, T. R., Hempel, R. J., Whalley, B., Byford, S., Chamba, R., Clarke, P., et al. (2020).
personality, 2004-2016: A systematic review and meta-analysis. Clinical Psychology Refractory depression - mechanisms and efficacy of radically open dialectical
Review, 46, 91–105. https://doi.org/10.1016/j.cpr.2016.04.005 behaviour therapy (RefraMED): Findings of a randomised trial on benefits and
Fassino, S., Pierò, A., Tomba, E., & Abbate-Daga, G. (2009). Factors associated with harms. British Journal of Psychiatry, 216(4), 204–212. https://doi.org/10.1192/
dropout from treatment for eating disorders: A comprehensive literature review. bjp.2019.53
BMC Psychiatry, 9, 67. https://doi.org/10.1186/1471-244X-9-67 Lynch, T. R., Morse, J. Q., Mendelson, T., & Robins, C. J. (2003). Dialectical behavior
Gilbert, K., Hall, K., & Codd, R. T. (2020). Radically open dialectical behavior therapy: therapy for depressed older adults: A randomized pilot study. American Journal of
Social signaling, transdiagnostic utility and current evidence. Psychology Research Geriatric Psychiatry, 11(1), 33–45. https://doi.org/10.1097/00019442-200301000-
and Behavior Management, 13, 19–28. https://doi.org/10.2147/PRBM.S201848 00006
Gilbert, P., Mcewan, K., Mitra, R., Richter, A., Franks, L., Mills, A., et al. (2009). An Martinez, M. A., & Craighead, L. W. (2015). Toward person(ality)-centered treatment:
exploration of different types of positive affect in students and patients with bipolar How consideration of personality and individual differences in anorexia nervosa may
disorder. Clinical Neuropsychiatry, (January), 135–143. improve treatment outcome. Clinical Psychology: Science and Practice, 22(3),
Hay, P. (2013). A systematic review of evidence for psychological treatments in eating 296–314. https://doi.org/10.1111/cpsp.12111
disorders: 2005-2012. International Journal of Eating Disorders, 46(5), 462–469. Murray, S. B., Quintana, D. S., Loeb, K. L., Griffiths, S., & Le Grange, D. (2019).
https://doi.org/10.1002/eat.22103 Treatment outcomes for anorexia nervosa: A systematic review and meta-analysis of
Hempel, R., Vanderbleek, E., & Lynch, T. R. (2018). Radically open DBT: Targeting randomized controlled trials. Psychological Medicine, 49(4), 535–544. https://doi.
emotional loneliness in anorexia nervosa. Eating Disorders, 26(1), 92–104. https:// org/10.1017/S0033291718002088
doi.org/10.1080/10640266.2018.1418268 National Institute for Health and Care Excellence. (2017). Eating disorders: Recognition
Holmbom Goh, M., Ramklint, M., Isaksson, M., & Wolf-Arehult, M. (2020). Psychometric and treatment (NICE guideline No. 69). Retrieved from https://www.nice.org.uk/
properties of the Swedish version of the social safeness and pleasure scale (SSPS) (in guidance/ng69.
preparation. Parker, R. I., Vannest, K. J., Davis, J. L., & Sauber, S. B. (2011). Tau - U - Behavior Therapy
Isaksson, M., Ghaderi, A., Wolf-Arehult, M., & Ramklint, M. (2020a). Overcontrolled, - 2011, 42, 284–299.
undercontrolled, and resilient personality styles among patients with eating disorders. Rance, N., Moller, N. P., & Clarke, V. (2017). “Eating disorders are not about food,
Manuscript Submitted for Publication. they’re about life”: Client perspectives on anorexia nervosa treatment. Journal of
Isaksson, M., Ghaderi, A., Wolf-Arehult, M., & Ramklint, M. (2020b). Psychometric Health Psychology, 22(5), 582–594. https://doi.org/10.1177/1359105315609088
properties of the Eating Disorder Symptom List (EDSL), a brief questionnaire for weekly Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., et al.
assessment of eating disorder symptoms. Manuscript Submitted for Publication. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I): The
Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to development and validation of a structured diagnostic psychiatric interview for
defining meaningful change in psychotherapy research. Journal of Consulting and DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59(20), 22–33.
Clinical Psychology, 59(1), 12–19. https://doi.org/10.1037//0022-006x.59.1.12 Smith, J. D. (2012). Single-case experimental designs: A systematic review of published
Krasny-Pacini, A., & Evans, J. (2018). Single-case experimental designs to assess research and current standards. Psychological Methods, 17(4), 510–550. https://doi.
intervention effectiveness in rehabilitation: A practical guide. Annals of Physical and org/10.1037/a0029312
Rehabilitation Medicine, 61(3), 164–179. https://doi.org/10.1016/j. Stevens, J., Truesdale, K. P., McClain, J. E., & Cai, J. (2006). The definition of weight
rehab.2017.12.002 maintenance. International Journal of Obesity, 30(3), 391–399. https://doi.org/
Kratochwill, T. R., Hitchcock, J. H., Horner, R. H., Levin, J. R., Odom, S. L., 10.1038/sj.ijo.0803175
Rindskopf, D. M., et al. (2013). Single-case intervention research design standards. Turner, H., Bryant-Waugh, R., & Marshall, E. (2015). The impact of early symptom
Remedial and Special Education, 34(1), 26–38. https://doi.org/10.1177/ change and therapeutic alliance on treatment outcome in cognitive-behavioural
0741932512452794 therapy for eating disorders. Behaviour Research and Therapy, 73, 165–169. https://
Letzring, T. D., Block, J., & Funder, D. C. (2005). Ego-control and ego-resiliency: doi.org/10.1016/j.brat.2015.08.006
Generalization of self-report scales based on personality descriptions from Watson, H. J., & Bulik, C. M. (2013). Update on the treatment of anorexia nervosa:
acquaintances, clinicians, and the self. Journal of Research in Personality, 39(4), Review of clinical trials, practice guidelines and emerging interventions.
395–422. https://doi.org/10.1016/j.jrp.2004.06.003 Psychological Medicine, 43(12), 2477–2500. https://doi.org/10.1017/
Linardon, J., Wade, T. D., De La Piedad Garcia, X., & Brennan, L. (2017). The efficacy of S0033291712002620
cognitive-behavioral therapy for eating disorders: A systematic review and meta- Welch, E., Birgegård, A., Parling, T., & Ghaderi, A. (2011). Eating disorder examination
analysis. Journal of Consulting and Clinical Psychology, 85(11), 1080–1094. https:// questionnaire and clinical impairment assessment questionnaire: General population
doi.org/10.1037/ccp0000245 and clinical norms for young adult women in Sweden. Behaviour Research and
Lindner, P., Frykheden, O., Forsström, D., Andersson, E., Ljótsson, B., Hedman, E., et al. Therapy, 49(2), 85–91. https://doi.org/10.1016/j.brat.2010.10.010
(2016). The Brunnsviken Brief quality of life scale (BBQ): Development and Westen, D., DeFife, J. A., Bradley, B., & Hilsenroth, M. J. (2010). Prototype personality
psychometric evaluation. Cognitive Behaviour Therapy, 6073(March), 1–14. https:// diagnosis in clinical practice: A viable alternative for DSM-5 and ICD-11. Professional
doi.org/10.1080/16506073.2016.1143526 Psychology: Research and Practice, 41(6), 482–487. https://doi.org/10.1037/
Lynch, T. R. (2018a). Radically open dialectical behavior therapy: Theory and Practice for a0021555
treating disorders of overcontrol. Oakland, CA: New Harbinger Publications. Westen, D., & Harnden-Fisher, J. (2001). Personality profiles in eating disorders:
Lynch, T. R. (2018b). The skills training manual for Radically open dialectical behavior Rethinking the distinction between Axis I and Axis II. American Journal of Psychiatry,
therapy. New Harbinger Publications. 158(4), 547–562. https://doi.org/10.1176/appi.ajp.158.4.547
Lynch, T. R., Gray, K. L. H., Hempel, R. J., Titley, M., Chen, E. Y., & O’Mahen, H.a. n.d. World Health Organization. Body mass index - BMI. Retrieved from http://www.
(2013). Radically open-dialectical behavior therapy for adult anorexia nervosa: euro.who.int/en/health-topics/disease-prevention/nutrition/a-healthy-lifestyle/
Feasibility and outcomes from an inpatient program. BMC Psychiatry, 13(1). https:// body-mass-index-bmi
doi.org/10.1186/1471-244X-13-293, 293–209. Zipfel, S., Wild, B., Grob, G., Friederich, H. C., Teufel, M., Schellberg, D., et al. (2014).
Lynch, T. R., Hempel, R. J., & Dunkley, C. (2015). Radically open-dialectical behavior Focal psychodynamic therapy, cognitive behaviour therapy, and optimised
therapy for disorders of over-control: Signaling matters. American Journal of treatment as usual in outpatients with anorexia nervosa (ANTOP study): Randomised
Psychotherapy, 69(2), 141–162. https://doi.org/10.1176/appi. controlled trial. The Lancet, 383(9912), 127–137. https://doi.org/10.1016/S0140-
psychotherapy.2015.69.2.141 6736(13)61746-8