Q & A: AN with Borderline Personality Disorder

Q: I’m treating a patient with anorexia nervosa (AN), binge-purge type, who also meets diagnostic criteria for borderline personality disorder. In addition to severe weight restriction and frequent purging she’s often suicidal, highly emotional, and habitually engages in cutting behavior. I know that dialectic behavior therapy (DBT) can be helpful for patients with borderline personality disorder, but is there any evidence that DBT might help a patient with both this co-morbid mix of bulimic type of anorexia nervosa plus a severe personality disorder? (G.J., Omaha, NE).

A: The patient you’re describing is among the most challenging patients with eating disorders that clinicians are likely to encounter. Not surprisingly, patients with this clinical picture often have the worst prognoses. In efforts to treat such patients, clinical programs often employ amalgams of individual and group psychotherapies, using a variety of individual and group-based cognitive-behavioral, psychodynamic, and family treatments, highly scheduled and structured programming, medications, and, increasingly, DBT. Thus, today’s clinicians basically attempt to take advantage of virtually every tool in the contemporary therapeutic bag to treat such patients.

Although randomized controlled trials of DBT have not to my knowledge been conducted with this population, a recent report describing a systematically conducted open trial and 15-month follow-up may be instructive. Overall, the results suggest some improvement, but certainly no miracle cure. In this German study, 24 women with borderline personality disorder (9 with co-morbid AN and 15 with bulimia nervosa [BN]), all of whom had previously failed to respond to eating-disorder-related inpatient treatments, were then treated in a specially adapted inpatient DBT program.

At follow-up, the remission rate was 54% for those with BN, and 33% for those with AN. Of note, 44% of women with AN crossed over to BN, and one woman additionally met criteria for AN. Although the mean weight of women with AN was not significantly increased immediately post-treatment, it had improved at follow-up. For women with BN, the frequency of binge-eating episodes was reduced at post-treatment as well as at follow-up. Self-rated eating-related complaints and general psychopathology, and ratings of global psychosocial functioning were significantly improved at post-treatment and at follow-up (J Behav Ther Exp Psychiatry. 2010 Apr 14. [Epub ahead of print]). On the whole, these findings support the utility of the adapted DBT inpatient program for those who have failed prior treatment attempts. But, we clearly need to do a lot better with our treatment efforts.

— JY