Cognitive behavior therapy (CBT) is considered the first line treatment for bulimia nervosa (BN). However, less than half of patients treated with CBT fully recover. Dialectical behavior therapy (DBT) is a promising alternative that combines cognitive and behavioral change strategies with Eastern philosophies of awareness and acceptance. DBT is increasingly popular in clinical settings (Swenson, 2000) and recently has been adapted for the treatment of binge eating (Telch, Agras, & Linehan, 2001) and bulimia nervosa (BN; Safer, Telch, & Agras, 2001b).

The present study seeks to extend existing research by integrating DBT with Appetite Awareness Training (AAT; Craighead, 2006). AAT is another approach to treating BN that uses appetite monitoring to re-sensitize women to their internal, appetite signals and teaches them to rely primarily on these signals to guide them towards more "normal" eating. Thus, the goals of this modified treatment, Appetite Focused DBT (DBT-AF), are to increase women's awareness of both their emotional and appetite signals and to teach them to use appetite awareness skills and adaptive emotion regulation to replace maladaptive eating behaviors.

In the present study, 32 women with binge and purge episodes of at least once per week were randomly assigned to receive 12 sessions of DBT-AF ( n = 18) or to a 6-week delayed treatment control group ( n = 14). At 6-weeks, the DBT-AF group reported significantly greater reductions in BN symptoms compared to delayed treatment. Including 8 of the delayed-treatment controls who received treatment, a total of 26 participants entered treatment. Of these, 30.8% were recovered at the 12-week posttest and an additional 23.1% had remitted. Participants reported significant reductions in focal and secondary symptoms of BN, as well as significant increases in appetite awareness and effective emotion regulation. Replicating prior findings for CBT, participants demonstrated a rapid rate of response to treatment, with 72.7% of the reduction in binges and 67.8% of the reduction in purges occurring by the first half of treatment. Mediational analysis identified early improvement in restraint and appetite awareness as the central mechanisms of DBT-AF in reducing purge episodes. No mediators were significant for binge episodes. Treatment attrition was low (15.4%), and DBT-AF was rated as highly acceptable by both therapists and clients. Results suggest that DBT-AF warrants further investigation as an alternative to DBT or CBT for BN.