Research project: Radically Open Dialectical Behaviour Therapy

RO-DBT Research Studies, Collaborations & Publications

The underlying model for RO-DBT
Based on a biosocial theory for emotionally-constricted disorders (Lynch & Cheavens, 2008) we contend that individuals who develop treatment-resistant or chronic forms of depression are by nature highly sensitive to threat and insensitive to reward, have strong tendencies for constraint, and under stress prefer order and structure to novelty. These predispositions interact with a socio-biographic environment that values high self-control and avoiding mistakes. The individual acquires a coping style characterised by inhibited expression, risk avoidance, perfectionism, distress over-tolerance, and covert expression of hostility. This style of coping is intermittently negatively reinforced by reductions in arousal associated with avoidance of feared situations, and positively reinforced by achievement or performance. Unfortunately, rigid and over-controlled coping appears to result in poor interpersonal relationships and general difficulties with adapting to changing environmental circumstances, leading to depression and other related problems.

Our research has tested components of this theory: we have found that temperamental negative affectivity is linked with increased thought suppression and ambivalence towards emotional expression, which in turn lead to increased presence of hopelessness, depression and suicidal ideation (Lynch et al., 2001; 2004; 2007). Furthermore, the presence of personality disorder and cognitions including guilt or sinfulness contribute to the persistence or re-emergence of depressive symptoms and suicidal ideation (Morse & Lynch, 2004; Lynch et al., 1999). We have also examined the role of biological vulnerabilities such as reward insensitivity and risk aversion, which are key components of our model. Among depressed individuals we have found enhanced feedback-based decision-making and risk aversion using behavioural performance measures (Smoski et al., 2008) and decreased activation during reward anticipation in the right caudate, supporting the hypothesis of hypo-responsivity in mesolimbic reward regions during reward anticipation (Smoski et al., 2009).

Evidence base for anorexia nervosa
We have conducted studies demonstrating the promise of RO-DBT for patients with both mild and extremely severe symptoms of anorexia. In a recent uncontrolled trial of RO-DBT with severely underweight or chronic inpatients (n = 47) we demonstrated clinically important changes (mean baseline BMI = 14.4; mean change in BMI = +3.6), a large pre-post BMI effect of D = 1.7 (Lynch et al., 2013). Analyses showed 20% of the sample to be in full remission and 41% in partial remission, with higher rates of remission among those completing treatment in full. We also found significant changes (and large effect sizes) for eating disorder pathology, quality of life, and distress. Read more about this study here: http://www.biomedcentral.com/1471-244X/13/293
In addition, RO-DBT has been examined in a small case-series pilot with adult anorexia outpatients (n = 8; baseline BMI = 18.7, manuscript in preparation). RO-DBT yielded a large effect size for BMI (D=1.22), reduction in other Axis I and II disorders (D=0.88), and medium effect sizes for total EDE-Q (D=0.60) and GAF (D=0.66).

Evidence-base for chronic depression
We are currently conducting a multi-site randomised controlled trial investigating the efficacy and mechanisms of RO-DBT for patients with treatment-resistant and chronic depression: project REFRAMED (see www.reframed.org.uk ). In addition, a PhD student at St Patrick’s hospital in Dublin has now completed her research project “A non-randomised controlled trial comparing RO-DBT skills alone to Treatment as Usual (TAU) for chronically depressed adults with overcontrolled personality dysfunction”. Results will be made available as soon as possible.

On-going treatment trials & research collaborations

1. The Haldon Unit – Devon Partnership Trust is a centre of excellence. The Haldon Approach has proved to be highly successful in the treatment of eating disorders including anorexia. It is pioneering up-to-date treatment which teaches radical openness skills to support anorexia recovery using RO-DBT.
2. St Patrick’s Hospital, Dublin : mental health services offer Radical Openness as part of their day programme , which is accessible to a range of patients such as those with anorexia and depression.
3. South London and Maudsley NHS Trust : professionals from the DBT and Eating Disorders Services have attended RO-DBT training and are collaborating with Prof Lynch on several research projects.
4. Uppsala University Hospital : the DBT team at the Uppsala University Hospital has been trained in RO-DBT and involved in several treatment evaluation studies.