Journal of

Personalized
Medicine

Article
Dialectical Behaviour Therapy Improves Emotion
Dysregulation Mainly in Binge Eating Disorder and Bulimia
Nervosa: A Systematic Review and Meta-Analysis
Natalia Rozakou-Soumalia † , Ştefana Dârvariu † and Jan Magnus Sjögren *

Psychiatric Centre Ballerup, Eating Disorder Research Unit, 2750 Copenhagen, Denmark;
[email protected] (N.R.-S.); [email protected] (S.D.)
* Correspondence: [email protected]
† These authors contributed equally to this work.

Abstract: Emotion dysregulation is a transdiagnostic phenomenon in Eating Disorders (ED), and

Dialectical Behaviour Therapy (DBT) (which was developed for reducing dysregulated emotions
in personality disorders) has been employed in patients with ED. This systematic review and meta-
analysis investigated whether the effect of DBT was stronger on emotion dysregulation, general
psychopathology, and Body Mass Index (BMI) in participants with ED, when compared to a con-
trol group (active therapy and waitlist). Eleven studies were identified in a systematic search in
accordance with PRISMA guidelines. Most studies included participants with Binge Eating Disorder
(BED) (n = 8), some with Bulimia Nervosa (BN) (n = 3), and only one with Anorexia Nervosa (AN).




The pooled effect of DBT indicated a greater improvement in Emotion Regulation (ER) (g = −0.69,

 p = 0.01), depressive symptoms (g = −0.33, p < 0.00001), ED psychopathology (MD = −0.90, p = 0.005),
Citation: Rozakou-Soumalia, N.; Objective Binge Episodes (OBE) (MD = −0.27, p = 0.003), and BMI (MD = −1.93, p = 0.01) compared
Dârvariu, Ş.; Sjögren, J.M. Dialectical to the control group. No improvement was detected in eating ER following DBT (p = 0.41). DBT
Behaviour Therapy Improves demonstrated greater efficacy compared with the control group in improving emotion dysregulation,
Emotion Dysregulation Mainly in ED psychopathology, and BMI in ED. The limitations included the small number of studies and
Binge Eating Disorder and Bulimia high variability.
Nervosa: A Systematic Review and
Meta-Analysis. J. Pers. Med. 2021, 11, Keywords: emotion regulation; eating disorders; dialectical behaviour therapy; binge eating disorder;
931. https://doi.org/10.3390/
bulimia nervosa
jpm11090931

Academic Editor: Marco Costanzi

1. Introduction
Received: 5 August 2021
Accepted: 15 September 2021
Eating disorders (ED) are defined as bio-psycho-social disorders, likely caused by
Published: 18 September 2021
a combination of genetic, psychological, and sociocultural factors. The Diagnostic and
Statistical Manual of Mental Disorders (DSM) describes three major ED, namely Anorexia
Publisher’s Note: MDPI stays neutral
Nervosa (AN), Bulimia Nervosa (BN), and Binge-Eating Disorder (BED), while also in-
with regard to jurisdictional claims in
cluding Other Specified Feeding and Eating Disorders (OSFED), previously termed Eating
published maps and institutional affil- Disorder Not Otherwise Specified (EDNOS) [1]. In the last 20 years, an increasing trend
iations. has been observed in the prevalence of ED, from 3.5% to 7.8%.
These disorders are characterised by high mortality rates as well, which indicates an
escalating health threat [2]. AN is responsible for 5.1 deaths/1000 person-years (1.3 deaths
due to suicide), BN for 1.74 deaths/1000 person-years and BED together with OSFED
Copyright: © 2021 by the authors.
for 3.31 deaths/1000 person-years [3]. This is further underscored by the poor treatment
Licensee MDPI, Basel, Switzerland.
outcome, where only 64% of AN and 45% of BN achieved full remission, and around 20%
This article is an open access article
and 23% endured chronic AN and BN, respectively. The mean follow up in these studies
distributed under the terms and was 25 years for AN and 30 years for BN [4,5]. Patients with BED and OSFED presented
conditions of the Creative Commons the highest remission rate (70%), while 10% of BED patients still had the disorder at the
Attribution (CC BY) license (https:// 5-year follow up [6].
creativecommons.org/licenses/by/ Emotion dysregulation is a transdiagnostic phenomenon in ED [7], with Emotion
4.0/). Regulation (ER) defined as all the processes that influence and control the emotions that

J. Pers. Med. 2021, 11, 931. https://doi.org/10.3390/jpm11090931 https://www.mdpi.com/journal/jpm

J. Pers. Med. 2021, 11, 931 2 of 20

individuals experience. The influences on emotion regulation capacity can be external

(typically family and friends), or internal, neurophysiological processes (e.g., the develop-
ment of cognitive skills) [8,9]. In ED, emotion dysregulation is characterised by enhanced
emotional responses, which are further amplified by reduced emotional awareness and
adaptability [7].
In other words, the emotional dimension is strongly associated with ED psychopathol-
ogy, which raises the question of its impact in treating ED [10,11]. The most commonly
investigated treatments in ED are Cognitive Behaviour Therapy (CBT) and Interpersonal
Psychotherapy (IPT). The former achieves reduced emotional distress and problematic
behaviours through addressing automatic maladaptive thought patterns and challenging
their validity.
In contrast, IPT aims to strengthen the individual’s social support, improve their
interpersonal skills, and decrease emotional distress through addressing the social and
interaction difficulties frequently observed in ED patients, which may stem from a crucial
interpersonal problem in their lives [12–15]. While emotion dysregulation is part of these
treatments, none of these specifically focus on this component. Therapies are more con-
cerned either with elements of cognition, such as selective attention or cognitive control in
CBT or with aspects of interpersonal capacity and functioning in IPT.
DBT (Dialectical Behavioural Therapy) is based on biosocial theory, developed by
Linehan (1993), which explains how biological vulnerability together with an invalidating
environment result in emotion dysregulation [16]. The latter affects psychological and
social functioning (e.g., the experience of the sense of self, behaviour control, interpersonal
relationships, etc.). This theory highlights the need for patients to obtain new skills that
can be used in the individual’s environment to neutralize these deficits [17].
According to Linehan (1993), the treatment must strengthen the patient’s skills and
motivate the patient to employ the skills and apply them in all relevant contexts. The
strategies and skills utilized in DBT are categorized as those that encourage acceptance of
reality and those that promote change. For instance, the process of learning how to change
emotions or interpersonal relationships is the focus of change skills, while acceptance of
situations and emotional pain is the aim of mindfulness and distress tolerance [18].
Since the biosocial theory framework also applies in ED patients, DBT was suggested
as a treatment in these disorders. DBT’s focus on emotion dysregulation as well as its initial
development for patients with multiple problems (Axis I and Axis II comorbidities are
commonly observed in ED) demonstrate DBT’s eligibility in treating ED [19]. In the past
few years, DBT has been gaining empirical support for the treatment of all typical ED, with
the evidence being more extensive in the case of BED and BN [20–22]. Previous studies have
investigated the effect of DBT in ED patients with and without comorbidity [23] as well as
adaptations and implementation of DBT [24–27]. Most studies found an encouraging rate
of binge abstinence (from 29–89%) and reduction in the frequency of ED symptoms [20].
Despite awareness that emotion dysregulation is a transdiagnostic phenomena in
ED, the state of knowledge on the efficacy of DBT in influencing Emotion Regulation (ER)
in ED is currently unknown. Since ER may have a substantial impact on the treatment
outcomes in all types of ED, this is important to investigate. Previous studies only focused
on summarizing the literature on psychological interventions for ED and included DBT as
one of these interventions [18,19] without specifying its individual effects.
We therefore undertook the first systematic review and meta-analysis of the effect of
DBT in ED and specifically studied the effect of DBT on ER in comparison to a control
group. In addition, we also investigated the effect on general psychopathology and Body
Mass Index (BMI) as secondary aims. The ambition was to provide a current state of
evidence for the effect of DBT by only including RCT with high-quality of evidence in
order to provide guidance for clinical decisions and directions for future research on the
use of DBT in ED.
J. Pers. Med. 2021, 11, 931 3 of 20

2. Materials and Methods

2.1. Search Strategy and Study Selection
A systematic review and a meta-analysis were carried out in accordance with the
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guide-
lines and the Cochrane Handbook for Systematic Reviews [28,29]. The protocol was
registered in the International Prospective Register of Systematic Reviews, PROSPERO
(CRD42021223633). The electronic databases Pubmed, Embase (Ovid), PsychInfo (EBSCO),
and ClinicalTrials.gov were thoroughly searched on the 7th of December 2020. Further,
the reference lists of the included articles were assessed for the identification of additional
studies.
The keywords included the major, as well as less common ED and spelling variations
of DBT. A detailed description of search terms and strategy can be viewed in Supplementary
Material Table S1. The search results were imported in Endnote for duplicate removal, a
step that was reiterated in Rayyan [30,31]. Assessment of the retrieved publications was
carried out by two authors (S.D. and N.R.-S.), with input from a third author (J.M.S.) in the
event of disagreements.

2.2. Eligibility Criteria

The inclusion criteria for studies were: (1) participants diagnosed with an ED or
atypical ED, (2) studies investigating the effect of DBT, (3) studies including ER as an
outcome, (4) studies with a control group (active therapy or wait list), (5) clinical trials
(randomised and non-randomised), (6) written in English and (7) published after 2000. This
date cut-off was selected as the state of knowledge regarding ED, especially BED, has been
maturing over the last 20 years and due to absence of classification and knowledge about
the application of DBT in ED before that time period. Although a few papers may have
been published before 2000, these were still considered when found through the identified
publications.
In terms of exclusion criteria, these were: (1) reviews, meta-analyses, or editori-
als, as original publications were sought, to allow an unbiased analysis, (2) studies that
lacked a control, which was considered a requirement for determining the efficacy of DBT,
(3) participants below 12 years old, since children are yet to develop the cognitive skills to
identify and report cognitions and emotional states, (4) participants with substance abuse,
(5) pregnant participants, both (4) and (5) are considered as confounding states where
emotions may be affected differently than in ED and thus not representative of the general
ED population.

2.3. Outcomes and Data Extraction

The primary outcome of this study was Emotion Regulation (ER) represented in
several ways as follows: (1) primary ER (one Outcome Measure Instrument [OMI] per
study), (2) overall ER (all ER-related OMI per study), also divided into general ER (OMI
depicting general presence or regulation of negative affect (DERS, NMRS, EDI-3 emotion
dysregulation subscale, and PANAS)) and eating ER (OMI depicting desire to eat in
response to negative affect (EES and DEBQ)). Depressive symptoms (OMI indicating
depressive symptoms (BDI, EES depression subscale and PANAS-NA)) were considered
reflective of ER.
The secondary outcomes were ED psychopathology, as well as BMI. The former was
investigated as (1) the frequency of key behavioural features of ED, such as restraint, eating
concern, weight concern, shape concern, and the presence of binge eating behaviours
(Eating Disorder Examination-Questionnaire (EDE-Q) and Binge Eating Scale (BES)) and
(2) frequency of binge-eating, which was measured as Objective Binge Episodes (OBE).
For the systematic review, essential information—including OMI—was extracted and
organized in Tables 1 and 2. Any missing data that were relevant to the study were
requested from the corresponding author of the specific publication.
J. Pers. Med. 2021, 11, 931 4 of 20

2.4. Quality Assessment and Risk of Bias in the Included Studies

The risk of bias in the included randomised and non-randomised studies was assessed
according to the Cochrane Collaboration’s Tool Risk of Bias 1 (RoB 1) and Risk of Bias in
Non-randomised Studies-I (ROBINS-I), respectively. The assessment was performed by
S.D. and N.R.-S. independently, both at the study and outcome level across all bias domains.
Any discrepancies were discussed until a consensus was reached. The key domains for
the subjective and objective outcomes were identified and evaluated across randomised
studies based on their relative importance in the current review.
The domains that were evaluated in the randomised papers were the following:
random sequence generation, allocation concealment, participants, personnel and outcome
assessor blinding and incomplete outcome data. Regarding the non-randomised study,
the domains that were assessed were: bias due to confounding, deviations from intended
interventions, missing data, bias in selection of the study participants, classification of
interventions and measurement of outcomes. The studies were rated as low, intermediate,
or high quality based on the level of risk of bias at each key bias domain, which would
correspond to one or more domains at high risk, one or more domains at unclear risk, or
all domains at low risk of bias, respectively.

2.5. Statistical Analysis

Due to the absence of comparison analyses and standard deviations in the included
studies, Welch’s two-sample t-tests and SD imputations were conducted. The pooled
effects of the outcomes of interest were estimated in Review Manager 5.4.1.—where a
random-effects meta-analysis model was used—in which the mean changes from baseline
to post-treatment were included [32]. The effect size was presented as the weighted mean
differences (MD) or Hedges’ g—when outcomes were assessed by different instruments
across papers—with 95% confidence intervals (CI). The cut-off points were applied accord-
ing to the multicomponent empirically-based guidelines for rehabilitation treatment by
Kinney et al. (2020) [33].
As such, effect sizes up to 0.31 were considered as small, between 0.31–0.55 as medium,
and over 0.55 as large. When more relevant measures were available per study, all of them
were included. To avert the statistical interpretation of the same studies as independent
ones, and overestimation of the effects, adjustments were carried out. This correction
was achieved through dividing the sample size by the number of times the study was
introduced in the analysis.
A negative value demonstrated an effect favouring the experimental group, whereas
a positive indicated an effect favouring the control (active therapy and wait list). For some
outcome measures, a positive coefficient was an indication of improvement (e.g., NMRS,
PANAS positive, etc.). Thus, in these cases, the signs were reversed where DBT had a
greater absolute value compared with the control.
The degree of heterogeneity across studies was depicted by I2 statistics, which was
evaluated based on the guidelines created by Higgins et al. Based on these, the I2 can
indicate low (25–50%), moderate (50–75%), or high (>75%) heterogeneity [34]. Due to dif-
ferences in the binge frequency measurements between studies, binge rates were calculated
as follows: Binge days/episodes were divided by 28, the number of days the measure was
reflective of. In one paper, the values were first multiplied by 4 and then divided by 28, as
the measure was recorded weekly [35].
Subgroup analyses based on comparison group (active therapy vs. wait list), gender
(male vs. female), ED type (BED vs. miscellaneous) and ER outcome (primary studies-ER
as primary outcome vs. secondary studies-ER as a secondary outcome) were performed to
investigate possible differences between groups in the magnitude of DBT’s effect. Meta-
regression analyses were also conducted subsequently to explore sources of heterogeneity
and to indicate the possible influence of different predictor variables, such as country (US
vs. Non-US), BMI, age, sample size, and ED type.
J. Pers. Med. 2021, 11, 931 5 of 20

3. Results
3.1. Study Selection
The literature search revealed a total of 535 eligible articles. Among those, 27 were
reviewed for eligibility in full text, according to the inclusion and exclusion criteria. Two
studies were included as one—seeing that one paper presented the post-treatment results
and the other one reported the follow-up findings [36]—and 11 were ultimately included
in the systematic review and meta-analysis (see Figure 1).

3.2. Study Characteristics

The 11 studies included 669 participants of ages ranging from 18–65 years, assigned
either to a DBT group or a control group. (In some studies, the latter consisted of a waitlist
group (six studies) whereas others comprised an evidence-based active therapy form (five
studies). The active therapy comparisons were CBT and CBT+, Behavioural Treatment Plan
(BTP), Active Comparison Group Therapy (ACGT), and Supportive Group Therapy (SGT).
Among the studies, 10 were RCTs (one of which breached the randomisation technique
occasionally when it was convenient) [37], and only one was a non-randomised controlled
clinical trial [36]. The studies were published in the time period between 2001 and 2020,
and interventions lasted from 10 up to 24 weeks with either one or two sessions per week.
Some studies included a follow-up period which ranged from 3 months to a year, with one
notably longer, which lasted 6 years [36].
Most studies were conducted in the USA (n = 6) and the remaining were from the
Netherlands, Iran, Spain, and Canada. The preponderance of participants had BED, with
one study examining BED and loss of control. Only two papers included participants
diagnosed with BN and one investigated participants with AN, BN, and OSFED. The
majority of the studies considered exclusively female participants, and the few studies
including males still had predominantly women participants (more than 85%) [35,37–40].
More details on the characteristics of the included studies can be seen in Tables 1 and 2.

Figure 1. Prisma flow diagram of the current study.

J. Pers. Med. 2021, 11, 931 6 of 20

Table 1. Characteristics of the included studies (DBT vs. WL).

First Author, Year Study Design Sample Size (n) Population Demographics ED Type and Diagnostic Manual Treatment Key Findings Post-Treatment
1. Emotion regulation
Total: 40 Age (range): 18–50 ED: BED Intervention: DBT vs. WL (no -EES global, anger/frustration, anxiety subscales:
RCT
Dastan et al., 2019 [41] DBT: 20 Females: 100% Criteria: DSM-IV intervention) significantly higher improvements in DBT
Follow-up: -
WL: 20 Nationality: Iranian Assessment: SCID-I Duration: 20 weeks (2 h session/week) -EES depression: no significant difference
2. BMI: significantly higher reduction in DBT
1. Emotion regulation
Intervention: DBT vs. WL (6-week -EES, NMRS, PANAS-NA: no significant differences
ED: BN (n = 26) and delayed intervention) -PANAS-PA, BDI-II: significantly higher improvements in DBT
Total: 32 Age (SD): 22 (6.3)
RCT sub-clinical BN (n = 6) Duration: 12 weeks (1 h session/week: 2. ED psychopathology
Hill, 2007 [42] Follow-up: - DBT: 18 Females: 100% Criteria: DSM-IV the length of the -EDE-Q global, restraint, shape, eating concern:
WL: 14 Nationality: American Assessment: SCID-I first 6 sessions was increased to significantly higher improvements in DBT
90 min) -Weight concern: no significant differences
-OBE: significantly greater reductions in DBT
1. Emotion regulation
-DERS: significantly greater improvements in DBT
Age (SD): 42.8 (10.5) Intervention: DBT-guided self-help vs.
RCT Total: 60 ED: BED 2. ED psychopathology
Follow-up: 6 Females: 88.3% Criteria: DSM-IV WL (no intervention)
Masson et al., 2013 [39] DBT: 30 -EDE-Q all subscales, except eating concern:
Males: 11.7% Assessment: SCID-I and EDE Duration: 13 weeks (6 biweekly
months WL: 30 significantly higher improvements in DBT
Nationality: Canadian 20-min support phone calls)
-OBE: significantly greater reductions in DBT
-EDQLS: significantly greater improvements in DBT
1. Emotion regulation
Intervention: DBT vs. WL (offered -DERS: significantly greater improvements in DBT
Total: 60 Age (SD): 30.5 (7.5) ED: BED
RCT treatment at the end of study)
Rahmani et al., 2018 [43] DBT: 30 Females: 100% Criteria: DSM-IV-TR 2. ED psychopathology
Follow-up: - Duration: 10 weeks (2 h session/twice
WL: 30 Nationality: Iranian Assessment: SCID-DSM-IV-TR -BES: significantly greater reductions in DBT
a week)
3. BMI: significantly greater reductions in DBT
1. Emotion regulation
ED: BN (80.6%) and -EES global and subscales, PANAS-NA, NMRS, BDI:
Total: 29 Age (SD): 34 (11) Intervention: DBT vs. WL (offered
RCT sub-clinical BN (19.4%) significantly greater improvements in DBT
Safer et al., 2001 [44] DBT: 14 Females: 100% treatment at the end of study)
Follow-up: - Criteria: DSM-IV -PANAS-PA: no significant differences
WL: 15 Nationality: American Duration: 20 weeks
Assessment: EDE 2. ED psychopathology
-OBE: significantly greater reductions in DBT
1. Emotion regulation
-EES global, anxiety and depression: no significant differences
-EES anger: greater improvements in DBT (borderline significant)
Total: 44 Age (SD): 50 (6.1) ED: BED Intervention: DBT vs. WL -PANAS, NMRS, BDI: no significant differences
RCT
Telch et al., 2001 [45] DBT: 22 Females: 100% Criteria:DSM-IV (no intervention) 2. ED psychopathology
Follow-up: -
WL: 22 Nationality: American Assessment: SCID-I and SCID-II Duration: 20 weeks (2 h session/week) -OBE, BES: significantly greater reductions in DBT
-EDE-Q weight, shape, eating concern: significantly higher
improvements in DBT
-EDE-Q global and restraint concern: no significant differences
J. Pers. Med. 2021, 11, 931 7 of 20

Table 2. Characteristics of the included studies (DBT vs. AT).

First Author, Year Study Design Sample Size (n) Population Demographics ED Type and Diagnostic Manual Treatment Key Findings Post-Treatment
1. Emotion regulation
RCT Age (SD): 49.4 (11.4) -EES, BDI: no significant differences
Total: 17 ED: BED (subthreshold: n = 4) Intervention: DBT + Alli (weight loss drug)
Adler, 2008 [35] Follow-up: DBT: 8 Females: 88.2% Criteria: DSM-IV vs. BTP + Alli 2. ED psychopathology
18 weeks BTP: 9 Males: 11.8% Assessment: EDE Duration: 12 weeks (2 h session/week) -OBE: no significant differences
Nationality: American
-BES: significantly greater reductions in DBT
1. Emotion regulation
Age (SD): 51.6 (11.2) -DERS: no significant difference
Total: 101 ED: BED -BDI: significantly greater reductions in DBT
RCT Females: 85.1% Intervention: DBT vs. SGT
Hoffman, 2006 [38] DBT: 50 Criteria: DSM-IV
Follow-up: - Males: 14.9% Duration: 20 weeks (2 h session/week) 2. ED psychopathology
SGT: 51 Assessment: SCID-I and SCID-II
Nationality: American -OBE: significantly greater reductions
3. BMI: no significant differences in DBT
1. Emotion regulation
-DEBQ, EDI-3 (emotion dysregulation), BDI-II: no
Quasi- significant difference
randomised Age (SD): 37.3 (11.8)
Total: 74 ED: BED Intervention: DBT-BED vs. CBT+
control trial Females: 89.2% Criteria: DSM-V 2. ED psychopathology
Lammers et al., 2020 [37] DBT: 41 Duration: 20 weeks (2 h session/week)
Follow-up: CBT+: 33 Males: 10.8% Assessment: DEBQ and SCID -EDE-Q, EDI-3 (self-esteem), SCL-90: no significant
6 months Nationality: Dutch differences
-OBE: significantly greater reductions in CBT+
3. BMI: no significant differences in DBT
Non-randomised Age (SD): 27.3 (8.1) 1. Emotion regulation
Total: 109 ED: BN, AN or EDNOS -EES: significantly greater improvements in TAU-CBT
Navarro-Haro et al., control trial Females: 100% Intervention: DBT vs. TAU-CBT
DBT: 64 Criteria: DSM-IV
2020 [36] Follow-up: 4 and Nationality: Spanish Duration: 6 months (2 h session/week) -ERQ, BDI-II, PANAS-PA: no significant difference
TAU-CBT: 45 Assessment: SCID-I
6 years Comorbidity: BPD -PANAS-NA: borderline significant
1. Emotion regulation
-NMRS, EES, PANAS, DERS: no significant difference
-BDI: significantly greater reductions in DBT
RCT Age (SD): 52.2 (10.6) 2. ED psychopathology
Total: 101 ED: BED
Follow-up: 3, 6 Females: 86% Intervention: DBT-BED vs. ACGT -EDE-Q global and eating concern: significantly greater
Safer et al., 2010 [40] DBT: 50 Criteria: DSM-IV
Males: 14% Duration: 21 weeks (2 h session/week) improvements in DBT
and 12 months ACGT: 51 Assessment: SCID-I
Nationality: American -Restraint, weight and shape concern: no significant
improvements in DBT
-OBE: significantly reduced in DBT
3. BMI: no significant differences

Abbreviations for Tables 1 and 2: Active Comparison Group Therapy (ACGT), Active Therapy (AT), Anorexia Nervosa (AN), Beck Depression Inventory (BDI), Behavioural Treatment Plan (BTP), Binge Eating
Disorder (BED), Binge Eating Scale (BES), Body Mass Index (BMI), Borderline Personality Disorder (BPD), Bulimia Nervosa (BN), Cognitive Behaviour Therapy (CBT), Diagnostic and Statistical Manual of Mental
Disorders (DSM), Dialectical Behaviour Therapy (DBT), Difficulties in Emotion Regulation Scale (DERS), Dutch Eating Behaviour Questionnaire (DEBQ), Eating Disorder(s) (ED), Eating Disorder Examination
(Questionnaire) (EDE(-Q)), Eating Disorder Inventory (EDI-3, emotion dysregulation subscale), Eating Disorder Quality of Life Scale (EDQLS), Eating Disorders not Otherwise Specified (EDNOS), Emotional
Eating Scale (EES), Emotion Regulation Questionnaire (ERQ), Negative Mood Regulation Scale (NMRS), Objective Binge Episodes (OBE), Positive and Negative Affect Schedule (PANAS), Positive affect (PA),
Negative affect (NA), Randomised Control Trial (RCT), Structural Clinical Interview for DSM (SCID), Standard Deviation (SD), Supportive Group Therapy (SGT), Symptom Checklist (SCL-90), Treatment as
Usual (TAU), and Waitlist (WL).
J. Pers. Med. 2021, 11, 931 8 of 20

3.3. Quality Assessment

In total, the overall quality of the current review was rated as intermediate with three
studies at low risk of bias [37,39,41], four at unclear risk [35,40,43,44], and three at high
risk [38,42,45]. The domains at the highest risk of bias were randomisation and allocation
concealment, due to a lack of explicit mentioning. For the non-randomised study, all key
domains were at moderate risk, except for deviations from the intended interventions and
missing data, which were at low risk. Overall, the quality of the non-randomised study was
moderate and in line with the total quality of the current review. The figures are available
in Supplementary Material, Figures S10 and S11.

3.4. Effectiveness of DBT

3.4.1. Emotion Regulation (ER)
The analysis including only primary outcomes revealed a significant effect of DBT
on ER (g = −0.69, p = 0.01), accompanied by a high heterogeneity (I2 = 90%), as well as a
wide confidence interval (95% CI: [−1.22, −0.16]) (Figure 2). The analysis including all ER
measures available showed a significant pooled effect (p < 0.001) in favour of DBT. The
standardised mean difference was g = −0.46 with a 95% confidence interval of [−0.67,
−0.26] and presented high heterogeneity (I2 = 81%) (Table A1, Appendix A). After adjusting,
a small decrease in the standardised mean difference was observed; however, the analysis
still yielded a significant effect (p = 0.001) in favour of DBT. The heterogeneity decreased
substantially (I2 = 53%) (Figure 3).
Distinguishing between the types of affect regulation, DBT had a significant effect
only on general ER (p < 0.01). The effect was five-times greater than in eating ER, while
the heterogeneity and the confidence interval were also wider (g = −0.70, 95% CI: [−1.23,
−0.18], p = 0.009, I2 = 89%, g = −0.15, 95% CI: [−0.51, 0.21], p = 0.41, I2 = 69%) (Table A1,
Appendix A). After adjustment, the effect sizes were unchanged (Table A2, Appendix A).
The overall effect of DBT on depressive symptoms favoured DBT, with a significant effect
size of g = −0.33 (95% CI: [−0.45, −0.20], p < 0.00001, I2 = 9%). Following adjustment, the
effect remained significant, whilst the heterogeneity diminished to zero (see Figure 4).

Figure 2. Forest plot: analysis of Emotion Regulation (ER) including one (primary) outcome per study.
J. Pers. Med. 2021, 11, 931 9 of 20

Figure 3. Forest plot: adjusted analysis of Emotion Regulation (ER) including all relevant outcomes
per study.

Figure 4. Forest plot: adjusted analysis of depressive symptoms including all relevant outcomes
per study.

Subgroup Analyses
Overall, there was a significant subgroup difference between waitlist and active
therapy studies, as observed in overall, general and eating Emotion Regulation (ER)
(Tables S2 and S6, Supplementary Material). The trend displayed higher effects of DBT
in studies that compared to a wait list group, as opposed to those comparing to active
therapy studies, and the difference was a three-fold and ten-fold increase, respectively.
Heterogeneity and confidence intervals were also notably larger in wait list studies relative
to active therapy. In terms of depressive symptoms, there was no significant difference
between wait list and active therapy studies. Subgroup differences were identified in overall
ER between studies that exclusively investigated females and those that also included
males (Tables S3 and S7, Supplementary Material).
J. Pers. Med. 2021, 11, 931 10 of 20

While both presented a significant effect, this was four-times higher in the females-
only subgroup. No significant subgroup difference was identified in general ER and
depressive symptoms. The females-only group showed greater effects, especially in general
ER where the effect size was over six-times higher. Heterogeneity was generally low
in the mixed gender group and high in the females-only group, except for depressive
symptoms, where both were low. The CI followed similar patterns. There were no subgroup
differences identified in overall and general ER, where the effect sizes were significant in
both subgroups and larger in BED-only studies (Tables S4 and S8, Supplementary Material).
Heterogeneity was low only in the mixed groups, while the CI were generally wide in
both subgroups. With regards to depressive symptoms, the effects were also significant
in both groups and larger in the mixed subgroup, which presented a wide CI and zero
heterogeneity. The BED-only group also had low heterogeneity and was accompanied by a
narrower CI.
There was no subgroup difference between primary and secondary ER studies in over-
all and general ER, as both showed significant effect sizes (Tables S5 and S9, Supplementary
Material). They were higher in studies primarily focusing on ER, which also presented
wider CI and heterogeneity. The latter was absent in secondary studies. In the case of
depressive symptoms, the effect was greater and only significant in secondary studies, but
the subgroup test was not significant. Heterogeneity was 0 in both groups, while the CI
was only wide in primary studies.

3.4.2. ED Psychopathology
Severity of Symptoms
The overall effect of DBT on the severity of symptoms favoured DBT, with g = −0.90
(p = 0.002) and a wide confidence interval (95% CI: [−1.45, −0.34]) (Table A1, Appendix A).
After adjustment, the effect remained significant (Figure 5).

Figure 5. Forest plot: adjusted analysis of the severity of symptoms.

Objective Binge Episodes (OBE)

The total effect of DBT on OBE followed a negative direction (MD = −0.27, 95% CI:
[−0.45, −0.09], p = 0.003), along with a heterogeneity of 85%, indicating a greater reduction
of OBE in DBT (Figure 6).

Figure 6. Forest plot: analysis of OBE.

J. Pers. Med. 2021, 11, 931 11 of 20

Subgroup Analyses
The subgroup analyses showed higher effects of DBT on ED psychopathology in
studies with a waitlist group. However, no significant differences were detected between
the waitlist and active therapy groups in OBE analysis (p = 0.12, I2 = 59%) (Tables S2 and S6,
Supplementary Material). Studies with exclusively female participants showed larger effect
sizes compared to mixed gender studies, namely nine-times higher in symptoms and three-
times greater in OBE.
The tests for subgroup differences yielded a non-significant result (Tables S3 and S7,
Supplementary Material). Subgroup analysis by ED type showed a greater effect on OBE in
the miscellaneous ED group compared to the BED group. Both groups were characterised
by high heterogeneity (I2 = 78% and I2 = 91%, respectively). However, no significant
difference was detected between the groups (Tables S4 and S8, Supplementary Material).

3.4.3. Body Mass Index (BMI)

The effect of DBT on BMI was significant (p = 0.01) with a MD = −1.93, 95% CI: [−3.42,
−0.44] and presented moderate heterogeneity I2 = 32% (Figure 7).

Figure 7. Forest plot: analysis of BMI.

Subgroup Analyses
A significantly greater effect was seen in the exclusively female group compared to
the mixed gender group, while both groups presented wide confidence intervals. However,
the difference was not reflected in the subgroup test, which yielded non-significant results
between the groups (p = 0.27) (Tables S3 and S7, Supplementary Material).

3.5. Meta-Regression Analysis

When investigating heterogeneity in overall Emotion Regulation (ER), no single
explanatory variable significantly accounted for the between-study variance. When testing
the interaction between predictor variables, the highest proportion of explained variance
was detected in the model based on BMI and age (R2 = 91%, 95% CI: [0.02, 0.10], 95% CI:
[−0.05, 0.00], respectively). Only BMI showed a significant influence (p < 0.01) (Figures S1
and S3, Supplementary Material). No other combinations of predictors explained a higher
proportion of the variance. The full meta-regression analysis and bubble plots are available
in Supplementary Material (Figures S1–S9).

3.6. Publication Bias

The funnel plot for overall ER and depressive symptoms showed no evidence of
asymmetric distribution of studies, as the points of the plot mostly scattered evenly on
both sides of the reference line, suggesting a low risk of publication bias (Figures S12 and
S13, Supplementary Material). With regards to variation of the sampling distribution, there
was a gap in lower-powered articles, as all publications included in this review tended to
be aggregated in the upper part of the plot.

4. Discussion
The aim of this study was to investigate primarily the effect of DBT on Emotion
Regulation (ER) in ED and secondarily its effect on ED psychopathology and BMI as
J. Pers. Med. 2021, 11, 931 12 of 20

compared to a reference treatment or wait list group. The systematic review and meta-
analysis of the current literature indicated an improvement following DBT on all outcomes,
with clearer effects on general psychopathology and BMI.

4.1. Emotion Regulation (ER)

In the meta-analysis, DBT showed a moderate to large improvement in the ER of ED
participants (primary model: g = −0.56; overall model: g = −0.42). The current results were
mainly applicable in BED, as sample sizes for BN and especially AN were considerably
lower. Therefore, the findings have very limited reliability in the context of other ED, as
the investigation of DBT in BN and AN is in its infancy. Currently, the effects of DBT
on reducing difficulties in ER have only been documented in a systematic review, which
investigated a mixed population [46]. Their findings indicated a possible effect of DBT on
ER, while emphasising the inability to draw clear conclusions on the topic due to sparse and
inconsistent data. In contrast, the current study examined a more homogeneous population,
while still lacking consistency in the use of active controls, as well as DBT variations.
As defined in the methods, distinguishing between the two types of affect regulation
(general versus eating ER), a significant influence of DBT was only observed in general
Emotion Regulation (ER). The large effect size indicates that DBT may be effective in
improving the general regulation of emotions, rather than directly modulating disordered
eating in reaction to negative affect (g = −0.70). However, these mechanisms may be
dependent on each other, since emotional eating has previously been associated with
difficulties in the specific dimensions of ER [47,48].
Emotional eating induced by negative affective states—especially depression—was
specifically associated with increased difficulties of engaging in goal-directed behaviour,
controlling impulse and accepting emotional reactions. Eating triggered by negative affect
was also associated with insufficient access to emotion regulation strategies [49]. Negative
emotional eating may act as a precursor for experiencing disordered eating symptoms,
which emphasises the relevance of targeting this, along with poor emotion regulation
in treatment. Therefore, future studies could focus on creating adaptations of DBT with
increased focus on these particular dimensions of general ER, as well as assessing emotion
regulation and emotional eating as two separate constructs [50].
Longer follow-up periods may also be necessary to observe larger changes in eating
ER, since the current literature search has revealed that this is a rather uncommon finding
with only one study presenting a considerable follow-up period of 6 years [36].
The smallest effect of DBT was observed in the treatment of depressive symptoms
(g = −0.29). Even though the improvement was small, it can be of great importance, due
to the fact that a decrease in depressive symptoms and behaviours may reduce or even
prevent self-injury behaviours, as well as suicide attempts and deaths in ED patients [51].
The latter is relevant in both AN and BN, where suicide is one of the most common
causes of death [52,53]. Apart from the use of ER skills, implementation of interpersonal
effectiveness skills that patients are taught in DBT may alternatively explain this result.
The focus of this module is on insufficient psychosocial functioning—an essential element
in the process of treating depression and depressive symptoms—typically not used by
other therapies [54].

4.2. ED Psychopathology
The included studies showed consistent DBT-induced improvements in binge fre-
quency and severity, along with reductions in overall intensity of ED symptoms. This was
confirmed by the largest effect seen in the meta-analysis results in severity of symptoms
(g = −0.83). The subscales of shape, weight and eating concern were improved in the ma-
jority of the studies, implying that DBT may have a specific effect on ED psychopathology.
The restraint scores showed an improvement only in a few studies, causing inconsistencies
in the interpretation. This could be explained by the dissimilarities between DBT interven-
J. Pers. Med. 2021, 11, 931 13 of 20

tions employed in the studies, as some may focus more on mindfulness, leading indirectly
to a higher reduction in the restrictive attitude of the participants [40].
An improvement following DBT was also observed in studies that assessed quality of
life, participants’ relationship with their body-self and appearance, as well as self-esteem.
The mindfulness module taught in DBT may be responsible for improving body acceptance,
by enhancing the present-moment experience and reducing the obsessive thoughts of body-
appearance dissatisfaction [55]. Since increased severity of symptoms can have a serious
impact on everyday life, reduction of ED psychopathology can lead to an increase in the
quality of life in ED [56].

4.3. Body Mass Index (BMI)

When reviewing the existing literature, DBT was associated with no significant im-
provement in BMI in most of the included papers. In the majority of these studies, only post
values were considered and used to assess the effect of DBT, which decreased the robust-
ness of the analysis. Although the meta-analysis revealed a significant large effect on BMI
(MD = −1.93), the findings cannot be extrapolated to all ED patients, since predominantly
BED studies were used in this analysis.
This result was consistent with other research carried out in obese individuals who
did not meet the criteria for BED, where BMI was significantly decreased after DBT [57].
Binge eating has been associated with emotional eating—especially in obese individuals—
whether diagnosed with BED or not [58,59]. Therefore, BMI improvement is expected
following DBT, due to an enhancement in patients’ ER skills and a reduction in binge eating
cycles and the corresponding caloric intake. This highlights DBT’s potentially important
role in reducing obesity rates and other diseases in later life, such as metabolic syndrome,
which BED patients have been associated with [60–63].

4.4. Subgroup Analyses

DBT showed improvements in all outcomes when compared to wait list, whereas
in active therapy studies superiority of DBT transpired only in depressive symptoms.
The lack of an effect in the active therapy group may imply that DBT has similar effects
to the other therapies. Previous studies have shown that CBT was equally beneficial to
behavioural therapies in improving ED symptomatology [64,65]. However, this may be
due to contrasting DBT to a mixture of therapies rather than exclusively to individual
ones. Consequently, future trials should be conducted investigating differences between
DBT and other common therapies in their potential to improve Emotion Regulation (ER).
Increasing the level of singular evidence can facilitate reaching clearer conclusions through
reviews and meta-analyses.
The role of gender on the psychotherapeutic outcomes of DBT may be considered,
since higher effects were seen in studies exclusively consisting of females. Some studies
propose that there are subtle differences in the male ED experience in terms of clinical
presentation and underlying causes. Seeing that females have been the primary focus when
developing treatment models for ED, males may require gender specific adaptations to
existing treatment approaches, as well as to the diagnostic framework and measures of
symptom severity [66,67]. In the current study, the group that also included males was
still predominantly composed of women (∼85%), confirming the underrepresentation of
the male population affected by ED. This can also be due to differences between men and
women in terms of help-seeking attitudes, as well as the use of mental health services [68,69].
Nevertheless, the sample was mixed and not representative, and thus caution must be
taken when interpreting these results.
A notable difference was observed in overall and general Emotion Regulation (ER), as
DBT elicited double the effect in participants with BED. The latter is characterized by higher
impulsivity, which is likely the driving factor underlying rapid avoidance of emotional
experience and resolution [70]. On account of DBT’s key effects in impulsive behaviours,
possible explanations could be acquisition of skills involved in distress tolerance, along with
J. Pers. Med. 2021, 11, 931 14 of 20

awareness of impulsive and emotion-driven behaviours [71,72]. In contrast, depressive

symptoms and binge episodes showed larger effects in miscellaneous ED, groups mainly
composed of BN. Since the sample size was much lower, adequately powered studies are
required to confirm these ED specific differences in the effect of DBT.
Generally, effects were higher in studies that reported ER as a primary outcome than
in those that included it as a secondary or exploratory outcome. Taken together with
the considerable difference in heterogeneity between the corresponding subgroups (i.e.,
considerable heterogeneity in primary studies and negligible in secondary studies), these
results suggest that the pooled estimate in the secondary studies subgroup may be closer
to the true effect. Seeing that the result of an RCT is generally determined by its primary
outcome, detection bias could represent a possible underlying reason for a much more
pronounced effect [73].

4.5. Strengths and Limitations

This is the first systematic review on DBT in ED that includes a meta-analysis and
the first study to provide effects of DBT on ER alongside effects on ED psychopathology
and BMI. Moreover, exclusively including controlled trials allowed the comparison of the
results with a reference group, i.e., excluding uncontrolled trials led to statistically stronger
and more interpretable results [74]. In order to increase the robustness of the analysis and
avoid excluding data that were not calculated or analysed in the original studies (e.g., SD),
a set of statistical adaptations and calculations were conducted. This allowed the collection
of more data, increasing the power of the analysis. Finally, instead of comparing differences
in mean post-treatment values between groups, changes pre- and post-treatment were
analysed. This ensured more robust results, as baseline differences were accounted for.
The current study presented a number of limitations worth reflecting upon. First,
despite funnel plots indicating no risk of publication bias, the assessment was hypothetical
since the figures are based on the non-adjusted analyses. Thus, the strength of the bias
assessment was limited by the insufficient number of studies introduced in the analysis.
Further, no test was conducted to examine asymmetry, and the plots were only inspected
visually. The results were also limited by the moderate quality and considerable hetero-
geneity in the included studies.

Quality of the Included Studies and Heterogeneity

This study scored moderate in the quality assessment, indicating flaws in the method-
ologies of the included publications. The main shortcomings were found in random
sequence generation and allocation concealment, as well as in the blinding of participants,
personnel and outcome assessors. These are especially important because of the subjec-
tive nature of the outcomes, and thus emphasis should be placed on designing study
methodologies that clearly distinguish and report these aspects. Another weakness in the
included studies was the lack of consensus regarding outcome measurement instruments
for Emotion Regulation (ER).
These varied considerably between the studies as different methods of measuring
ER were used. This increases the difficulty of comparing and combining findings in a
systematic review and meta-analysis [75]. While informative, indirect measures are more
difficult to interpret, as the possibility of making cause and effect inferences becomes
more challenging, an issue also highlighted in a previous review on DBT [20]. More
direct measures of affect regulation, such as the Emotion Regulation Questionnaire (ERQ)
and Difficulties in Emotion Regulation Scale (DERS) may represent changes in ER more
accurately [76,77].
Moreover, heterogeneity was considered relatively high, indicating variability in the
study designs and outcome measurements between the studies. In a further exploration
of heterogeneity, the interaction between BMI and age explained the highest proportion
of variance. A lower BMI was associated with a larger effect on Emotion Regulation (ER),
while a younger age was associated with a smaller effect. This indicates a possible optimal
J. Pers. Med. 2021, 11, 931 15 of 20

weight, in addition to an age “window” where DBT may be more suitable. A greater effect
with increasing age suggests that DBT may be more efficient in older populations, thus,
reinforcing a potential association between emotional regulatory changes that occur with
ageing and psychotherapy efficacy. In terms of ER, earlier research has supported that age
is associated with the development of more stable affective experiences [78,79].
Nevertheless, developmental research in psychology has addressed different specific
challenges that arise in psychotherapy with ageing (e.g., vocabulary used in therapy
sessions). Integrating existing literature with the current results may indicate a demand for
adapting DBT to fit the requirements of younger adults with ED.

4.6. Future Directions

Future investigations are necessary to validate the conclusions that are drawn from
this study. First, the efficacy of DBT in emotion regulation should be examined in specific
ED, rather than looking into all ED jointly. This may allow for future comparison between
adapted forms of DBT and better determination of their effectiveness on the corresponding
disorder. Secondly, as previously mentioned, only a few studies that included participants
with BN and AN were available, suggesting that this area is still in its infancy. Therefore,
further research in these two populations is pertinent to determine if there are any discrep-
ancies between different types of ED regarding DBT’s efficacy on emotion dysregulation.
Thirdly, it is recommended to focus on the male population (which is generally underrepre-
sented in the included studies on eating disorders), as well as the adolescent population,
since the existing studies consisted mainly of females, and no relevant study was found
with adolescents.

5. Conclusions
The present results indicate a beneficial effect of DBT on improving emotion dysregu-
lation in ED patients, including depressive symptoms, as well as ED psychopathology and
BMI. However, there are not many studies consistently comparing DBT to active therapy
for ED or investigating other ED than BED. Consequently, further studies are required
to determine the effectiveness of DBT in patients with BN, AN, and OSFED, as well as
research contrasting DBT to known ED therapies, such as CBT and IPT. Additionally, it
would be pertinent to analyse individual factors (e.g., gender, age, and BMI) which can
contribute to the development of ED specific interventions.

Supplementary Materials: The following are available in https://www.mdpi.com/article/10.3390/

jpm11090931/s1: Figures S1–S5. Random effects meta-regressions: BMI, sample size, age, country,
and ED type as predictor/explanatory variable for the observed effect on emotion regulation; Figures
S6–S9. Random effects meta-regression: Combinations of age and BMI; age, BMI, and sample size;
ED type and BMI; BMI, ED type, and age as predictor/explanatory variable for the observed effect on
emotion regulation; Figures S10–S11. Quality assessment: an overview by bias domain and by study,
respectively; Figures S12 and S13. Funnel plot: overall emotion regulation and depressive symptoms;
Table S1. Search terms used in the systematic search; Tables S2–S5. Subgroup analysis results by
comparison, gender, ED type, prioritization of ER, and non-adjusted; Tables S6–S9. Subgroup analysis
results by comparison, gender, ED type, prioritization of ER, and adjusted.
Author Contributions: Conceptualization, J.M.S., N.R.-S. and Ş.D. Formal analysis, N.R.-S. and Ş.D.
Investigation, N.R.-S. and Ş.D. Methodology, J.M.S., N.R.-S. and Ş.D. Project administration, J.M.S.
Supervision, J.M.S. Writing—original draft, N.R.-S. and Ş.D. Writing—review and editing, J.M.S.,
N.R.-S. and Ş.D. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no funding.
Acknowledgments: The authors thank Christian Ritz (University of Southern Denmark (SDU)) for
helping with the methods, especially statistical analysis, as well as for input on the original document
(dissertation).
Conflicts of Interest: The authors declare no conflict of interest.
J. Pers. Med. 2021, 11, 931 16 of 20

Abbreviations
The following abbreviations are used in this manuscript:
ACGT Active Comparison Group Therapy
AN Anorexia Nervosa
BDI Beck Depression inventory
BED Binge Eating Disorder
BES Binge Eating Scale
BMI Body Mass Index
BN Bulimia Nervosa
BPD Borderline Personality Disorder
BTP Behavioural Treatment Plan
CBT Cognitive Behaviour Therapy
CBT-E Enhanced CBT
CI Confidence Interval
DBT Dialectical Behaviour Therapy
DEBQ Dutch Eating Behaviour Questionnaire
DERS Difficulties in Emotion Regulation Scale
DSM The Diagnostic and Statistical Manual of Mental Disorders
ED Eating Disorder(s)
EDE-Q Eating Disorder Examination Questionnaire
EDI-3 Eating Disorder Inventory
EDNOS Eating Disorder Not Otherwise Specified
EDQLS The Eating Disorder Quality of Life Scale
EES Emotional Eating Scale
ER Emotion Regulation
IPT Interpersonal Psychotherapy
MD Mean Difference
NMRS Negative Mood Regulation Scale
OBE Objective Binge Episode(s)
OMI Outcome Measure Instrument(s)
OSFED Other Specified Eating Disorders
PANAS Positive and Negative Affect Schedule
RCT Randomised controlled trial(s)
ROB 2 Risk of Bias
ROBINS-I Risk of Bias in Non-randomised Studies
SCID Structural Clinical Interview for DSM
SCL-90 The Symptom Checklist
SGT Supportive Group Therapy
SD Standard Deviation
TAU Treatment as Usual

Appendix A

Table A1. Overall analysis results—non adjusted.

Outcome DBT (n) Control (n) MD/g 95 CI% p I sq. p for I sq.
Primary ER 345 313 −0.69 [−1.22; −0.16] 0.01 90% <0.00001
Overall ER 1206 1071 −0.46 [−0.67; −0.26] <0.00001 81% <0.00001
General ER 408 368 −0.66 [−1.13; −0.19] 0.006 89% <0.00001
Eating ER 237 209 −0.15 [−0.51; 0.21] 0.41 69% 0.002
Depressive symptoms 588 533 −0.33 [−0.45; −0.20] <0.00001 9% 0.35
Severity of symptoms 221 211 −0.9 [−1.45; −0.34] 0.002 86% <0.00001
OBEs 232 218 −0.27 [−0.45; −0.09] 0.003 85% <0.00001
BMI 204 195 −1.93 [−3.42; −0.44] 0.01 32% 0.2
J. Pers. Med. 2021, 11, 931 17 of 20

Table A2. Overall analysis results—adjusted.

Outcome DBT (n) Control (n) MD/g 95 CI% p I sq. p for I sq.
Overall ER 346 292 −0.42 [−0.68; −0.16] 0.001 53% <0.0001
General ER 317 284 −0.70 [−1.23; −0.18] 0.009 89% <0.00001
Depressive symptoms 286 253 −0.28 [−0.46; −0.11] 0.001 0% 0.93
Severity of symptoms 199 189 −0.83 [−1.33; −0.32] 0.001 80% 0.00001

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