Bio

Bio


Dr. Debra L. Safer specializes in the treatment of eating and weight disorders. She obtained her MD from the University of California, San Francisco and completed her residency as well as a post-doctoral fellowship in eating disorder intervention research within the Department of Psychiatry & Behavioral Sciences at Stanford University. She has practiced psychiatry for more than 15 years. Dr. Safer is the Co-Director of the Stanford Adult Eating and Weight Disorders Program. Her research and clinical work in eating disorders and obesity focus on improving patient outcomes by developing and conducting clinical intervention trials to establish evidence-based treatments. She has co-authored multiple peer-reviewed articles, books, and book chapters, and presented her work both nationally and internationally. In addition to her research on clinical interventions and medication trials for patients with eating disorders, other research interests include designing interventions for post-bariatric surgery patients, the use of virtual reality in treating eating disorders, and evaluating the outcomes of evidence-based treatments for eating disorders in “real world” settings. More broadly, she is interested in helping efforts to address climate change mitigation with serial dramas (prosocial entertainment-education programs with methodology based on Dr. Albert Bandura's theories of self-efficacy and social modeling).

Clinical Focus


  • Psychiatry

Academic Appointments


Professional Education


  • Fellowship:Stanford University Medical Center (1999) CA
  • Residency:Stanford University Medical Center (1998) CA
  • Board Certification: Psychiatry, American Board of Psychiatry and Neurology (2000)
  • Internship:Stanford University Medical Center (1995) CA
  • Medical Education:UCSF Medical Center (1994) CA

Research & Scholarship

Current Research and Scholarly Interests


Primary research interests include the nature and treatment of eating disorders
(particularly bulimia nervosa and binge eating disorder), the development and treatment of obesity, and the development and treatment of problematic eating patterns in patients following bariatric surgery.

Clinical Trials


  • Adding Guided Self-Help Group Therapy to the Alli Weight Loss Program in Treating Binge Eating Disorder Not Recruiting

    This study will evaluate the effectiveness of adding guided self-help group therapy to a weight loss program in achieving weight loss and reducing binge eating in overweight binge eaters.

    Stanford is currently not accepting patients for this trial.

    View full details

  • Comparing Two Group Therapy Treatments for Binge Eating Disorder Not Recruiting

    This study will compare two different approaches for the treatment for Binge Eating Disorder.

    Stanford is currently not accepting patients for this trial.

    View full details

  • FDA Approved Medication to Reduce Binge Eating and/or Purging Not Recruiting

    This study will demonstrate the efficacy of Qsymia versus placebo in treating bulimia nervosa and binge eating disorder.

    Stanford is currently not accepting patients for this trial. For more information, please contact Debra L Safer, MD, 650-723-7928.

    View full details

Teaching

2018-19 Courses


Publications

All Publications


  • Correlates of Dietary Adherence and Maladaptive Eating Patterns Following Roux-en-Y Bariatric Surgery OBESITY SURGERY Adler, S., Fowler, N., Robinson, A., Salcido, L., Darcy, A., Toyama, H., Safer, D. 2018; 28 (4): 1130–35

    Abstract

    Self-reported poor dietary adherence following bariatric surgery is associated with less successful weight loss outcomes. Poor dietary adherence is a global construct lacking specificity regarding its underlying, clinically targetable, maladaptive eating behaviors.Comprehensive online survey data were obtained from a sample of 274 adults who underwent Roux-en-Y surgery in the prior 1-12 years. Correlations between dietary adherence and six eating-related behaviors were calculated, with the frequency of each behavior reported on a 7-point scale. Linear regression modeling was applied.All six maladaptive eating behaviors were highly correlated with dietary adherence (Pearson's r > 0.5): grazing (r = - 0.565), mindless eating (r = - 0.572), loss of control eating (r = - 0.517), eating "more than is best" after dinner (r = - 0.518), eating foods off of one's plan (r = - 0.557), and "when I eat something off-plan, I feel like I have blown it and I give up and eat more" (r = - 0.574). The estimated regression coefficients in the linear model was statistically significant, [F(5, 261) = 60.006, p < 0.001] and accounted for approximately 54% of the variance of global dietary adherence (R 2 = 0.535, adjusted R 2 = 0.526).Six maladaptive eating behaviors accounted for a highly significant portion of post-Roux-en-Y patients' poor self- reported dietary adherence. Prospective studies are needed to investigate the relationship between targetable maladaptive eating behaviors and bariatric surgery outcomes.

    View details for DOI 10.1007/s11695-017-2987-9

    View details for Web of Science ID 000429032600034

    View details for PubMedID 29076007

  • Study protocol and rationale for a randomized double-blinded crossover trial of phentermine-topiramate ER versus placebo to treat binge eating disorder and bulimia nervosa. Contemporary clinical trials Dalai, S. S., Adler, S., Najarian, T., Safer, D. L. 2018; 64: 173–78

    Abstract

    Bulimia nervosa (BN) and binge eating disorder (BED) are associated with severe psychological and medical consequences. Current therapies are limited, leaving up to 50% of patients symptomatic despite treatment, underscoring the need for additional treatment options. Qsymia, an FDA-approved medication for obesity, combines phentermine and topiramate ER. Topiramate has demonstrated efficacy for both BED and BN, but limited tolerability. Phentermine is FDA-approved for weight loss. A rationale for combined phentermine/topiramate for BED and BN is improved tolerability and efficacy. While a prior case series exploring Qsymia for BED showed promise, randomized studies are needed to evaluate Qsymia's safety and efficacy when re-purposed in eating disorders. We present a study protocol for a Phase I/IIa single-center, prospective, double-blinded, randomized, crossover trial examining safety and preliminary efficacy of Qsymia for BED and BN.Adults with BED (n=15) or BN (n=15) are randomized 1:1 to receive 12weeks Qsymia (phentermine/topiramate ER, 3.75mg/23mg-15mg/92mg) or placebo, followed by 2-weeks washout and 12-weeks crossover, where those on Qsymia receive placebo and vice versa. Subsequently participants receive 8weeks follow-up off study medications. The primary outcome is the number of binge days/week measured by EDE. Secondary outcomes include average number of binge episodes, percentage abstinence from binge eating, and changes in weight/vitals, eating psychopathology, and mood.To our knowledge this is the first randomized, double-blind protocol investigating the safety and efficacy of phentermine/topiramate in BED and BN. We highlight the background and rationale for this study, including the advantages of a crossover design.Clinicaltrials.gov identifier NCT02553824 registered on 9/17/2015. https://clinicaltrials.gov/ct2/show/NCT02553824.

    View details for DOI 10.1016/j.cct.2017.10.007

    View details for PubMedID 29038069

  • A Standardized Preoperative Group Intervention Is Feasible and Acceptable to Orthognathic Surgery Patients. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons Li, X., Safer, D. L., Paz, I. C., Menorca, R., Girod, S. 2017

    Abstract

    PURPOSE: Nearly 10% of patients remain dissatisfied after orthognathic surgery, largely because of psychoeducational or psychosocial factors. The purpose of this study was to evaluate the feasibility and acceptability of a psychoeducationally based group intervention to improve preoperative preparation of orthognathic surgical patients and their caregivers.MATERIALS AND METHODS: The intervention consisted of 2 group sessions, with each session lasting 2hours. The sessions provided realistic expectations of the surgery, offered teaching strategies for coping with pre- and postoperative symptoms of psychopathology, and highlighted the importance of social support. Feasibility was based on attendance, homework completion, and data collection rates, and acceptability was based on post-treatment participant satisfaction scores on the Client Satisfaction Questionnaire-8 (CSQ-8) and credibility and expectancy scores on 2 subscales of the Credibility/Expectancy Questionnaire-Modified (CEQ-M).RESULTS: Twenty-six orthognathic surgical patients were recruited from an outpatient oral and maxillofacial surgery clinic to attend the group-based intervention. Seventy percent of patients who attended at least 1 session completed the 2 sessions, and 64% of those who attended the 2 sessions completed at least 1 homework assignment. The authors successfully collected 84% of the total measures given to patients and their caregivers. The mean satisfaction rating of the patients was 30.12 of 32 (CSQ-8; n=13; standard deviation [SD], 2.33), the mean credibility rating of the patients and their caregivers was 25.2 of 27 (CEQ-M; n=20; SD, 1.85), and the mean expectancy rating of the patients and their caregivers was 20.54 of 27 (CEQ-M; n=20; SD, 4.39).CONCLUSION: The psychoeducationally based group intervention was feasible and acceptable for participants and their caregivers. This article offers suggestions to further improve the feasibility and acceptability of the intervention, including optimizing standardization of data collection procedures, decreasing barriers to access, and increasing participant engagement.

    View details for DOI 10.1016/j.joms.2017.11.025

    View details for PubMedID 29245004

  • Shifts in the Enjoyment of Healthy and Unhealthy Behaviors Affect Short- and Long-Term Postbariatric Weight Loss BARIATRIC SURGICAL PRACTICE AND PATIENT CARE Vuorinen, A., Strahilevitz, M. A., Wansink, B., Safer, D. L. 2017; 12 (1): 35-42
  • Follow-up of selective eaters from childhood to adulthood. Eating behaviors Van Tine, M. L., McNicholas, F., Safer, D. L., Agras, W. S. 2017; 26: 61-65

    Abstract

    The aim of this study was to examine the prevalence and course of selective eating, the stability of its behavioral profile over time, and the presence of eating disorder psychopathology among selective eaters in a non-treatment seeking cohort of young adults followed longitudinally from birth to age 23.A prospective design tracking a subset of the original participants from the Stanford Infant Growth Study (n=216) who had been followed since birth. At age 11, 120 participants had completed all assessments. The current study included a subset of the original participants who, at age 11, had completed all assessments (n=120) and, at age 23, had current contact information available (n=62) and agreed to participate (n=61).Of the 61 young adults, 17 (28%) were identified as selective eaters at age 23. The selective eating-related behaviors reported during adulthood were similar to those endorsed during childhood. New onset selective eating cases were reported during adolescence or young adulthood by 35% of the selective eating sample. Participants who were selective eaters for >6years prior to age 11 remained selective at age 23. There was no evidence of increased eating disorder psychopathology, excessive thinness, or obesity in selective eaters compared with non-selective eaters.These results suggest that a proportion of selective eaters continue from childhood into adulthood with similar eating patterns; new onset selective eating occurs in adolescence or young adulthood; and selective and non-selective eaters at age 23 do not differ with regard to weight or eating psychopathology.

    View details for DOI 10.1016/j.eatbeh.2017.01.003

    View details for PubMedID 28152419

  • Early Adherence Targeted Therapy (EATT) for Postbariatric Maladaptive Eating Behaviors COGNITIVE AND BEHAVIORAL PRACTICE Robinson, A. H., Adler, S., Darcy, A. M., Osipov, L., Safer, D. L. 2016; 23 (4): 548-560
  • Does implicit emotion regulation in binge eating disorder matter? Eating behaviors Robinson, A., Safer, D. L., Austin, J. L., Etkin, A. 2015; 18: 186-191

    Abstract

    To examine if implicit emotion regulation (occurring outside of awareness) is related to binge eating disorder (BED) symptomatology and explicit emotion regulation (occurring within awareness), and can be altered via intervention.Implicit emotion regulation was assessed via the Emotion Conflict Task (ECT) among a group of adults with BED. Study 1 correlated BED symptomatology and explicit emotion regulation with ECT performance at baseline (BL) and after receiving BED treatment (PT). Study 2 generated effect sizes comparing ECT performance at BL and PT with healthy (non-eating disordered) controls (HC).Study 1 yielded significant correlations (p<.05) between both BED symptomatology and explicit emotion regulation with ECT performance. Study 2 found that compared to BL ECT performance, PT shifted (d=-.27), closer to HC. Preliminary results suggest a) BED symptomatology and explicit emotion regulation are associated with ECT performance, and b) PT ECT performance normalized after BED treatment.Implicit emotion regulation may be a BED treatment mechanism because psychotherapy, directly or indirectly, decreased sensitivity to implicit emotional conflict. Further understanding implicit emotion regulation may refine conceptualizations and effective BED treatments.

    View details for DOI 10.1016/j.eatbeh.2015.05.011

    View details for PubMedID 26117164

  • Internet-based preventive intervention for reducing eating disorder risk: A randomized controlled trial comparing guided with unguided self-help BEHAVIOUR RESEARCH AND THERAPY Kass, A. E., Trockel, M., Safer, D. L., Sinton, M. M., Cunning, D., Rizk, M. T., Genkin, B. H., Weisman, H. L., Bailey, J. O., Jacobi, C., Wilfley, D. E., Taylor, C. B. 2014; 63: 90-98
  • What variables are associated with successful weight loss outcomes for bariatric surgery after 1 year? SURGERY FOR OBESITY AND RELATED DISEASES Robinson, A. H., Adler, S., Stevens, H. B., Darcy, A. M., Morton, J. M., Safer, D. L. 2014; 10 (4): 697-704
  • Change in emotion regulation during the course of treatment predicts binge abstinence in guided self-help dialectical behavior therapy for binge eating disorder. Journal of eating disorders Wallace, L. M., Masson, P. C., Safer, D. L., von Ranson, K. M. 2014; 2 (1): 35-?

    Abstract

    Dialectical behavior therapy (DBT), which appears to be an effective treatment for binge eating disorder (BED), focuses on teaching emotion regulation skills. However, the role of improved emotion regulation in predicting treatment outcome in BED is uncertain.This secondary analysis explored whether change in self-reported emotion regulation (as measured by the Difficulties in Emotion Regulation Scale) during treatment was associated with abstinence from binge eating at post-treatment and 4-, 5-, and 6-month follow-up in individuals who received a guided self-help adaptation of DBT for BED. Participants were 60 community-based men and women with BED who received a self-help manual and six 20-minute support phone calls.Greater improvement in self-reported emotion regulation between pre- and post-treatment predicted abstinence from binge eating at post-treatment, 4-, 5-, and 6-month follow-up. However, some follow-up results were no longer significant when imputed data was excluded, suggesting that the effect of emotion regulation on binge abstinence may be strongest at 4-month follow-up but decline across a longer duration of follow-up.This study provides preliminary support for the theoretical role played by improved emotion regulation in achieving binge eating abstinence. If this finding is replicated with larger samples, further research should identify specific techniques to help more individuals to effectively regulate their emotions over a longer duration.

    View details for DOI 10.1186/s40337-014-0035-x

    View details for PubMedID 25516798

  • Do end of treatment assessments predict outcome at follow-up in eating disorders? International journal of eating disorders Lock, J., Agras, W. S., Le Grange, D., Couturier, J., Safer, D., Bryson, S. W. 2013; 46 (8): 771-778

    Abstract

    To examine the predictive value of end of treatment (EOT) outcomes for longer term recovery status.We used signal detection analysis to identify the best predictors of recovery based on outcome at EOT using five different eating disorder samples from randomized clinical treatment trials. We utilized a transdiagnostic definition of recovery that included normalization of weight and eating related psychopathology.Achieving a body weight of 95.2% of expected body weight by EOT is the best predictor of recovery for adolescents with anorexia nervosa (AN). For adults with AN, the most efficient predictor of weight recovery (BMI > 19) was weight gain to greater than 85.8% of ideal body weight. In addition, for adults with AN, the most efficient predictor of psychological recovery was achievement of an eating disorder examination (EDE) weight concerns score below 1.8. The best predictor of recovery for adults with Bulimia Nervosa (BN) was a frequency of compensatory behaviors less than two times a month. For adolescents with BN, abstinence from purging and reduction in the EDE restraint score of more than 3.4 from baseline to EOT were good predictors of recovery. For adults with binge eating disorder, reduction of the Global EDE score to within the normal range (<1.58) was the best predictor of recovery.The relationship between EOT response and recovery remains understudied. Utilizing a transdiagnostic definition of recovery, no uniform predictors were identified across all eating disorder diagnostic groups. © 2013 Wiley Periodicals, Inc. (Int J Eat Disord 2013; 46:771-778).

    View details for DOI 10.1002/eat.22175

    View details for PubMedID 23946139

  • A randomized wait-list controlled pilot study of dialectical behaviour therapy guided self-help for binge eating disorder. Behaviour research and therapy Masson, P. C., von Ranson, K. M., Wallace, L. M., Safer, D. L. 2013; 51 (11): 723-728

    Abstract

    This study examined the efficacy of guided self-help based on dialectical behaviour therapy (DBTgsh) for binge eating disorder (BED). Individuals (88.3% female; mean 42.8 years) were randomized to DBTgsh (n = 30) or wait-list (WL; n = 30). DBTgsh participants received an orientation, DBT manual, and six 20-min support calls over 13 weeks. All participants were assessed pre- and post-treatment using interview and self-report; also, DBTgsh participants were re-assessed six months post-treatment. At treatment end, DBTgsh participants reported significantly fewer past-month binge eating episodes than WL participants (6.0 versus 14.4) and significantly greater rates of abstinence from binge eating (40.0% versus 3.3%). At six-month follow-up, DBTgsh participants reported significantly improved quality of life and reduced ED psychopathology compared to baseline scores. In addition, most improvements in the DBTgsh group were maintained, although binge eating abstinence rates decreased to 30%. These preliminary positive findings indicate that DBTgsh may offer an effective, low-intensity treatment option for BED.

    View details for DOI 10.1016/j.brat.2013.08.001

    View details for PubMedID 24029304

  • Race/Ethnicity, Education, and Treatment Parameters as Moderators and Predictors of Outcome in Binge Eating Disorder JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Thompson-Brenner, H., Franko, D. L., Thompson, D. R., Grilo, C. M., Boisseau, C. L., Roehrig, J. P., Richards, L. K., Bryson, S. W., Bulik, C. M., Crow, S. J., Devlin, M. J., Gorin, A. A., Kristeller, J. L., Masheb, R., Mitchell, J. E., Peterson, C. B., Safer, D. L., Striegel, R. H., Wilfley, D. E., Wilson, G. T. 2013; 81 (4): 710-721

    Abstract

    Objective: Binge eating disorder (BED) is prevalent among individuals from minority racial/ethnic groups and among individuals with lower levels of education, yet the efficacy of psychosocial treatments for these groups has not been examined in adequately powered analyses. This study investigated the relative variance in treatment retention and posttreatment symptom levels accounted for by demographic, clinical, and treatment variables as moderators and predictors of outcome. Method: Data were aggregated from 11 randomized, controlled trials of psychosocial treatments for BED conducted at treatment sites across the United States. Participants were N = 1,073 individuals meeting criteria for BED including n = 946 Caucasian, n = 79 African American, and n = 48 Hispanic/Latino participants. Approximately 86% had some higher education; 85% were female. Multilevel regression analyses examined moderators and predictors of treatment retention, Eating Disorder Examination (EDE) global score, frequency of objective bulimic episodes (OBEs), and OBE remission. Results: Moderator analyses of race/ethnicity and education were nonsignificant. Predictor analyses revealed African Americans were more likely to drop out of treatment than Caucasians, and lower level of education predicted greater posttreatment OBEs. African Americans showed a small but significantly greater reduction in EDE global score relative to Caucasians. Self-help treatment administered in a group showed negative outcomes relative to other treatment types, and longer treatment was associated with better outcome. Conclusions: Observed lower treatment retention among African Americans and lesser treatment effects for individuals with lower levels of educational attainment are serious issues requiring attention. Reduced benefit was observed for shorter treatment length and self-help administered in groups. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

    View details for DOI 10.1037/a0032946

    View details for Web of Science ID 000322353100013

    View details for PubMedID 23647283

  • Group dialectical behavior therapy adapted for obese emotional eaters; a pilot study NUTRICION HOSPITALARIA Roosen, M. A., Safer, D., Adler, S., Cebolla, A., van Strien, T. 2012; 27 (4): 1141-1147

    Abstract

    Dialectical Behavior Therapy (DBT) has been shown to effectively target binge eating disorder (BED). This study pilots the effectiveness of group DBT for obese "emotional eaters" to reduce eating psychopathology and achieve weight maintenance. Thirty-five obese male and female emotional eaters receiving 20 group psychotherapy sessions of DBT adapted for emotional eating were assessed at end-of-treatment and 6 month follow-up for reductions in eating psychopathology and weight maintenance. DBT resulted in significant reductions in emotional eating and other markers of eating psychopathology at the end-of-treatment that were maintained at follow-up. The drop-out rate was very low, with only 1 participant dropping from treatment. Thirty-three (94%) of the sample provided data at every assessment point. Of these, 80% achieved either weight reduction or weight maintenance after treatment and throughout the follow-up period. The effect size for weight reduction was small. This pilot study demonstrates group DBT targeting emotional eating in the obese to be a highly acceptable and effective intervention for reducing eating related psychopathology at both at end-of-treatment and during follow-up. The ability of DBT to limit the upward trajectory of weight gain in obese patients with high degrees of emotional eating suggests that DBT may also help limit the increase or even prevent onset of obesity related morbidity in these patients.

    View details for DOI 10.3305/nh.2012.27.4.5843

    View details for Web of Science ID 000307042300025

    View details for PubMedID 23165554

  • Moderators of dialectical behavior therapy for binge eating disorder: Results from a randomized controlled trial INTERNATIONAL JOURNAL OF EATING DISORDERS Robinson, A. H., Safer, D. L. 2012; 45 (4): 597-602

    Abstract

    Investigate moderators of a randomized clinical trial of group Dialectical Behavior Therapy for Binge Eating Disorder (DBT-BED) compared to an active comparison group control (ACGT) on the post-treatment outcome of binge frequency after twenty 2-h weekly sessions.Moderation analyses.Participants were 101 adults with BED [mean (SD) age, 52.2 (10.6) years and BMI, 36.4 (8.6)]. Analyses identified two moderators of post-treatment outcome. Participants with (1) Avoidant Personality Disorder or (2) an earlier onset of overweight and dieting (<15 years old) evidenced significantly worsened outcome when treated with ACGT versus DBT-BED.Participants with certain indicators of higher baseline pathology respond better to DBT-BED than ACGT at post-treatment.

    View details for DOI 10.1002/eat.20932

    View details for Web of Science ID 000302546500016

    View details for PubMedID 21500238

  • Racial/Ethnic Differences in Adults in Randomized Clinical Trials of Binge Eating Disorder JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY Franko, D. L., Thompson-Brenner, H., Thompson, D. R., Boisseau, C. L., Davis, A., Forbush, K. T., Roehrig, J. P., Bryson, S. W., Bulik, C. M., Crow, S. J., Devlin, M. J., Gorin, A. A., Grilo, C. M., Kristeller, J. L., Masheb, R. M., Mitchell, J. E., Peterson, C. B., Safer, D. L., Striegel, R. H., Wilfley, D. E., Wilson, G. T. 2012; 80 (2): 186-195

    Abstract

    Recent studies suggest that binge eating disorder (BED) is as prevalent among African American and Hispanic Americans as among Caucasian Americans; however, data regarding the characteristics of treatment-seeking individuals from racial and ethnic minority groups are scarce. The purpose of this study was to investigate racial/ethnic differences in demographic characteristics and eating disorder symptoms in participants enrolled in treatment trials for BED.Data from 11 completed randomized, controlled trials were aggregated in a single database, the Clinical Trials of Binge Eating Disorder (CT-BED) database, which included 1,204 Caucasian, 120 African American, and 64 Hispanic participants assessed at baseline. Age, gender, race/ethnicity, education, body mass index (BMI), binge eating frequency, and Eating Disorder Examination (EDE) Restraint, Shape, Weight, and Eating Concern subscale scores were examined.Mixed model analyses indicated that African American participants in BED treatment trials had higher mean BMI than Caucasian participants, and Hispanic participants had significantly greater EDE shape, weight, and eating concerns than Caucasian participants. No racial or ethnic group differences were found on the frequency of binge eating episodes. Observed racial/ethnic differences in BED symptoms were not substantially reduced after adjusting for BMI and education. Comparisons between the CT-BED database and epidemiological data suggest limitations to the generalizability of data from treatment-seeking samples to the BED community population, particularly regarding the population with lower levels of education.Further research is needed to assess alternative demographic, psychological, and culturally specific variables to better understand the diversity of treatment-seeking individuals with BED.

    View details for DOI 10.1037/a0026700

    View details for Web of Science ID 000301882600002

    View details for PubMedID 22201327

    View details for PubMedCentralID PMC3668439

  • Suprathreshold duloxetine for treatment-resistant depression, anorexia nervosa binge-purging type, and obsessive-compulsive disorder: a case report. Innovations in clinical neuroscience Safer, D. L., Arnow, K. D. 2012; 9 (3): 13-16

    Abstract

    Duloxetine, a serotonin norepinephrine reuptake inhibitor (SNRI) indicated for the treatment of depression, is used for off-label purposes such as treatment-resistant obsessive compulsive disorder, bulimia, and binge eating disorder. Although establishing a dose-response relationship for antidepressants in the treatment of depression is difficult, it is possible that for certain patterns of comorbidity, suprathreshold doses may be important to achieve remission. There is currently a paucity of literature regarding the use of suprathreshold doses of duloxetine in treatment refractory cases. This case report describes a clinical situation in which suprathreshold duloxetine was used to treat a patient with severe depression as well as co-morbid anorexia nervosa binge-purging type and obsessive compulsive disorder. One year after the initial increase to 180mg, the patient's mood remains improved. Our clinical account appears to be only the second case report describing the efficacy of high dose 180mg duloxetine in the management of symptoms refractory to treatment at standard doses.

    View details for PubMedID 22567604

  • Does rapid response to two group psychotherapies for binge eating disorder predict abstinence? BEHAVIOUR RESEARCH AND THERAPY Safer, D. L., Joyce, E. E. 2011; 49 (5): 339-345

    Abstract

    Extend understanding of a rapid response (RR) to treatment by examining its prognostic significance at end-of-treatment (EOT) and 1 year follow-up within two group treatments for binge eating disorder (BED): Dialectical Behavior Therapy for BED (DBT-BED) and an active comparison group therapy (ACGT).101 adults with BED randomized to 20-weeks DBT-BED versus ACGT (Safer, Robinson, & Jo, 2010). RR defined as ≥65% reduction in the frequency of days of binge eating by week 4. RR across and within treatment conditions used to predict binge eating abstinence and secondary outcomes (e.g., binge eating pathology, treatment attrition) at EOT and 1 year follow-up.(1) Significantly higher binge eating abstinence for rapid responders (RR; n = 41) vs. non-rapid responders (non-RRs; n = 60) at EOT (70.7% vs. 33.3%) and 1 year follow-up (70.7% vs. 40.0%), respectively, as well as improvement on most secondary measures (2) Significantly less attrition among RRs vs. non-RRs (3) Significantly higher binge eating abstinence rates at both time points for DBT-RRs vs. DBT-non-RRs, but not for ACGT-RRs vs. ACGT-non-RRs.Current study extends prognostic significance of RR to 1 year follow-up. RR more prominent for those randomly assigned to DBT-BED than ACGT. Implications discussed.

    View details for DOI 10.1016/j.brat.2011.03.001

    View details for Web of Science ID 000291180100005

    View details for PubMedID 21459363

  • Appetite-Focused Dialectical Behavior Therapy for the Treatment of Binge Eating with Purging: A Preliminary Trial INTERNATIONAL JOURNAL OF EATING DISORDERS Hill, D. M., Craighead, L. W., Safer, D. L. 2011; 44 (3): 249-261

    Abstract

    This treatment development study investigated the acceptability and efficacy of a modified version of dialectical behavior therapy (DBT) for bulimia nervosa (BN), entitled appetite focused DBT (DBT-AF).Thirty-two women with binge/purge episodes at least one time per week were randomly assigned to 12 weekly sessions of DBT-AF (n = 18) or to a 6-week delayed treatment control (n = 14). Participants completed the EDE interview and self-report measures at baseline, 6 weeks, and posttreatment.Treatment attrition was low, and DBT-AF was rated highly acceptable. At 6 weeks, participants who were receiving DBT-AF reported significantly fewer BN symptoms than controls. At posttest, 26.9% of the 26 individuals who entered treatment (18 initially assigned and 8 from the delayed treatment control) were abstinent from binge/purge episodes for the past month; 61.5% no longer met full or subthreshold criteria for BN. Participants demonstrated a rapid rate of response to treatment and achieved clinically significant change.Results suggest that DBT-AF warrants further investigation as an alternative to DBT or cognitive behavior therapy for BN.

    View details for DOI 10.1002/eat.20812

    View details for Web of Science ID 000288339900009

    View details for PubMedID 20196109

  • Use of Mirtazapine in an Adult with Refractory Anorexia Nervosa and Comorbid Depression: A Case Report INTERNATIONAL JOURNAL OF EATING DISORDERS Safer, D. L., Darcy, A. M., Lock, J. 2011; 44 (2): 178-181

    Abstract

    The objective of this report was to describe an efficacious treatment of an adult with long-standing anorexia nervosa (AN). A 50-year-old woman with an over 7-year history of AN and comorbid major depression had been treated unsuccessfully with numerous psychotropic medications, manualized cognitive behavior therapy, and an intensive outpatient treatment program before referral. After treatment with mirtazapine, she gained weight and her depression improved. A 9-month follow-up revealed a maintenance of these benefits. Mirtazapine may be useful for older, chronically ill patients presenting with AN and comorbid depression.

    View details for DOI 10.1002/eat.20793

    View details for Web of Science ID 000287551500011

    View details for PubMedID 20127940

  • Anorexia Nervosa as a Disorder of Emotion Dysregulation: Theory, Evidence, and Treatment Implications Clinical Psychology: Science and Practice Safer DL, Chen EY 2011; 18: 203-207
  • Outcome From a Randomized Controlled Trial of Group Therapy for Binge Eating Disorder: Comparing Dialectical Behavior Therapy Adapted for Binge Eating to an Active Comparison Group Therapy BEHAVIOR THERAPY Safer, D. L., Robinson, A. H., Jo, B. 2010; 41 (1): 106-120

    Abstract

    Dialectical Behavior Therapy for Binge Eating Disorder (DBT-BED) aims to reduce binge eating by improving adaptive emotion-regulation skills. Preliminary findings have been promising but have only compared DBT-BED to a wait-list. To control for the hypothesized specific effects of DBT-BED, the present study compared DBT-BED to an active comparison group therapy (ACGT). Men and women (n=101) meeting DSM-IV BED research criteria were randomly assigned to 20 group sessions of DBT-BED (n=50) or ACGT (n=51). DBT-BED had a significantly lower dropout rate (4%) than ACGT (33.3%). Linear Mixed Models revealed that posttreatment binge abstinence and reductions in binge frequency were achieved more quickly for DBT-BED than for ACGT (posttreatment abstinence rate=64% for DBT-BED vs. 36% for ACGT) though differences did not persist over the 3-, 6-, and 12-month follow-up assessments (e.g., 12-month follow-up abstinence rate=64% for DBT-BED vs. 56% for ACGT). Secondary outcome measures revealed no sustained impact on emotion regulation. Although both DBT-BED and ACGT reduced binge eating, DBT-BED showed significantly fewer dropouts and greater initial efficacy (e.g., at posttreatment) than ACGT. The lack of differential findings over follow-up suggests that the hypothesized specific effects of DBT-BED do not show long-term impact beyond those attributable to nonspecific common therapeutic factors.

    View details for Web of Science ID 000275349100010

    View details for PubMedID 20171332

  • Outcome from a randomized controlled trial of group therapy for binge eating disorder: Comparing Dialectical Behavior Therapy adapted for binge eating to an active comparison group therapy Behavior Therapy Safer DL, Robinson AH, Jo B 2010; 41 (1): 106
  • A comparison of ethnic groups in the treatment of bulimia nervosa. Eating behaviors Chui, W., Safer, D. L., Bryson, S. W., Agras, W. S., Wilson, G. T. 2007; 8 (4): 485-491

    Abstract

    This exploratory study investigated whether White and ethnic minority bulimic participants differ on key features of eating psychopathology and treatment outcome. Data from a randomized controlled multi-site study comparing the efficacy of either cognitive-behavioral therapy (CBT) or interpersonal therapy (IPT) for 219 women with bulimia nervosa were analyzed. A significant baseline ethnic difference for body mass index (BMI) (p<.001) was found as well as an ethnicity by center interaction for a prior history of depression (p<.05). In addition, there was a significant ethnic difference for the Weight Concerns subscale of the Eating Disorder Examination (EDE). However, once BMI was controlled, this difference did not retain significance. At post-treatment, while all ethnic groups responded with higher abstinence rates to CBT than IPT, an ethnicity by treatment effect was found for the reduction of objective binge eating episodes. Black participants, compared to other groups, showed greater reductions in binge eating episodes when treated with IPT than CBT. Other findings related to secondary outcome measures, though limited by small sample size, are discussed as providing directions for future research.

    View details for PubMedID 17950937

  • The relationship of weight suppression and dietary restraint to binge eating in bulimia nervosa INTERNATIONAL JOURNAL OF EATING DISORDERS Lowe, M. R., Thomas, J. G., Safer, D. L., Butryn, M. L. 2007; 40 (7): 640-644

    Abstract

    Recent research has raised important questions about the relationships between weight suppression (WS) (discrepancy between highest-ever and current weight), dietary restraint, and binge eating in bulimia nervosa (BN).In the current study, these variables were studied cross-sectionally through secondary analyses of baseline data collected in a multi-site treatment study. Participants (N = 182) were treatment-seeking women diagnosed with BN. Dietary restraint and binge eating were measured via the Eating Disorders Examination.WS was directly and dietary restraint was inversely related to frequency of binge eating. The inverse relationship between dietary restraint and binge eating may be explained in part by the fact that the most restrained patients with BN had the greatest desire to lose weight.Implications of these findings for future research on the perpetuation and treatment of BN are discussed.

    View details for DOI 10.1002/eat.20405

    View details for Web of Science ID 000250115100008

    View details for PubMedID 17607698

  • Dialectical behavior therapy modified for adolescent binge eating disorder: A case report COGNITIVE AND BEHAVIORAL PRACTICE Safer, D. L., Lock, J., Couturier, J. L. 2007; 14 (2): 157-167
  • Dialectical Behavior Therapy modified for adolescent binge eating disorder: A case report Cognitive and Behavioral Practice Safer DL, Couturier JL, Lock J 2007; 14: 157-167
  • Designing a control for a behavioral group therapy BEHAVIOR THERAPY Safer, D. L., Hugo, E. M. 2006; 37 (2): 120-130

    Abstract

    To evaluate whether the specific techniques of a newly developed behavioral therapy exceed the effects of its common factors (e.g., therapeutic alliance), an ideal comparison control must omit the unique ingredients of the active treatment while possessing the common factors in equal measure. Reviews of the controlled-trial psychotherapy research literature show that such systematic matching is not a common practice. Addressing this gap between theory and practice, we delineate 7 steps for designing a credible control for a recently developed behavioral therapy adapted for binge eating disorder--dialectical behavior therapy (DBT). Our detailed description of matching the common factors to the extent possible and specifically measuring these offers a useful research design template for investigators of controlled behavioral treatment trials.

    View details for Web of Science ID 000244380800003

    View details for PubMedID 16823465

  • Weight suppression is a robust predictor of outcome in the cognitive-behavioral treatment of bulimia nervosa JOURNAL OF ABNORMAL PSYCHOLOGY Butryn, M. L., Lowe, M. R., Safer, D. L., Agras, W. S. 2006; 115 (1): 62-67

    Abstract

    This study examined weight suppression (difference between highest premorbid weight and pretreatment weight) as a predictor of outcome in 188 outpatients with bulimia nervosa enrolled in a cognitive-behavioral therapy intervention. Participants who dropped out of treatment had significantly higher levels of weight suppression than treatment completers. Of participants who completed treatment, those who continued to engage in binge eating or purging had significantly higher levels of weight suppression than those who were abstinent from bingeing and purging. Results did not change when body mass index, dietary restraint, weight and shape concerns, or other relevant variables were controlled. Relinquishing bulimic behaviors and adopting normal eating patterns may be most feasible for patients who are closest to their highest premorbid weights.

    View details for DOI 10.1037/0021-843X.115.1.62

    View details for Web of Science ID 000236055600007

    View details for PubMedID 16492096

  • Comparing two measures of eating restraint in bulimic women treated with cognitive-behavioral therapy INTERNATIONAL JOURNAL OF EATING DISORDERS Safer, D. L., Agras, W. S., Lowe, M. R., Bryson, S. 2004; 36 (1): 83-88

    Abstract

    To examine changes in dietary restraint patterns revealed by the Eating Disorders Examination Restraint subscale (EDE-R) and the Three-Factor Eating Questionnaire Cognitive Restraint scale (TFEQ-CR) in a large sample of women with bulimia nervosa (BN) who completed 18 weeks of cognitive-behavioral therapy (CBT).Data from 134 subjects were obtained from a larger study and analyzed using repeated-measures analysis of variance (ANOVA).The EDE-R showed statistically and clinically significant decreases post-CBT, whereas the TFEQ-CR did not change significantly.This is the first study to directly compare the EDE-R and TFEQ-CR before and after CBT in the same population. The contrasting results suggest the two measures tap different aspects of the dietary restraint construct. The EDE-R may primarily reflect dieting to lose weight whereas the TFEQ-CR may reflect dieting to avoid weight gain. In assessing changes in dietary restraint targeted by CBT for BN, the TFEQ-CR appears less useful.

    View details for DOI 10.1002/eat.20008

    View details for Web of Science ID 000222053000011

    View details for PubMedID 15185276

  • Women in psychiatric training ACADEMIC PSYCHIATRY Bogar, A. M., Safer, D. L. 2004; 28 (4): 305-309

    View details for Web of Science ID 000226175400010

    View details for PubMedID 15673827

  • Psychological predictors of patient satisfaction with laser skin resurfacing. Archives of facial plastic surgery Koch, R. J., Newman, J. P., Safer, D. L. 2003; 5 (5): 445-446

    View details for PubMedID 12975147

  • Predictors of relapse following successful dialectical behavior therapy for binge eating disorder INTERNATIONAL JOURNAL OF EATING DISORDERS Safer, D. L., Lively, T. J., Telch, C. F., Agras, W. S. 2002; 32 (2): 155-163

    Abstract

    To identify predictors of relapse at 6-month follow-up for women with binge eating disorder (BED).Participants were 32 women with BED who had initially achieved abstinence from binge eating after 20 weeks of dialectical behavior therapy (DBT) adapted for patients with BED. Posttreatment predictor variables included the subscales Restraint, Weight Concerns, and Shape Concerns from the Eating Disorders Examination (EDE), the Emotional Eating Scale score, the Rosenberg Self-Esteem Scale, body mass index, and early versus late age of binge eating onset.The largest effect sizes for predicting relapse were found with early onset of binge eating and higher EDE Restraint scores.Previous findings that earlier age of onset (age 16 years or younger) is linked to less successful treatment outcome are now extended to the 6-month follow-up assessment. The finding that higher restraint scores after treatment predict relapse adds to the literature concerning the role of restraint in patients with BED.

    View details for DOI 10.1002/eat.10080

    View details for Web of Science ID 000177207600004

    View details for PubMedID 12210657

  • Early body mass index and other anthropometric relationships between parents and children INTERNATIONAL JOURNAL OF OBESITY Safer, D. L., Agras, W. S., Bryson, S., Hammer, L. D. 2001; 25 (10): 1532-1536

    Abstract

    To assess longitudinally the relationship between measures of adiposity in children over the first 8 y of life with that of their parents and to explore the role of parental adiposity in the development of childhood adiposity.Longitudinal study of measures of adiposity in children.A community sample from three health service systems including 114 children followed annually from infancy to age 8 and their 228 biological parents.Measurements were assessed at baseline for parents (6 months post-partum for mothers) and at regular intervals for children beginning at age 2 months. Measurements included weight, height, triceps skinfold, subscapular skinfold, midarm circumference, waist and hip.The major findings were: (1) significant correlations between parental body mass index (BMI), both maternal and paternal, and their biological offspring first emerged at age 7; (2) children with two overweight parents had consistently elevated BMI compared to children with either no overweight parents or one overweight parent. These differences became significant beginning at age 7.This study supports the hypothesis that familial factors (biological and/or environmental) affecting the development of adiposity emerge at specific ages and are related to the adiposity of both parents.

    View details for Web of Science ID 000171515800021

    View details for PubMedID 11673777

  • Prolonged bottle feeding in a cohort of children: Does it affect caloric intake and dietary composition? CLINICAL PEDIATRICS Safer, D. L., Bryson, S., Agras, W. S., Hammer, L. D. 2001; 40 (9): 481-487

    Abstract

    Little is known about the consequences to children of bottle feeding prolonged beyond age 1 year on caloric intake and overall dietary composition. To obtain these data, 165 children, followed up from infancy, were assessed in these respects for a 24-hour period at age 3 1/2 years. Bottle-fed children (n = 14) consumed more milk than their weaned counterparts (p < 0.001), had a higher mean daily calcium intake (p < 0.05), received fewer calories from carbohydrates (p = 0.034), and received a greater percentage of calories from protein (p = 0.033). There were no significant differences between the groups in total caloric intake, total iron intake, total volume ofjuice, or calories from fat. Pediatricians questioned about the effects of continuing to offer children nutritive liquids from bottles as well as cups (versus offering cups alone) may inform parents that this feeding practice is associated with significantly greater milk consumption and daily calcium intake. However, this study could not find evidence that prolonged bottle feeding at age 3 1/2 years is associated with a significantly decreased total daily iron intake or an increased risk for factors associated with adiposity such as a greater daily calorie intake, a higher body mass index, or greater percentage of total calories derived from fat.

    View details for Web of Science ID 000171030600002

    View details for PubMedID 11583046

  • Dialectical behavior therapy adapted for bulimia: A case report INTERNATIONAL JOURNAL OF EATING DISORDERS Safer, D. L., Telch, C. F., Agras, W. S. 2001; 30 (1): 101-106

    Abstract

    This case report describes the application of dialectical behavior therapy (DBT) to the treatment of bulimia nervosa in a 20-session manualized therapy.The treatment, based on an affect regulation model of eating disorders, was developed to teach emotion regulation skills to replace eating-disordered behaviors. The patient, a 36-year-old woman, had a long history of binge eating and purging that had not responded to 2 years of counseling. In the 4 weeks before treatment began, she reported 13 objective binges and 21 purging episodes.Upon initiating DBT, her binge eating and purging rapidly declined. She achieved abstinence by the fifth week of treatment and maintained it through treatment. In the 6 months following treatment, she reported a total of two objective binge episodes and two purge episodes.

    View details for Web of Science ID 000169077300011

    View details for PubMedID 11439414

  • Dialectical behavior therapy for bulimia nervosa AMERICAN JOURNAL OF PSYCHIATRY Safer, D. L., Telch, C. F., Agras, W. S. 2001; 158 (4): 632-634

    Abstract

    The effects of dialectical behavior therapy adapted for the treatment of binge/purge behaviors were examined.Thirty-one women (averaging at least one binge/purge episode per week) were randomly assigned to 20 weeks of dialectical behavior therapy or 20 weeks of a waiting-list comparison condition. The manual-based dialectical behavior therapy focused on training in emotion regulation skills.An intent-to-treat analysis showed highly significant decreases in binge/purge behavior with dialectical behavior therapy compared to the waiting-list condition. No significant group differences were found on any of the secondary measures.The use of dialectical behavior therapy adapted for treatment of bulimia nervosa was associated with a promising decrease in binge/purge behaviors.

    View details for Web of Science ID 000167931900018

    View details for PubMedID 11282700

  • Risperidone in the treatment of delusional parasitosis: A case report JOURNAL OF CLINICAL PSYCHOPHARMACOLOGY Safer, D. L., Wenegrat, B., Roth, W. T. 1997; 17 (2): 131-132

    View details for Web of Science ID A1997WQ26500021

    View details for PubMedID 10950485

  • AFFINITY LABELING OF BOVINE LIVER GLUTAMATE-DEHYDROGENASE WITH 8-[(4-BROMO-2,3-DIOXOBUTYL)THIO]ADENOSINE 5'-DIPHOSPHATE AND 5'-TRIPHOSPHATE BIOCHEMISTRY Ozturk, D. H., Safer, D., Colman, R. F. 1990; 29 (30): 7112-7118

    Abstract

    Bovine liver glutamate dehydrogenase reacts with 8-[(4-bromo-2,3-dioxobutyl)thio]adenosine 5'-diphosphate (8-BDB-TA-5'-DP) and 5'-triphosphate (8-BDB-TA-5'-TP) to yield enzyme with about 1 mol of reagent incorporated/mol of enzyme subunit. The modified enzyme is catalytically active but has decreased sensitivity to inhibition by GTP, reduced extent of activation by ADP, and diminished inhibition by high concentrations of NADH. Since modified enzyme, like native glutamate dehydrogenase, reversibly binds more than 1 mol each of ADP and GTP, it is unlikely that 8-BDB-TA-5'-TP reacts directly within either the ADP or GTP regulatory sites. The rate constant for reaction of enzyme exhibits a nonlinear dependence on reagent concentration with KD = 89 microM for 8-BDB-TA-5'-TP and 240 microM for 8-BDB-TA-5'-DP. The ligands ADP and GTP alone and NADH alone produce only small decreases in the rate constant for the reaction of enzyme with 8-BDB-TA-5'-TP, but the combined addition of 5 mM NADH + 200 microM GTP reduces the reaction rate constant more than 10-fold and the reagent incorporation to about 0.1 mol/mol of enzyme subunit. These results suggest that 8-BDB-TA-5'-TP reacts as a nucleotide affinity label in the region of the GTP-dependent NADH regulatory site of bovine liver glutamate dehydrogenase.

    View details for Web of Science ID A1990DR43700024

    View details for PubMedID 2223765