125 Dialectical behavior therapy and cognitive behavior therapy in individuals with binge eating disorder: what works for whom? 5 Beside the strengths, some limitations must be noted. An important limitation is the fact that CBT+ is a more intensive treatment than DBT-BED: CBT+ offers more face-to-face contact time per treatment day (3.75 h versus 2 h per week in DBT-BED), six follow-up sessions for some compared to one in DBT-BED, and optional group meetings for patients with a partner, where there are none in DBT-BED. This limits the ability to conclude that patients with certain symptom presentations do better in one or the other treatment due to specific treatment characteristics (like addressing the overvaluation of shape and weight on self-esteem in CBT+). The moderator effects favoring CBT+ may merely imply that individuals with certain characteristics do best in an intensive treatment format, with more social interactions and opportunities for support. Others, i.e. those with the highest emotional eating or difficulties in identifying feelings, might respond better in a less intensive format. Another limitation is related to the fact that, in the CBT-model, ‘strict dieting’ is proposed as an important maintaining factor (Fairburn, 2008). The current study may not have used the right measure to operationalize dieting as some evidence suggests that dietary restraint scales are not necessarily valid measures of actual dietary restriction (Stice et al., 2004; 2010). However, others have challenged this conclusion (van Strien et al., 2006), supported by more recent data (Zambrowicz et al., 2019). Moreover, actual restriction of food seems to be significantly lower in BED when compared to AN binge-purge type and BN (Elran-Barak et al., 2015). Next, all variables were assessed with self-report measures. Although validated instruments were used, findings may be limited by self-bias or blind spots. Ecological momentary assessment (EMA) in the week before the start of treatment could provide a more reliable and valid image of the relevant predictor/moderator variables (Engel et al., 2016). Also, internal consistency of both the EDE-Q subscale weight concern and the EDI-3 subscale emotional dysregulation was relatively low (Cronbach’s α = .651 and .618 respectively). This means that we may not have exactly measured what we intended to measure. Therefore future research should include more specific measures of emotional dysregulation (e.g. difficulties in emotion regulation scale (DERS; Gratz & Roemer, 2002 and/or EMA) as well as consider to combine shape and weight subscales, as suggested by others (Peterson et al., 2007; Wade et al., 2008).
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