136 Chapter 6 Summary and general discussion The aim of this thesis was to improve the effectiveness of treatment for individuals with binge eating disorder (BED). To this end, the effectiveness of an alternative treatment, i.e. dialectical behavior therapy (DBT-BED), was compared to the current first line treatment (cognitive behavior therapy: CBT). Also, variables that predict outcome for DBT-BED and CBT specifically, and variables that predict outcome regardless of treatment type, were identified. In this general discussion, we will first summarize our main findings by means of the research questions formulated in the Introduction (Chapter 1). Subsequently, we will reflect on these main findings in the context of theory and current literature, discuss strengths and limitations of our research, address clinical implications and provide recommendations for future research. Summary of main findings What is the effectiveness of DBT-BED compared to an intensive outpatient group CBT-program (CBT+), based on the manual as developed by Fairburn and colleagues (1993), in a group of individuals with BED who may arguably profit most from an emotion regulation focused intervention? As a prerequisite for the comparison of CBT+ and DBT-BED, we first confirmed the effectiveness of CBT+ in a large group of treatment-seeking individuals with (subthreshold) BED (Chapter 2). Binge eating pathology significantly decreased between the start and the end of treatment (EOT) with a large effect. This was sustained at six-month follow-up (FU). Next, we directly compared CBT+ and DBT-BED. For reasons of feasibility, we did so in a quasi-randomized trial (Chapter 3). From the outset, there was an uneven playing field with DBT-BED encompassing less therapy time than CBT+: 2 hours of face-to-face contact time per week (vs. 3.75 h per week in CBT+), one follow-up session (vs. six for some in the CBT+ group) and no group meetings for patients with a partner. Therefore, we optimized chances for DBT-BED by including only individuals with BED who might be most likely to profit from an emotion regulation intervention: those with obesity and high emotional eating. When looking at outcome, the data suggest that both groups reached comparable levels of clinically meaningful change in global eating disorder psychopathology at both EOT and FU. At the same time findings favored CBT+ over DBT-BED on the number of objective binge eating (OBE) episodes at EOT and on eating disorder psychopathology at FU with a medium effect. On secondary measures, findings also favored CBT+ over DBT-BED on emotional dysregulation and self-esteem at EOT and on self-esteem at FU with a small to medium effect. In short, regardless of the dose-difference, the data suggest that DBT-BED and CBT+ lead to comparable levels of clinically meaningful change in global eating disorder
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