139 Summary and general discussion 6 Taken together, several patient characteristics are, more or less consistently, associated with BED treatment outcome. Treatment outcome could possibly be enhanced by addressing these topics in treatment. Discussion Effectiveness In the Introduction (Chapter 1) we argued that dietary restraint and the overvaluation of body shape and weight, two central concepts in the transdiagnostic model of CBT (Fairburn et al., 2003), may not be so central in maintaining binge eating in individuals with BED as they are in individuals with anorexia nervosa (AN) and bulimia nervosa (BN). Instead, binge eating in individuals with BED may be especially triggered by negative affect (e.g. Haedt-Matt & Keel, 2011; Leehr et al., 2015). Besides, emotional eating is associated with other affect-related problems like emotional dysregulation and poor interoceptive awareness (van Strien, 2018). Therefore, we hypothesized that an affect-regulation treatment (i.e. DBT-BED) might lead to better outcome than CBT in individuals with BED in general. In short, this hypothesis was not confirmed by our data (Chapters 3 and 4). The significant differences in effectiveness between CBT+ and DBT-BED were inconsistent over the two studies and fewer in the group that more closely reflected everyday clinical practice, but they consistently favored the more intensive CBT+ over DBT-BED. This could lead us to conclude that DBT-BED should be put aside as an inferior treatment for BED. However, it is of note that the robust and meaningful improvements on both primary and secondary measures in DBT-BED are reached with about half the therapy time of CBT+. That would make DBT-BED more cost-effective. Furthermore, there is reason to assume that differences between treatments may have diminished or disappeared, had we dose-matched the two treatments, since a dose-matched comparison between DBT-BED and CBT-enhanced (CBT-E) in a mixed BN and BED sample did not show any differences in OBE days between treatments at any time point (Chen et al., 2017). In addition, despite the dose-difference, we did not find differences in the longer term when looking at OBE episodes, an important (defining) outcome measure. So, on the one hand, our findings are encouraging for DBT-BED as a candidate for BED-treatment. Concurrently they do not indicate that DBT-BED could lead to better outcome than CBT in individuals with BED in general. In order to provide a more definite answer, future research should include dose-matched comparisons of CBT and DBT-BED. That would also provide an opportunity to look into the question whether the differences found between the two treatments, are related to the intensity of treatment or to specific CBT/DBT elements.
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