141 Summary and general discussion 6 The difference in dose between the two treatments prevents us from resolving the issue whether differences in outcome are related to specific CBT/DBT elements or to the intensity of treatment. However, despite the dose difference, the decrease in OBE episodes in DBT-BED did not differ from that in CBT+ at FU. So, a treatment without specific attention to a regular and sufficient eating pattern leads to similar drops in OBE episodes as CBT. This is remarkable, given the central role of restraint and its behavioral consequences in CBT. It may suggest that the behavioral consequences of the centrally positioned ‘restraint’ may not be essential to diminish OBE episodes in individuals with BED and obesity. Also, levels of restraint are, as in other obese BED samples (e.g. Anderson et al., 2020; Dounchis et al., 2021), rather low and do not predict or moderate outcome in BED (Chapter 5). This may add to findings that question the importance of restraint in the maintenance of binge eating in BED and suggest that other factors (i.e. interpersonal problems and mood intolerance) may play a more critical role (Dakanalis et al., 2015), especially in individuals with BED and obesity. Higher restraint scores may be more indicative for bulimic dynamics (Carrard et al., 2012; Jordan et al., 2014). Further, in DBT-BED, no attention is being paid to shape/weight-related issues and still, in the non-randomized effectiveness study (Chapter 4), no differences were detected on global eating disorder psychopathology (including shape and weight concerns) at FU. This suggests that improvements might be attributable to therapeutic elements shared across various treatments and not to unique ‘DBT’ or ‘CBT’-interventions. Generally, treatments are described by their unique ‘selling points’: restraint and the overvaluation of body shape and weight in CBT, and emotion regulation in DBT. Thus, it would make sense that we find differences in ‘CBT-related’ and ‘DBT-related’ outcome measures. Looking at the CBT-related EDE-Q global score, made up of the subscales restraint, eating concern, shape concern, and weight concern, this assumption seems confirmed: the detected differences in EDE-Q global outcome favor CBT+ (at FU, Chapter 3, and at EOT, Chapter 4). However, the other way around, no differences between CBT+ and DBT-BED in emotional eating were detected and the decrease in emotional dysregulation was even greater in CBT+ than in DBT-BED (Chapter 3). Apart from discussing the chosen measures, it could be argued that, in CBT+, more emotion regulation skills are trained than explicated. For instance, in CBT, the implementation of a regular and sufficient eating pattern constitutes a fundamental pillar of this approach. It requires e.g. the registration of what is eaten and of related thoughts and emotions. This likely leads to more awareness of inner processes. Attaining a regular and sufficient eating pattern also requires not giving in to the urge to eat in between planned meals. This urge to eat can be triggered by, or related to, several preceding factors: e.g. not having eaten for 5 hours, feeling angry or sad, seeing or smelling tasty food and other environmental cues / be habit-related (come home from work, sit on the couch and watch TV with a bag of chips). This means that, in CBT, patients learn to deal with urges to (over)eat in between meals, irrespective of the
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