142 Chapter 6 trigger (may it be dieting, emotional dysregulation or an external cue like the smell of food). Patients learn skills like distract oneself, notice and let pass (‘ride the wave’ / ‘surf the urge’), and cognitive restructuring: “I may want to eat but my body does not need it. This sensation may signal something else”. These skills overlap with the skills taught in DBT-BED as emotion regulation skills. So, overall, the effect of the emotion regulation skills taught in DBT may not surpass the effect of similar skills taught in CBT over groups. However, it may for some with certain symptom presentations, i.e. individuals who have high baseline emotional eating or high difficulty identifying feelings (Chapter 5). The latter would be in line with the underlying DBT-model. Another explanation for the limited differences found between treatments could be that different therapies lead to comparable results through different, specific pathways (De Rubeis et al., 2005). Also, common factors, shared across various psychotherapy treatments, could account for the improvements in symptoms over time (Frank, 1961; Wampold, 2015). After all, both CBT+ and DBT-BED provide a plausible rationale for the patient’s symptoms and what can be done about it with specific procedures, within the context of a therapeutic relationship. It is beyond the scope of this thesis to provide directions based on data as we did not specifically assess and test these common factors. Indeed, it is very hard to find out whether therapies work through common and/ or specific factors (Cuijpers et al., 2019). However, some thoughts will be noted here, because findings of a well conducted randomized controlled trial (RCT) in BN suggest that specific treatment factors might matter in binge type eating disorders. Poulsen et al. (2014) compared the effects of two bona fide treatments: two years of weekly psychoanalytic psychotherapy versus 20 sessions of CBT over five months. Findings clearly indicate that CBT was more efficacious than the indirect approach to core bulimic symptoms in psychoanalytic psychotherapy, up until two years after the start of treatment. The authors conclude that directive and behavioral interventions are needed to influence binge eating and purging. It might well be that, when this condition is met, many treatments including CBT and DBT-BED lead to comparable results (this thesis; Chen et al., 2017; Grenon et al., 2018). Whether these results are realized through specific and/or common factors remains unclear (Cuijpers et al., 2019). Moderation The hypothesis, that DBT-BED would result in greater symptom improvement than CBT for patients with more distinct emotion regulation problems at baseline, was partly confirmed. Although emotional dysregulation (EDI-3) did not moderate treatment outcome, baseline levels of emotional eating (DEBQ) and difficulties identifying feelings (TAS) may inform treatment plans. In line with the DBT-model, individuals with high levels tend to have better outcome in DBT-BED. On the other hand, the hypothesis that patients with greater baseline difficulties in areas related to dieting and overvaluation of body
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