144 Chapter 6 Our findings regarding depressive symptoms, when assessed with the internationally much used BDI, are inconsistent. Lower depression levels predicted better treatment outcome at both EOT and FU in the combined CBT+ / DBT-BED group (Chapter 5) but not in the CBT+ only group (Chapter 2). This inconsistency may be due to the use of different outcome measures in the two studies: a more general bulimia measure (Chapter 2) versus, more specific, reduction in OBE-episodes from baseline (Chapter 5). Nevertheless, the present findings add to the mixed evidence regarding the predictive value of baseline depression-scores in BED treatment. Interestingly, studies with seemingly lower mean levels of baseline BDI-scores (15,54 – 18.65 - 20.7) (respectively Grilo, Gueorguieva & Pittman, 2021, this thesis Chapter 2, and Dingemans et al., 2007) do not find a significant association, whereas studies with relatively higher mean levels of baseline BDI-scores (23.08 / 22.85 – 26.5) (respectively this thesis Chapter 5, and Dingemans et al., 2020), do find significant associations. Findings more or less coincide with the much used cut-off of 20, which indicates moderate depression (Beck et al., 1996). Although BDI-scores are used to indicate the severity of a person’s depression, and are thus related to the diagnosis of depression, it is not a diagnostic tool. Nevertheless, and in line with the above, absence of unipolar depression at baseline has been associated with full recovery in BED (Castellini et al., 2011). Furthermore, comorbid depression at baseline is significantly associated with higher likelihood of relapse in a meta-analysis in eating disorders in general (Sala et al., 2023). Together, these findings indicate that special attention to raised levels of depressive symptoms, seems justified in the treatment of BED. We recommend that depressive symptoms (BDI-II ≥ 20) should always be of special concern in the treatment plan. Looking broadly at statistically significant results in both studies, one consistent finding appeared: more difficulties in identifying internal sensations (i.e. interoceptive awareness and difficulties identifying feelings) predicted more binge eating problems in the longer term (at six-month FU). This is in line with the only other study we know of, that tested interoceptive awareness (Fichter et al., 2008) as a predictor in eating disorders. So, explicitly addressing difficulties in identifying internal sensations seems to be of importance in BED treatment. Indeed, it fits with our finding that individuals with marked difficulties in identifying feelings tend to have better outcome in DBT-BED than in CBT (Chapter 5). Next to the relevant skills taught in DBT-BED, body-oriented therapies (e.g. psychomotor therapy) could provide specific interventions in this area of affect regulation (Probst et al., 2010). Interestingly, and related to the above, lower baseline emotional eating (i.e. the self-reported desire to eat in response to negative emotions) quite robustly predicted better outcome at FU in the combined CBT+ / DBT-BED group: emotional eating showed a medium effect, while all other significant effects were small. To date, emotional eating
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