13 General introduction 1 The most extensive and empirically validated affect regulation treatment to date, is dialectical behavior therapy (DBT) (Gillespie et al., 2022; Lynch et al., 2007). DBT was originally developed for patients with borderline personality disorder and ongoing self-harm or suicidal behaviors (Linehan, 1993). The treatment is built on the biosocial theory, asserting that a biological tendency toward emotional vulnerability, in combination with an invalidating rearing environment, leads to pervasive emotion dysregulation. Thus, behavioral dysregulation like self-harm, is understood as a natural reaction to environmental reinforcers (Lynch et al., 2007). In the same way, binge eating in BED can be seen as a way to regulate emotions: binge eating is triggered by high levels of negative affect and binge eating reduces negative affect (Hawkins & Clement, 1984; Telch et al., 2001). While the second part of this hypothesis has received mixed empirical support (e.g. Arnow et al., 1992; Berg et al., 2015 and Haedt-Matt & Keel, 2011), the first part has received substantial support from both experimental studies (Leehr et al., 2015), retrospective studies (e.g. Arnow et al., 1992; Vanderlinden et al., 2004), and ecological momentary assessment (EMA) studies (Berg et al., 2015; Haedt-Matt & Keel, 2011). Also, greater elevations of negative affect preceded binge eating in BED when compared to BN (Haedt-Matt & Keel, 2011). Thus, DBT has been adapted for BED (DBT-BED: Safer et al., 2009; Telch et al., 2001). DBT-BED aims to improve adaptive emotion regulation skills, so these can replace binge eating as a way of coping with negative affect. This is done from a ‘dialectical’ stance: validate patients’ current experiences and behaviors and simultaneously stimulate them to change so they can reach their goals. The adaptive skills are taught over three modules: 1) mindfulness (e.g. nonjudgmental observation and moment-to-moment awareness of emotional experiences, thoughts and action urges); 2) emotion regulation (e.g. acting opposite to one’s emotion and ‘ride the wave’ of emotions); and 3) distress tolerance (e.g. radical acceptance and self-soothing) (Safer et al., 2009). Figure 1 depicts a schematic outline of the CBT and the DBT-models of binge eating.
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