59 Dialectical behavior therapy adapted for binge eating compared to cognitive behavior therapy in obese adults with binge eating disorder 3 Introduction Binge eating disorder (BED) is characterized by psychologically distressing, recurrent, brief episodes of uncontrollable overeating (American Psychiatric Association [APA], 2013). It is associated with psychiatric comorbidity, impaired social functioning and impaired physical well-being (Brownley et al., 2016; Welch et al., 2016). An estimated 70% of BED patients have a body mass index (BMI) between 30 and 40, and about 20% have a BMI of 40 or higher (Grucza et al., 2007). While aspects of body-image disturbance are part of the diagnostic criteria for anorexia nervosa and bulimia nervosa, these aspects are not included in the criteria for BED (APA, 2013). Nevertheless, several aspects (e.g. body dissatisfaction and the overvaluation of body shape and weight) have shown to be relevant to BED (Lydecker et al., 2017). Current guidelines recommend cognitive behavior therapy (CBT) as the treatment of choice for BED (Hay et al., 2014; NICE, 2017). The most widely supported form of CBT for BED is based on the transdiagnostic model of eating disorders, suggesting that distinctive eating disorders are maintained by similar mechanisms (Fairburn et al., 2003). Clinical perfectionism, interpersonal difficulties, low self-esteem and mood intolerance are acknowledged to act as maintaining factors in many patients. However, the core CBT-protocol focusses on behavior (i.e. dietary restraint) that is related to the overvaluation of body shape and weight (Fairburn, 2008; Fairburn et al., 2009). Although CBT is quite effective in BED, about 50% do not fully respond to treatment (Linardon, 2018). This may be related to the fact that overvaluation of body shape and weight is only present in a subset of individuals with BED (Grilo, 2013). In addition, dietary restraint seems to be stronger in bulimia nervosa than in BED (ElranBarak et al., 2015; Raymond et al., 2012). Interventions that focus on other maintaining mechanisms may therefore improve abstinence rates. One model of interest is the affect regulation model. It assumes that binge eating is triggered by high levels of negative affect and that binge eating reduces negative affect (Hawkins et al., 1984; Telch et al., 2001). While mixed empirical support has emerged for the second part of this hypothesis (e.g. Abraham & Beumont, 1982; Arnow et al., 1992; Berg et al., 2015; Haedt-Matt & Keel, 2011), the first part has received extensive support from both retrospective studies (e.g. Abraham & Beumont, 1982; Arnow et al., 1992; Vanderlinden et al., 2004), experimental studies (Leehr et al, 2015) and ecological momentary assessment (EMA) studies (Berg et al., 2015; Haedt-Matt & Keel, 2011). Also, greater elevations of negative affect prior to binge eating were found in BED when compared to bulimia nervosa (Haedt-Matt & Keel, 2011). Therefore, interventions that specifically target affect-related difficulties may improve outcome in patients with BED. One treatment that specifically aims to address deficits in affect regulation is dialectical behavior therapy (DBT; Linehan, 1993). DBT, originally developed for patients with
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