71 Dialectical behavior therapy adapted for binge eating compared to cognitive behavior therapy in obese adults with binge eating disorder 3 in favor of CBT+, as all non-significant differences favored CBT+. However, despite the power issues, we did find significant differences between treatments on both primary measures. Also, treatment adherence was lower in CBT+, possibly due to the fact that therapists received no supervision. Since higher adherence levels are related to better outcome (Linardon et al., 2017; Waller, 2009), differences in outcome between the two treatments may even have been bigger had the adherence to the CBT+ protocol been higher. We could have further optimized the assessment of BED pathology by either making use of the Eating Disorder Examination interview (EDE) instead of the EDE-Q (Berg et al., 2012) or by providing a specific definition of binge eating when administering the EDE-Q (as suggested by Celio and colleagues, 2004). In addition, we did not control for content which may have compromised differential effects of both therapies. Finally, allocation was strictly not entirely random. Despite the limitations, the present study has several strengths. To our knowledge, this is the first controlled study in individuals with BED, comparing DBT-BED, previously tested only against a waitlist (Masson et al., 2013; Telch et al., 2001) and an active comparison (Safer et al., 2010), to a CBT-program. This study is therefore a step forward in evaluating the efficacy of DBT-BED. The selection of a subgroup of BED patients (obese BED patients who report an above average urge to eat in response to negative emotions) optimized the chances of DBT-BED to prove itself as a viable alternative to an intensive outpatient CBT program. Further, although dropout rates in DBT-BED (17.1%) were relatively high when compared to Safer and colleagues (2010) (4%), dropout rates in CBT+ (6%) were low when compared to other controlled CBT-treatment studies (e.g. 16.7% to 30% (Peterson et al., 2009; Wilson et al., 2010). Besides that, generalizability was optimized by conducting the study in routine clinical practice, with few exclusion criteria, and making use of various therapist-pairs (which enables us to generalize beyond the present therapist sample). Finally, the follow-up period provides insight in the medium-long term effects of both treatments. In conclusion, the more intensive CBT+ reduced eating disorder related measures and self-esteem more than DBT-BED, even in a population that arguably may be more likely to profit from an emotion regulation intervention. This clearly favors CBT+ above DBT-BED. Yet, when looking at outcome from a different perspective, the data suggest that both groups reached comparable levels of clinically meaningful change in global eating disorder psychopathology. This is particularly interesting given that the DBT-BED program is less time-consuming so less costly than CBT+ as applied in the current study. To be able to fully understand the value of DBT-BED, future research should include dose-matched comparisons of CBT and DBT-BED in a sufficiently powered randomized
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