83 Dialectical behavior therapy compared to cognitive behavior therapy in binge eating disorder 4 Introduction Dialectical behavior therapy (DBT; Linehan, 1993) is one of the leading treatments for individuals with borderline personality disorder and ongoing self-harm or suicidal behaviors (NICE, 2017). DBT conceptualizes self-injury as a functional, although maladaptive, way to cope with painful emotional states. Based on the affect regulation model (Hawkins & Clement, 1984; Telch et al, 2001) and supported by accumulating empirical evidence linking affect and binge eating (e.g. Abraham & Beumont, 1982; Arnow et al., 1992; Berg et al., 2015; Berg et al., 2017; Haedt-Matt & Keel, 2011; Leehr et al., 2015; Schaefer et al., 2020; Vanderlinden et al., 2004), DBT has been adapted for binge-type eating disorders including bulimia nervosa (BN) and binge eating disorder (BED). This therapy (DBT-BED) teaches adaptive emotion regulation skills in order to replace binge eating as a way of coping with negative affect (Safer et al., 2009; Telch et al., 2001). In a systematic review, Linardon, Fairburn et al. (2017) evaluated seven randomized controlled trials of DBT-BED. While most studies compared DBT to a waitlist or a non-specific supportive psychotherapy, one study (Chen et al., 2017) directly compared DBT-BED to cognitive behavior therapy (CBT), the current treatment of choice for BED recommended by practice guidelines (e.g. Hay et al., 2014; NICE, 2017). Both DBT and CBT were helpful in reducing objective binge eating (OBE) episodes in a mixed BN and BED sample of early weak-responders to guided self-help CBT (n = 67). No differences were found between the two treatments at the end of treatment, six-month follow-up, or 12-month follow-up. Taken together, these data indicate that DBT-based treatments may be a relevant treatment for both BN and BED. However, these highly controlled studies have mostly been conducted in research settings and delivered by the developers of the treatment. In addition, patients who agree to randomization may not be representative of patients in ‘real life’ treatment settings. Thus, whether findings from these efficacy studies generalize to everyday clinical practice has been questioned (Hans & Hiller, 2013; Stewart & Chambless, 2009). In line with this, the importance of conducting effectiveness studies, in which ‘real life’ patients are not randomized to different conditions, has been stressed (e.g. Hans & Hiller, 2013; Linardon, et al., 2018; Seligman, 1995). To date, several effectiveness studies have evaluated the feasibility of group-based DBT-BED (Blood et al., 2020; Chen et al., 2008; Erb et al., 2013; Klein et al., 2012; Mushquash & McMahan, 2015; Telch et al., 2000). All found significant improvements in binge eating at the end of treatment that were maintained during six- to 12-month follow-up (Chen et al., 2008; Erb et al., 2013; Telch et al., 2000). One study included 56 adults with BED (Blood et al., 2020). However, most sample sizes were small, ranging from three to 11 treatment
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