86 Chapter 4 Participants Participants were referred to a Dutch community eating disorder service by their general practitioner or other clinician. After a telephone screen, a licensed psychologist or psychiatrist conducted a clinical interview, resulting in a case formulation and a DSM-5 classification. Both the formulation and the classification were discussed and ascertained in a multidisciplinary team. Individuals with BED (DSM-5: APA, 2013) or with subthreshold BED (those with BED of low frequency and those with subjective binge eating episodes) were eligible for participation in either the DBT-BED group or the CBT+ group. Exclusion criteria for participation were ascertained in the multidisciplinary team: concurrent treatment for BED or for weight problems (but those who had previously undergone bariatric surgery were included), comorbid psychiatric conditions that require immediate attention (e.g. suicidality and acute psychosis), medical conditions that preclude treatment of the eating disorder, conditions that warrant individual rather than group treatment (e.g. intellectual disability, pregnancy), and age below 16. Some patients chose to participate in a quasi-randomized study running at the center over the same period (Lammers et al., 2020) and were excluded from the present study, as were those that reported occasional purging behavior. Figure 1 shows the Consort flow diagram. Treatment Dialectical behavior therapy for binge eating disorder (DBT-BED) A session-by-session, prepublication version of the DBT-BED protocol (Safer et al., 2009) was used (courtesy of C. Telch and D. Safer). The main objective of DBT-BED is to help patients replace binge eating, as a way of coping with negative affect, by adequate emotion regulation skills. Over the course of 20 weeks, 20 sessions of two hours each are delivered in a closed group format; all patients (maximum of nine) start and end together. The first two sessions are devoted to the rationale and goals of therapy and to commitment to change. Both eating disorder specific diary cards and chain analyses, and the concept of therapy-interfering behavior are introduced. In sessions three to 18, adaptive emotion regulation skills are taught over three modules: mindfulness, emotion regulation, and distress tolerance. No specific attention is paid to eating patterns other than education on a balanced eating pattern and regular physical exercise. The two final sessions focus on the review of learned skills and on relapse prevention. In addition, by weekly weighing, patients monitor the consequences of (changes in) their eating behavior. Two trained psychologists / psychotherapists led each treatment-cycle of 20 weeks. Patients were excluded from treatment if they missed more than two sessions. At
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