Treating eating disorder symptoms with Eye Movement Desensitization and Reprocessing (EMDR)

Several studies show that both adults and adolescents with an eating disorder
have a history of traumatic experiences that can lead to Post-Traumatic Stress
Disorder (PTSD) symptoms(Brewerton et al., 2020; Brewerton et al., 2021;
Ferrell, Russin). & Flint, 2020). However, due to the eating disorder, these
symptoms are not always on the surface. Due to the distraction that the eating
disorder gives and because of the severe underweight of overweight, there can
be a flattening of emotions. In this way, the fears related to the trauma can
also be smoothed out. In addition, binge eating and vomiting may provide a
means of coping to numb or avoid trauma-related feelings. A complicating factor
for the treatment of PTSD complaints is that negative experiences are only
processed if arousal can be experienced (Beer & Hornsveld, 2012). This is often
not the case in people with an eating disorder, the eating disorder and the
PTSD symptoms perpetuate each other and makes the treatment complex. In
addition to PTSD symptoms, many patients have experiences that are not pleasant
and for which they blame themselves, for example experiences in which they have
not been able to stand up for themselves sufficiently. These small trauma
experiences also maintain the eating disorder. In addition to a positive image
of what the eating disorder brings in their lives (like feeling good or worth
something because of the eating disorder) (Fairburn 2013), the bar should
always be higher and more perfect (Fairburn et. al., 2003) and the EMDR-ES
protocol also focuses on these mechanisms.

Body image problems are the most obvious risk factors for the development of an
eating disorder (Stice, 2002), and are central traits in individuals with an ED
(American Psychiatric Association, 2013). Moreover, the chance of relapse is
high if the negative body image problems are not treated or not treated
sufficiently. Without a reduction in the fear of becoming fat and without an
improvement in body perception, criteria for recovery are not met. Various
studies have shown that weight recovery often leads to a more negative body and
self-esteem, so that the patients are motivated to lose weight again (Fennig,
Fennig & Roe, 2002). For sustainable recovery from an eating disorder, paying
specific therapeutic attention to body experience is important.

To recover from the eating disorder, trauma treatment for clients who have had
bad experiences seems a necessary step. This assumption is supported by
suggestions from previous research (Brewerton et al., 2021). Current guideline
treatments for eating disorders, such as Family Based Therapy (FBT) for
Adolescents and Cognitive Behavioural Therapy - Enhanced (CBT-E) (Fairburn,
2008), Maudsley Model of Anorexia Treatment for Adults (MANTRA) (Schmidt et
al., 2020) and Supportive Clinical Management (SSCM) for adults do not
prioritize processing of negative past experiences (Hilbert, Hoek & Schmidt,
2017; Hay et al., 2014; National Steering Committee Multidisciplinary
Development in Mental Health and Care, 2006).Previous research suggests that
trauma treatment through EMDR may contribute to improving this care (Balbo et
al., 2017; Beer & Jacobs, 2021; Bloomgarden, 2008; Pepers & Swart, 2014;
Zaccagnino et al., 2017). In response , Beer (2021) developed the protocol for
EMDR in the treatment of eating disorders (EMDR-ES).

This study will clarify to what extent adding the EMDR protocol in the
treatment of ED will lead to a change in self-reported PTSD symptoms, injured
self-image, clinical perfectionism and negative body perception as underlying
transdiagnostic factors. All four transdiagnostic phenomena will be assessed
every two weeks over a baseline period, during TAU, during EMDR and after the
interventions.
The secondary objective of this study is to examine whether intended changes in
the transdiagnostic factors are positively associated with reduction in ED
symptoms (fears related to food, weight and appearance, urge-driven behaviours
related to food, such as binge eating, fasting or compensatory behaviours
[hyperactivity, vomiting, laxatives]) and to an increase in Body Mass Index
(BMI) after the onset of EMDR therapy comparing to baseline and TAU phase. ED
symptoms will be assessed every two weeks over a baseline period, during TAU,
during EMDR and after the interventions.

A multiple case study will be performed with one group of participants. Various
quantitative measurements (questionnaires and BMI) are performed during 4
phases:
- phase A: Baseline
- phase B: Treatment as usual (TAU)
- phase C: EMDR
- phase D: follow up measurements.

Phase A: Period between start of study and start of TAU: 8 to 14 weeks
Measurements:
- start: personal data, Height, weight, EDI-3, EDE-Q, BAT and PCL-5
- every 2 weeks: weight, BAT, PCL-5 and EDI-3

Phase B: Treatment as usual: Multiple day family therapy (in Dutch:
MeerGezinsDagbehandeling: MGDB), duration 26 weeks.
Measurements:
- start: length, EDE-Q
- every 2 weeks: weight, PCL-5, BAT and EDI-3

Phase C: EMDR-ED: min. 6 and max. 18 sessions of 90 minutes: Duration: max. 18
weeks.
Measurements:
- start: length, EDE-Q
- every 2 weeks: weight, PCL-5, BAT and EDI-3

Phase D: No treatment. Duration: 8 weeks:
Measurements:
- start: length
- every 2 weeks: weight, PCL-5, BAT and EDI-3
- Length and EDE-Q again at last measurement

Participants are first offered the regular treatment: Multi-family day
treatment (MGDB). These treatment is already a regular form of treatment in
mental health care, the effectiveness of which has been established in previous
research.

Following this regular treatment, the subjects will be offered a minimum of 6
and a maximum of 18 sessions of EMDR of 90 minutes. These sessions focus on:
- Incriminating memories of negative past experiences
- Fears related to food, weight and appearance
- Urge-driven behavior related to food, such as binge eating, fasting, or
compensatory behavior (hyperactivity, vomiting, laxatives)
- Negative self image
- Clinical perfectionism
- Negative body perception.
The EMDR therapy in this study will be performed without the use of medical
devices.

There is no risk associated with participating in this study. The regular
treatment is part of the recommended treatments for people with an eating
disorder as described in the guidelines of care for eating disorders. In
addition, practical experience has already been gained with the EMDR-ED
protocol, which has shown that people can benefit from this treatment and that
there are no special risks associated with it.

However, the treatments can be difficult, for example because the subject
starts working with unpleasant memories from the past that he/she may prefer
not to think about anymore. The therapist will support the subject in this as
well as possible so that there are no special risks involved and it can
especially help in recovery.

Participation in the measurements takes time, which can be experienced as a
disadvantage. However, this also has the advantage that it is clearly mapped
out whether and how the treatment helps in recovery.