Concurrent Treatment for Patients with Severe Anorexia Nervosa and Post-Traumatic Stress Disorder: A Feasibility Study

Childhood maltreatment is a known risk factor for developing AN, a debilitating
disorder with poor treatment response (Waller, 2016) and high associated
treatment costs (Van den Berg et al., 2022). According to the self-medication
hypothesis AN pathology as starvation serves as a coping mechanism for dealing
with trauma-related intrusive symptoms (Brewerton, 2018). Childhood
maltreatment can also lead to the development of PTSD. Although guidelines
recommend an integrated treatment approach when dealing with AN and PTSD (Ten
Napel et al., 2022), up till now no integrated approaches have been developed
as severely underweight AN patients are not offered trauma treatment. The
present feasibility study is a necessary first step in building high quality
knowledge on an integrated treatment approach for severely underweight patients
with significant important PTSD symptoms.

The primary objective of the study is to determine the feasibility of
concurrent treatment for AN and PTSD. This study aims to determine whether (a)
participants are able to complete the trauma sessions while staying adherent to
the AN inpatient treatment and (b) whether trauma treatment is acceptable for
both participants and AN therapists.

Once this feasibility study indicates that trauma treatment can be completed
while receiving and staying adherent to co-occurring AN treatment, an
integrated AN-PTSD treatment approach can be developed. Next, the longterm
efficacy and cost-effectiveness of such an approach can be examined in a high
quality, sufficiently powered randomized controlled trial.

The study design of this feasibility study is a pre-experimental cohort study.
Due to the 12-months duration of this grant, a limited number of eligible
patients will be available. Therefore, findings on feasibility will be
preliminary and warrant a study design with a longer inclusion period and an
additional follow up period, in order to have sufficient power for findings to
be robust.
The inpatient unit of Novarum consists of 12 beds and serves between 57 and 60
inpatients during a 12-months period, around 80% of hospitalized
inpatients have a AN diagnosis. At Novarum, all AN inpatients have a body mass
index under 17.5 kg/m2.
Assuming a 23% rate of co-occuring PTSD, around 11 patients might be eligible.
We expect 5-10% of inpatients who are not willing to participate (Ten
Napel, 2022). As we aim to examine feasibility of the trauma-focused
intervention within a real-world clinical AN population, minimal exclusion
criteria will be applied. Inclusion is aimed at around 10-11 patients.

When completion rate is equal to or over 60%, it is assumed synchronous trauma
treatment is feasible. Due to the modest number of eligible patients,
statistical findings will not be robust and will be more qualitative by nature.
"The Journal Article Reporting Standards" and the "Strengthening the Reporting
of Observational Studies in Epidemiology"statement will be used for study
design and reporting of the results.

Individual CBT-based trauma-focused treatment (IE) for 8 weeks, twice a week,
will be offered by specialized trauma therapists, during a 12-weeks
hospitalization period for AN in a specialized eating disorder clinic. After
two weeks of hospitalization, trauma treatment will start.
The inpatient AN stay has a duration of 12 weeks and aims at regaining
psychiatric and physical stability in order for outpatient psychotherapy to
start
following hospitalization. During AN hospitalization, interventions are offered
on a voluntary basis by a multidisciplinary group of psychiatrists, medical
doctors, dieticians, nurses, and psychologists.

When participants are processing their trauma through imaginal exposure, they
may experience temporarily increased emotional distress which may present
through increased AN or PTSD symptoms, particularly directly after imaginal
exposure sessions.