Treating trauma during a severely underweight state in anorexia nervosa patients, a multiple baseline case series study.

The aim of this study is to determine whether treatment of PTSD, in an earlier stage during the treatment of anorexia nervosa or an eating disorder NOS (during severely underweight), leads to a better result of the treatment of the eating disorder. The first phase of treatment of anorexia nervosa and eating disorder NOS in severely underweight, is a phase of recovery. Many people who suffer from underweight find this a difficult phase. A proportion of the people who undergoes this treatment, does not complete the treatment. We assume that this maybe because experiencing emotions (can) change during the phase of weight recovery. This means that more PTSD symptoms can be 'felt' during this period of weight recovery. The current directive indicates that treatment should first be aimed at weight restoration. Thereafter, treatment of trauma will be able to take place. We want to examine if simultaneous treatment of trauma and weight recovery is possible and helps someone better or quicker. If this turns out to be of added value we can adjust the treatment accordingly. In this way, we hope that in the future more people will be better faster.

The primary hypothesis of this study is that it is possible and effective to treat trauma using Imaginary rescripting (IMRS) in reducing trauma-related complaints in severely underweight eating disordered patients.



The secondary hypothesis is that the treatment of trauma has a favorable effect on the process of weight gain and on eating disorder pathology in general.



We also hypothesize that patients will report satisfaction with the treatment of their trauma and the treatment in general, while being severely underweight.



Finally we hypothesize that the therapists experience that it is possible and effective to treat traumas using IMRS with these patients during severely underweight.

During this multiple baseline case series study the participant(s) will be measured between 6 and 11 weeks as a baseline period. Of this baseline period, three weeks are a naturalistic baseline before the start of the inpatient treatment and 3 weeks to 8 weeks constitute the varying baseline period during the inpatient treatment. The exact timing of the intervention will be randomly determined when the patient enters the study, given the abovementioned baseline limits. The treatment phase consists of 6 weeks (with twice-a-week IMRS sessions). The post IMRS treatment phase will be three weeks and after three months the follow-up assessment will be conducted.



During the (naturalistic and randomized) baseline phase, IMRS treatment phase and post IMRS treatment phase, the patient(s) will be measured biweekly for the primary outcome variables VAS and weekly for the primary outcome variable PSS-SR. The same measures will be taken at the 3 month follow-up.



Secondary outcome variables will be measured at a lower frequency: (1) At the start of the naturalistic baseline phase; (2) prior to the start of the IMRS treatment phase; (3) halfway the IMRS treatment phase, i.e. three weeks after the start of IMRS treatment; (4) after completion of the IMRS treatment phase; and (5) at three months post IMRS treatment.



The semi-structured interviews to explore patients’ and therapists’ views on the treatment is scheduled two weeks post IMRS treatment.

The IMRS treatment consists of 12 sessions of 90 minutes, and is conducted by either a health psychologist, psychotherapist, or clinical psychologist. The session frequency is twice a week.
Imagery Rescripting (IMRS) is a psychological treatment (Arntz, 2015; Arntz & Weertman 1999; Raabe et al., 2015; Smucker et al, 1995) which will be given in addition to the regular treatment that patients receive at Amarum. The investigational treatment focuses on changing the meaning of the memories of traumatic experiences by experiencing imagined interventions that correct the dysfunctional emotional and interpersonal meaning attached to the trauma through imagery rescripting. This may temporarily cause affective distress in patients (as do all therapies which focus on working through trauma), yet will help them to overcome their traumatic images and related distress (e.g., flashbacks and nightmares). Patients are fully informed on these effects.