Journal of Prenatal and Perinatal Psychology and Health 34(5), Fall 2020

A New Perspective on Extreme Recurring Anorexia
and Its Treatment: A Preliminary Study
Heleen Wesselius, Ingeborg Bosch, Lenneke van Hastenberg,
Jessica Simons, Chris Kuiper, and Peer van der Helm
Abstract: There is a need for a new perspective on treatment for adolescents and
adults with extreme recurring anorexia, underlying prenatal and perinatal
trauma, early childhood trauma (or Adverse Childhood Experiences), and complex
multi-problems. Current evidence-based therapies are successful with 66% of
patients suffering from anorexia with a BMI higher than 17.5. An approach is
suggested that regards the eating disorder as a coping strategy for underlying
emotional pain. We advocate this approach, which is based on principles like those
from CBT, the Self-Determination Theory, and trauma therapy: Past Reality
Integration (PRI). The following initial results of a PRI pilot study with 13 clients
appear promising.
Keywords: severe/extreme recurring anorexia, prenatal and perinatal trauma,
early childhood trauma, Adverse Childhood Experiences (ACES), Past Reality
Integration

Anorexia Nervosa is a multifaceted, multidimensional problem. The
current DSM-5 criteria (American Psychiatric Association, 2014) are
described in Box 1. Severe/extreme recurring anorexia is characterized by
an individual being underweight with a very low Quetelet’s body mass
index (BMI) of approximately < 17.5 kg/M2 (Lay et al., 2002).
Heleen Wesselius is a PhD student at Amsterdam University: heleen_wesselius@hotmail.com.
Ingeborg Bosch is a Psychologist, PRI therapist, and author: ingeborg.bosch@prionline.nl.
Lenneke van Hastenberg is a Psychologist and PRI therapist: lvhastenberg@prionline.nl.
Jessica Simons is a Doctor of Clinical Psychology and an Eating Disorder practitioner:
drjessicasimons@gmail.com. Chris Kuiper is a Professor of Transformation in Youth Care,
Leiden University of Applied Sciences, Leiden, The Netherlands, Horizon Youth Care and Special
Education, Rotterdam, The Netherlands. Corresponding address: Leiden University of Applied
Sciences, Leiden, Zernickedreef 11, 2300 AJ Leiden: kuiper.c@hsleiden.nl. Peer van der Helm
is a Professor of Residential Youth Care, Leiden University of Applied Sciences, Leiden, a
researcher at Amsterdam University, and Research Director at Fier National Centre of sexually
abused children. Corresponding author: Peer van der Helm: helm.vd.p@hsleiden.nl.

1
© 2020 Association for Pre-and Perinatal Psychology and Health

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Various personal characteristics play a role in the development and
maintenance of anorexia, including biological, psychological, and social
aspects (Engel, 1977).

Causal mechanisms can be explained in terms of the vulnerability-stress
model (Graham et. al., 2018; Guerry & Prinstein, 2010). According to
Woods-Jaeger et al. (2018), “toxic stress” impairs nervous system
development and growth in parts of the brain responsible for planning,
problem-solving, and self-regulation of emotions and behaviors. A review
by Raevuori, Linna, and Keski‐Rahkonen (2014) showed small effects of
prenatal and perinatal trauma on eating disorders. However, a recent
study of 1,167,043 subjects who experienced premature birth found more
robust relations with eating disorders (Larsen et al., 2020).
First of all, there is a broad consensus about biological aspects such as
a genetic vulnerability and pre- and perinatal trauma (Attia, 2010; Bulik
et al., 2016; Kaye, 2008; Keel & Klump, 2003; Sherag, 1968). Sherag
(1968) showed that genes on chromosomes 3 and 4 determine an anorectic
predisposition. Anorexia affects the functioning of the hypothalamus. This
part of the brain plays a role in saturation and energy management.
During anorexia, this energy management becomes too tightly adjusted
(Delfos 2011; Swaab, 2004). Pre- and perinatal problems also play an
important role, which can form an early trauma and lay the foundation
for lagging social-emotional development, anxiety, and negative
emotionality (Favaro et al., 2006; Graham et al. 2018; Wolf & Baglivio,
2017; Van der Helm, 2020).
On the psychological side, according to Kaye (2008), young people with
anorexia due to pre- and perinatal trauma, Adverse Childhood
Experiences (ACES), and anxiety, already have perfectionist and
obsessive-compulsive personality traits before revealing anorexia. These
characteristics may be reinforced by the performance society, in which

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individual performance is linked to dignity (Swierstra & Tonkens, 2008;
Young, 1994/1958). Research by the National Institute for Public Health
and Environment (RIVM), Trimbos, and Amsterdam Utrecht Medical
Center shows that internalizing problems among young people have
increased in the past years as a result of pressure to perform at school and
in society (Elchardus, 2012; Schoemaker et al., 2019). There is agreement
among professionals that anxiety plays a major role in the development
and maintenance of anorexia (Delfos, 2011; Godart et al., 2000; Kaye et
al., 2004). In addition to the fear of food, fear is often more encompassing.
In the study by Godart and colleagues (2000), 83% of respondents with
anorexia had at least one form of anxiety disorder in their life.
Social causes and social sustaining factors in anorexia can vary and
form the basis for the general fear that will eventually be “projected” on
to eating (Van der Helm, 2020; Van der Kolk, 2017). The social factors and
physical consequences seem to be more serious in the group of patients
who are faced with readmissions (Lay et al., 2002).
People with eating disorders suffer more often than average from preand perinatal problems, attachment problems, low self-management, less
recognition of emotions in themselves and others, the avoidance of facial
expressions of others, a negative self-evaluation, and sensitivity to social
dominance (Caglar-Nazali et al., 2014).
Severe/Extreme Recurring Anorexia:
An Eating Disorder Coexisting with Underlying Early Trauma
In this article we will speak about both severe and extreme cases of
anorexia (BMI<15). Severe/extreme anorexia often coexists with pre- and
perinatal trauma, early childhood trauma or ACES, and complex multiproblems like self-harm and suicide. It also tends to be a recurring
phenomenon. Characteristics for severe anorexia are currently defined by
Body Mass Index (see Box 2).

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Journal of Prenatal and Perinatal Psychology and Health

Anorexia has the highest mortality risk of all psychiatric illnesses.
The mortality rate ranges from 10% to 20% and the longer someone has
suffered from anorexia, the greater the risk of death (Hoek, 2006; Keel et
al., 2003). The actual mortality rate is higher, because death from
anorexia is not always registered as such, but as suicide or some other
physical disorder such as serious intestinal problems and heart failure at
an early age as a result of permanent sympathetic activation and stress
(Van der Helm, 2020). Only 46% of patients recover from anorexia
according to the current criteria; one third of patients improve with partial
features of anorexia, and 20% become chronically ill (Arcelus et al., 2011;
Steinhausen, 2009). The mental suffering from anorexia does not
automatically diminish as weight increases (Delfos, 2011). Programs
aimed at prevention of eating disorders for this BMI < 17.5 are not yet
very effective (Covorve Fingeret et al., 2006).
When pre- and perinatal trauma, early childhood trauma, or ACEs
have occurred in a young person’s life, their condition often worsens (Van
der Helm, 2020). As children develop into early adolescence, societal
pressures to perform at school mount and they also compare themselves
with their peers (Juvonen et al., 2000). Furthermore, their developmental
social-emotional delays and fears make them vulnerable to harassment
and victimization. As a consequence, internalizing problems or negative
emotionality (Wolf & Baglivio, 2017) continue to increase.
Smolak & Murnen (2002) found in their meta-analysis a small, but
significant relationship between eating disorders and childhood sexual
abuse. Van der Kolk (2014, 2017) makes a connection between childhood
sexual abuse, Post Traumatic Stress Disorder (PTSD), and eating
problems. This can be aggravated by frequent revictimization in
adolescence. Dramatic events such as early neglect and abuse that
children cannot control, frustrate their natural fight and flight responses.
This often leads to PTSD, upsets people’s self-image and frustrates the
satisfaction of their basic needs such as connectedness, competence, and
autonomy according to Self Determination Theory (Ryan & Deci, 2017;
Van der Helm, 2020).
Also, trauma makes one vulnerable to repetition and re-enactment of
trauma (De Keijser, et al., 2018; Van der Kolk, 2017). This results in
further aggravation of internalizing problems and eventually the
development of PTSD (Van der Helm, 2020). The self-image of young
people with anorexia is often low (Noordenbos & Ten Napel, 2017). They
often speak of a negative, inner voice—the inner critic (Noordenbos & Ten
Napel, 2017). Children “self-silence,” or remain silent about what
happened to them (Van der Helm, 2020), relive their fears and trauma,
and are therefore “stranded in their past” (Van der Helm, 2020; Van der
Kolk, 2014). To perpetuate their world view, they put themselves in risky

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5

situations and repeat their trauma (Van der Kolk, 2020). Therefore, there
appears to be a high risk of revictimization, especially in cases of sexual
abuse, self-harm, and suicide (Preti et al., 2011; Van der Helm, 2020). A
review by Papadopoulos et al. (2009) among 6009 women treated for
anorexia, shows that suicide is twice as likely to be the cause of death as
the medical consequences of the disease itself.
People with severe/extreme recurring anorexia are often
institutionalized, sometimes under mandated treatment in secure facilities.
Repression and coercion in institutions clashes with the client’s need for
control and increases this need for control, so that automatic negative
thoughts about food are strengthened rather than decreased (Hachtel et al.,
2019; Treasure et al., 2011; Van der Helm, 2020). This can be seen as a coping
mechanism, rather than a lack of motivation or mental instability.
Another Perspective: Severe (Extreme) Recurring Anorexia
as a Coping Mechanism for Trauma and ACEs
Anorexia could be seen as a form of coping in young people with preand perinatal trauma, early childhood trauma, and/or ACEs to deal with
this underlying mental suffering. Young people and adults often speak of
an internalized voice that yells at them (Van der Helm, 2020). The inner
critic is temporarily silenced by basing personal feelings of confidence on
weight loss (Noordenbos & Ten Napel, 2017). Deci and Ryan (2008) refer
to this as “internalized controlled regulation.” One’s focus on controlling
their body gives a goal, a sense of security, and temporarily removes the
perceived powerlessness (Vansteenkiste et al., 2005). Severe/extreme
anorexia could be seen as a defense mechanism in order not to have to feel
the weight of pre- and perinatal trauma, ACEs, and pain from the past;
personal needs are neglected in this process (Bosch, 2003; Van der Helm,
2020). Part of dealing with traumatic events from the past can be cutting
off feelings of contact with one’s own body (alexithymia, derealization, and
dissociation), a common mechanism in PTSD. The victim places a
partition between head and body and switches off the feeling as a means
of survival (Van der Kolk, 2014). Anorexia and PTSD multi-problems show
therefore the same mechanism; the body is treated as an object to be
checked in the absence of other control options (Vansteenkiste et al., 2005).
Long-term recovery is therefore more than (temporary) weight gain.
Current Recovery Criteria and Treatment
When a person has reached a healthy weight, behavior and cognition
are often still determined by anorexia (Wesselius, 2018), but the label
anorexia is officially dropped (American Psychiatric Association, 2014).

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Journal of Prenatal and Perinatal Psychology and Health

DSM-5 diagnoses only indicate when a patient falls into a certain
category, but not what the criteria for recovery are. Recovery in the DSM5 is therefore formulated negatively, namely as the absence of disease
criteria (underweight). Scientific research to map the outcomes of clinical
treatments for severe/extreme anorexia often measure a change in disease
symptoms, especially the physical ones (De Vos et al., 2017). The mere
recovery of the physical symptoms should not be regarded as recovery,
because even after the symptoms have disappeared, anorexia and fear of
food can still determine life (Delfos, 2011), resulting in frequent relapses,
and sometimes yo-yo effects with overeating, possibly combined with
vomiting. Usually a period of restrictive food intake follows. And often a
variety of other compulsive complaints, such as self-harm, are
strengthened. The overall quality of life of people with extreme or
severe/extreme anorexia is significantly lower than that of people without
anorexia (Winkler et al., 2014). From a positive health point of view,
recovery from a disease is therefore not just the absence of disease
symptoms, but the ability to adapt and be flexible in three health areas,
namely physical, mental, and social. If we develop a new way of looking at
severe/extreme anorexia and its treatment, we therefore will have to define
new criteria for recovery and base these criteria on this broad vision.
People who have recovered from anorexia speak retroactively about
the great mental burden of their illness and how their anorexia
symbolized, among other things, the suppression of feelings, pain, and a
great need for autonomy (De Vos et al., 2017). Current literature has an
emphasis on the somatic side of anorexia (Zipfel et al., 2006; Hearing,
2004; Stanga et al., 2008). Standard residential treatments for
adolescents with anorexia are strongly medically-oriented. The treatment
guideline prescribes structured meals under supervision and (possibly)
cognitive behavioral therapies after weight recovery (Quality Standard
Eating Disorders NICE, 2018).
A group of adolescents often does not recover within the current
programs of residential treatment. Traumatizing readmissions and
transfers are common in adolescents with anorexia. Steinhausen and
colleagues (2008) have followed 212 adolescents with anorexia from their
first clinical admission. They conclude that 44.8% needed at least one
readmission. The question therefore arises whether a mainly medical
approach, often focused unilaterally on returning to a normal BMI and
diet, is sufficient and what good alternatives could be. It is striking that a
group that was considered “recovered” according to clinical standards
after discharge often returns to residential settings after a while. The care
standard writes about “relapse” after somatic stabilization (Berends et al.,
2010; Care standard eating disorders, 2017).

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7

De Vos et al. (2017) have investigated how recovered adults view eating
disorder recovery. They found that adults who recover from an eating
disorder consider psychological well-being as a central criterion for eating
disorder recovery. A recommendation from this qualitative meta-analysis is
to include precisely this mental dimension in follow-up research into eating
disorders, in particular in evaluation studies of treatments.
So, recovery criteria are ambiguous. Public administration speaks of
“wicked problems” (Head & Alford, 2015). This is in line with current
thinking about recovery from mental illness in general (Dings, 2020).
These problems cannot be solved by routine or protocol because their
origins are complex and often situated in early childhood, including the
pre- and perinatal time, and continue to accumulate. However, it appears
that routine is still a frequently-used steering mechanism in youth care,
as De Valk’s dissertation (2019) shows: the more complex the symptons,
the more controllling and coercive the treatment.
Current Treatment: Direct and Indirect Coercion
Clinical treatment for severe and extreme anorexia is unfortunately
(for patients and staff involved) still largely based on behavioral control.
Perhaps this is because there is a gap in evidence-based treatment options
for adults with anorexia and a BMI of less than 17.5 (Brennan, 2020). The
current treatment paradigm focuses primarily on physical survival.
Behavioral control in treatment can lead to an external locus of control
orientation and introjected motivation and is therefore similar to methods
aimed at weight gain (Van der Helm, 2020). Supporting autonomy (as
advised by the Self Determination Therapy) and restoring “normal life”
(connectedness, competence and autonomy) is crucial for long-term
recovery (Vansteenkiste & Soenens, 2015). Current treatments that limit
autonomy can therefore be re-traumatizing for young people with
anorexia and underlying trauma because of rekindling PTSD and fear. In
the best interest of the patients, alternative treatments will be identified
and examined.
Treatments based on taking over control appear to work temporarily
when it comes to weight recovery (Le Grange et al., 2014), but have shown to
have an opposite effect in the long run (Vansteenkiste et al., 2005). In people
with (underlying) trauma, the loss of control can have a re-traumatizing effect
(Rusell, 2001; Treasure et al., 2011; Van der Kolk, 2014).
Force-feeding can reinforce food avoidance and diminishes intrinsic
motivation. Not (or barely) addressing common thinking patterns in
anorexia, such as old pain, low self-esteem, and perfectionism combined
with a decline in control can enhance existing eating disorder behaviors
(Treasure et al., 2011).

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Journal of Prenatal and Perinatal Psychology and Health

A meta-analysis by Bornstein (2001) shows that there is a statistically
significant connection between interpersonal dependence and eating
disorder symptoms. By taking away control, the young person develops an
external locus of control. He or she feels powerless, feelings of anxiety and
PTSD increase, motivation decreases, and self-image continues to decline
(Treasure et al., 2011; Van der Kolk, 2014). Developing an internal locus
of control is crucial in order to be able to recover and develop intrinsic
motivation (Vansteenkiste et al., 2005). This requires an autonomysupporting living environment (Ryan & Deci, 2000; Van der Helm, 2020;
Vansteenkiste et al., 2005).
Treatments based on coercion appear to be a reaction to the severity
of the eating disorder symptoms and a subsequent perceived need to
medically intervene to save the patient’s life. Also coercion is more
commonly applied with patients that suffer from higher co-morbidity,
multiple admissions, longer disease duration, self-mutilation, and
suicidality (Clausen & Jones, 2014).
In addition, coercion is not limited to apparently medical
interventions such as fixating, forced medication, and forced re-feeding,
but is used throughout the entire treatment system and can turn into
repression as a result of professional helplessness (de Valk, 2019; Neuvel,
2019; Rusell, 2001; Van der Helm, 2020; Wesselius, 2018). This can
include restrictions on freedom of movement, maintaining an eating list
and compliance with eating rules, rest rules, and rules for visiting the
toilet, or humiliation of patients (Neuvel, 2019). Several factors, like loss
of control, despair, and a feeling of not been heard appear to play a role in
the resistance of anorexic patients to compulsive treatment apart from the
fear of weight gain (Rusell, 2001). The consequences can be severe. Five
years after forced admission, mortality appears to be higher than in
patients without forced admission. This difference in mortality does not
level out for twenty years (Ward et al., 2015). Therefore, a different
approach is needed.
Towards a Different Approach
With pre- and perinatal trauma, early childhood trauma, ACEs, and
PTSD, a family environment aimed at relatedness, competence, and
autonomy promotes recovery (Judd et al., 2020; Van der Helm, 2020),
while an approach aimed at restriction of freedom and coercion threatens
recovery in the long term (Van der Kolk, 2017; Vansteenkiste & Soenens,
2015). Motivation and living environment quality have a direct link (Judd
et al., 2020; Ryan & Deci, 2017; Van der Helm, 2020; Vansteenkiste &
Soenens, 2015). The more the universal needs of autonomy, competence
and relatedness are met, the more people become intrinsically motivated

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9

(Ryan & Deci, 2017). Working on self-management in combination with
meaningfulness determines recovery from psychological vulnerabilities
(Dings, 2020; Van Os, 2014).
A positive living climate appears to form an essential basis for
treatment. Treatment as such appears to be more decisive for the
treatment result than the method used. After creating a healthy living
environment, it is critical to perform a thorough function and meaning
analysis of disordered eating behavior (Van der Helm, 2020). It is
important to understand the exact moment of onset of the anorexia, what
subconscious trauma the patient is avoiding to feel through the eating
disorder, and which learned factors from the past maintain the anorexia.
It is therefore important to treat pre- and perinatal trauma, early
childhood trauma, ACEs, and PTSD as soon as possible to avoid further
stress sensitization (Bremner, 2006). When the system plays a causal or
persistent role, it is important to work with the system as well.
Enhanced Cognitive Behavior Therapy (CBT-E) is most effectively
used for those with a BMI>17.5 (Eating disorders care standard, 2017). In
adolescents with severe/extreme recurring anorexia and underlying
trauma, CBT-E alone is not particularly effective (Van der Kolk, 2020).
Trauma responses from the past may interfere with the effectiveness of
CBT (Van der Kolk, 2017). Therefore, a suitable therapy must integrate
early pre- and perinatal trauma, childhood trauma, ACEs, and PTSD from
the past, with the present situation in order to overcome being “stranded
in the past.” Also, the use of body-oriented methods such as yoga,
mindfulness, theater, and focusing have proven effective in trauma
integration (Van der Kolk, 2017). The use of an assistance dog, for
example, can also be effective in PTSD and there is increasing scientific
support for the efficacy of equine therapy for people with anorexia and
trauma (Cumella & Simpson, 2007; Earles et al., 2015).
As an example of a promising therapy for adolescents and adults with
severe/extreme recurring anorexia that integrates past trauma and the
present, combined with the normalization of existence (connectedness,
competence, and autonomy), a possible alternative to the current medical
model could be a therapy that is called Past Reality Integration (PRI).
Past Reality Integration (PRI)
PRI can be compared to a functional (past) and meaning (present)
analysis from behavioral therapy. It is a specific combination of principles
like those of trauma therapy and CBT. PRI can also be seen as a
combination of principles like those of CBT and psychodynamic treatment
(Sliedregt, 2019). The efficacy of both client-centered psychodynamic
therapy and CBT is scientifically substantiated (Abbass et al., 2014;

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Journal of Prenatal and Perinatal Psychology and Health

Draijer & Langeland, 2017; Driessen et al., 2015; Hunot et al., 2013;
Kivlighan et al., 2015; Leichsenring & Rabung, 2011; Lilliengren et al.,
2016; Öst, 2008). PRI integrates such interventions in a specific way.
Work is being done on cognitions and behavior in the present, but with a
link to its origins—the origins seen in pre- and perinatal trauma, early
childhood trauma, ACEs, and the various defense mechanisms that have
evolved from those origins (Sliedregt, 2019). Children who experience
trauma are in a dependent position and need to develop survival
strategies in response to these painful experiences (Sliedregt, 2019). When
direct action is impossible, conditioned fear, negative thoughts about the
self (Kaufman & Crowell, 2018) and negative emotionality develop.
Defense mechanisms can consist of predominantly more internalizing
or more externalizing behavior (Sliedregt, 2019). Large-scale research by
Wolf & Baglivio (2017) show that externalizing behavior hides pain and
negative emotionality (Anglin, 2002). If underlying trauma is not
addressed, further stress sensitization arises (Bremner, 2006). These
responses to stress are a functional survival strategy when growing up
(Bosch, 2003). In PRI, triggers reflecting early childhood trauma are
perceived in daily life and as such disconnected from the traumas of the
past. With the help of the therapist (and later by her/himself) the client
can recognize the triggering reactions and adequately neutralize them. In
this way the client learns to see the present-day situation for what it truly
is, when the charge of the childhood trauma has been disconnected from
the perception of the present. For example, food intake can again be seen
as a non-threatening and possibly even pleasant activity.
It is important in PRI that the therapist makes a clear distinction
between primary and secondary pain by the therapist. Primary pain is the
initial pain arising from pre- and perinatal trauma, early childhood
trauma, and ACEs. Secondary pain is conditioned behavior arising from
the defense mechanism. Feeling through secondary pain in the hope of
recovery, is actually strengthening the conditioning or defense mechanism
and therefore is harmful. Recognizing this and anticipating it requires
adequate training of the therapist. The first results of this method are
promising as this preliminary study shows.
Methods
Respondents
The convenience sample consisted of 13 female respondents. Almost
all respondents were young adults; 12 respondents were between 14 and
30 years old. The majority were adolescents, since eight respondents were
between 14 and 23 years old. All had severe or extreme recurring anorexia

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11

at the start of treatment, given their BMI, the score on the Eating
Disorder Examination Questionnaire (EDE-Q; Fairburn & Cooper, 1993),
and their long-term treatment history. The respondents’ mean BMI at
baseline was 15.3 and their average EDE-Q scores were 5.1, with 6
representing very extreme eating disorder symptoms and 1.5 representing
no eating disorder symptoms.
The convenience sample was selected “through a network of failed
treatment.” All of them first followed various (clinical) treatments that
were unsuccessful and/or worsened their situation. After it became clear
that these treatments yielded insufficient results for them, they were
declared chronically ill and ended up in PRI through various channels.
For example, there were webinars, an online podcast, and information
posted on social media. Several parents of young people with anorexia also
made each other aware of the existence of this method, which brought
several seriously-ill respondents into contact with PRI therapists.
Perinatal Histories
Data on pre- and perinatal history could be obtained from 12 out of 13
respondents (R) in this paper. Of the 13 respondents, two are part of a
dizygotic twin (R8, R9). Respondent 3 could not deliver pre- and perinatal
information due to personal circumstances. These 12 respondents who did
provide their pre- and perinatal histories experienced one or more pre- or
perinatal stressful condition or trauma before, during, or within one
month after pregnancy (see Table One). Most stress-increasing conditions
or complications were experienced during pregnancy and childbirth itself
(R1, R2, R5, R7, R8, R9, R10, R11, R13), but even after childbirth, an
existing stress-increasing condition (R2, R4, R5, R6, R7, R8, R9, R11, R12)
was experienced by most of the clients. Before delivery, stress-increasing
conditions within the system were explicitly mentioned by four of the 12
respondents (R5, R6, R9, R11).
Procedure
Treatment data were acquired retrospectively from treatment files
sampled for quality purposes. All respondents (and their parents, if
applicable) gave written informed consent to use the data. Experienced
PRI therapists initially asked their clients to complete the EDE-Q for
quality purposes. They were free to do this and completed it in the absence
of their therapist. The respondents did not follow any other therapy
besides PRI and were not force-fed while in PRI therapy. The research
meets all criteria as described in the guideline for ethical research of the
Leiden University of Applied Sciences (anonymity, informed consent, data

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storage, and privacy) (VSNU, 2014). Patients were anonymized (given
numbers). The researchers were not part of the PRI-team.

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Journal of Prenatal and Perinatal Psychology and Health

Instrument
The EDE-Q is a self-report questionnaire and has been used to
measure eating disorder symptoms for the past decades (Peterson et al.,
2007). The EDE-Q is considered to be the gold standard for mapping
eating disorder cognitions and behaviors (Brennan, 2020). The reliability
of the EDE-Q is considered to be high (Peterson et al., 2007). The EDE-Q
identifies the degree of concern about weight, shape and the way in which
food is handled. The instrument has four subscales: “restraint,” “eating
concern,” “shape concern,” and “weight concern,” which can be computed
to a total score.
Results
Preliminary results with this respondent group (for individual results
see Table 1) shows a mean (M) total EDE-Q score before treatment of
5.154 (SD = 0.657) and after an average of 10 completed PRI sessions, M
= 2.342 (SD = 0.984). Results for the four subscales are listed in Table 2.
We computed effect sizes, using Cohen’s D. The total effect size for the
total score was 3.42 (high effect size). The effect size for restraint was 0.44
(medium effect size); for eating concern, 1.52 (high effect size); for shape
concern, 0.26 (medium effect size) and for weight concern, 1.96 (high effect
size). The BMI scores before/after treatment can even increase more
because 85% of the patients are still receiving treatment.
Respondents 8 and 11, with extremely low BMIs (below 12.3 and 13.9)
showed the least BMI improvement (to 12.9 and to 14.3), and also showed
the least improvement of all respondents on EDE-Q measures.
Interestingly, as compared to the other 11 respondents, nine of whom had
undergone coercive treatments and admissions, respondents 8 and 11 had
undergone the most extreme long-term compulsory admissions. Weighing
and gaining weight as a result had become very aversive stimuli to them.
However, after several sessions they showed signs of recovery and taking
up their ordinary life again, like living at home, being able to bicycle,
picking up their studies, and meeting with old friends, etc. The
respondents’ mean BMI at baseline was 15.3. The mean BMI after
treatment sessions with PRI increased to 17.12 (ES = 0.77, high).
We do see variations in BMI improvement. BMI scores usually show
large improvements (R2 went from 15.2 to 21.2; R7 went from 14.7 to 17.2;
R9 went from 15.9 to 19.8) and occasionally small improvements (R8’s
alarming BMI of 12.3 improved after eight sessions to 12.9, which is still
very critical, but nevertheless able to continue the therapy; R11 started
therapy with an EDE-Q score of 5.7 and ended with 5.2.).

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Table 3
EDE-Q and weight descriptives

All effect sizes are in the right direction. The biggest effect sizes are found
on eating concern and weight concern. Shape concern has the smallest
effect size. BMI gains vary across patients and across the number of
treatment sessions completed. These are preliminary results of clients
still under therapy.
Discussion
The introduction of PRI on patients with severe/extreme recurrent
anorexia focuses on etiology of anorexia, sometimes starting with pre- and
perinatal problems, which can then open up a vulnerability for early
childhood trauma, ACEs, PTSD, and revictimization and the need for
control (personality problems) as a result of these past experiences.
Indeed, in this sample with 13 subjects, 12 subjects experienced pre- and
perinatal trauma, while one subject had no access to information about
possible pre- and perinatal trauma. This is crucial information for
diagnosing the cause of anorexia and determining its subsequent
treatment. Further research is needed to determine the external validity
of these preliminary results.
These pre- and perinatal traumas, and later vulnerability for stressful
ACEs and revictimization, subsequently interact with treatment
paradigms and the amount of coercion and the behavioral-control centered
approach in current forms of treatment for anorexia. Within the current
paradigm, little attention is paid to pre- and perinatal problems, ACEs,
PTSD and contextual factors and their influence on the development and
maintenance of anorexia. The usual, medically-oriented forms of
treatment within this paradigm seem to have little or no long-term

20

Journal of Prenatal and Perinatal Psychology and Health

positive effect on the psychological well-being of a group of patients with
a low BMI (<17.5) and other psychiatric problems. This shows the need
for a more multidisciplinary approach. There is a gap in the scientific
literature regarding effective treatments for this group. It is therefore
necessary to critically examine alternative approaches and treatment
methods. PRI is such an alternative, acknowledging early childhood trauma
and pain. The initial results described in this study look promising, with a
decline of eating disorder cognitions and an increase in BMI.
The results present an initial phase with 13 clients and show a
promising total effect size (Cohens D 3.42). This is possibly a chance effect
because of the small population and the large standard deviation. With a
larger N, the effect sizes probably would drop to lower levels, but remain
promising, because all effect sizes are in the right direction. The biggest
effect sizes are found on eating concern and weight concern, while shape
concern has the smallest effect size. Compared to the normal population
of women aged 18-22 (M = 1.59), this mean total after treatment is slightly
higher (M = 2.5). But when we look at the high starting point (M = 5.1) we
can expect that with a larger population and/or a time series design,
significant results are likely to be substantiated further by a completed
treatment trajectory. BMI effect sizes are also promising.
Limitations
In measuring the effect of PRI, methods from the medical paradigm,
the EDE-Q and the BMI, have been used as a recovery measure in this
pilot study. The changes that the EDE-Q maps concern changes in
symptoms. The underlying problems addressed by a method such as PRI
have not been identified. The assumption is that a decrease in symptoms
also means a decrease in underlying problems. However, this has not been
measured. A possible decrease in anxiety complaints, PTSD complaints,
and self-hatred and depression have not been measured but can be
observed clearly in the clinical setting and in clients’ self-reports. While
at a more fundamental level, these complaints are so characteristic of
severe or extreme recurring anorexia (De Vos et al., 2017; Noordenbos &
Ten Napel, 2017).
The long-term effects of PRI have not yet been mapped; this requires
follow-up research. The results were generated on a preliminary sample
from two PRI therapists. It is advisable to involve more therapists and
clients for follow-up research. In this preliminary study, Self
Determination Theory scores were not researched. However as part of the
PRI process all respondents had returned to their homes (fostering
relatedness), were stimulated to restart education (competence), and most
importantly, have lost their fear of eating, of gaining weight, of living, of

Wesselius et al

21

needing to apply coercion to themselves, to self-harm, and had stopped
their medication and were involved in shared decision-making (enhancing
their autonomy) (Ten Brummelaar et al., 2017). Additionally, they were
planning their futures again; they wanted to live again.
Conclusion
Research on anorexia has shown a correlation between pre- and
perinatal trauma, early childhood trauma, ACEs, revictimization and
acquiring anorexia nervosa. Past Reality Integration is a multimodal
cognitive behavior therapy that works to address past traumas and
reinstates present reality testing. The results of this preliminary study
show utilizing PRI is a useful form of treatment for patients dealing with
severe/extreme recurring anorexia and often complex multi-problems.
Utilization of this modality was shown to both be an effective addition to
traditional forms of treatment for eating disorders and facilitate a
decrease in eating disorder-related symptoms. Integrating pre- and
perinatal problems, past ACEs, and revictimization with the present
seems to be a fruitful pathway to recovery as van der Kolk (2014) states
for PTSD therapy in general. Clinicians need to be aware of the link
between pre- and perinatal issues and anorexia nervosa.
In future research, even preventive measures could be developed in
early stages of development, such as screening for and reducing pre- and
perinatal trauma and ACEs, personality problems, and perhaps providing
anxiety-reducing training or therapy, such as mindfulness. PRI could be
further reviewed by using a time series design, using SCL-90 (a broad
psychopathology checklist) and interviews.
Patients who are struggling with anorexia have a high mortality rate
and current therapies do not seem to be able to reduce this. There is a
definite need for alternative therapeutic approaches, such as PRI
(Brennan, 2020). Additionally, utilizing PRI to address pre- and perinatal
problems, ACEs, and other past and present traumas, seems to be a
promising alternative to traditional interventions employed in residential
settings for anorexia nervosa, which can trigger traumas from the past.
Every day, there are (young) lives at stake. There is evidence that by
fulfilling clients’ basic psychological needs and integrating their past
traumas into the present via PRI, we can give them (and their parents)
hope and motivation for a meaningful future.

22

Journal of Prenatal and Perinatal Psychology and Health
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