A Case Series Trial on the effect of an Adaptation of Memory Reconsolidation Therapy on disease severity in Adults with Bulimia Nervosa and Posttraumatic Stress Disorder

The study will be conducted at the Queensland University of Technology Psychology and Counselling Clinic. Participants who appear to meet criteria for the study and express interest in participating will be further screened in a 60-minute face-to-face interview with a Master of Clinical Psychology student who will be trained in conducting a structured clinical interview (SCID-5RV) and will be supervised by the Research Project Supervisor, who is an experienced Clinical Psychologist. The participants will each be monitored over a four-week baseline period. During these weeks, the participants will be asked to complete the Treatment Outcome Package (TOP) Questionnaire as well as report the frequency of binge and purge episodes in the previous week. We anticipate that this will take 10 minutes to complete each week. This four week period is to receive a baseline estimate of functioning only, and is thus not being used as a control. Treatment will involve 12-16 x 90-minute sessions conducted weekly. The number of sessions required for each participant will be determined by the therapist based upon the progress of the participant. The therapy will be delivered by the Principal Researcher (a post-graduate Clinical Psychology student registered with the Psychology Board of Australia). Following the final treatment session, and at three-month follow-up participants will be asked to complete all the initial battery of questionnaires again. Treatment Outline. Phase One: Psychoeducation based upon Metacognitive Therapy (2-3 sessions) • Psychoeducation around the function of emotions o This will include an explanation of the metacognitive model where bingeing and purging are considered coping strategies to manage unbearable distress. Some patients may be afraid they will be unable to cope if they no longer binge, purge, or use compensatory behaviours o It will also involve discussion about the positive function of emotions (including negative emotions), exploration of unhelpful beliefs about emotions and Socratic Questioning to help the participant consider alternative perspectives regarding their unhelpful beliefs about emotions. o Participants will be trained in detached mindfulness and encouraged to become more mindful of their emotions as part of a behavioural experiment to test the validity of their unhelpful beliefs about emotions. Phase Two: Memory Reconsolidation (~10-12 treatment sessions) • A fear hierarchy will be developed by ranking the traumatic events that link to the PTSD according to the level of distress they envisage experience when they recall these events. The therapist and participant will start the Memory Reconsolidation Therapy protocol using memory of the lowest ranked traumatic event and then progress up the fear hierarchy after the successful extinction of the current traumatic memory being addressed. • The client’s mental state during the week will be reviewed, as a measure of progress. Also, the therapist will be sensitive to the risk of self-harm. If the client has already engaged in an MRT session, any primary or secondary emotions associated with the last fear memory during the week will be explored. If there is still an ongoing primary fear response associated with the last memory, then the therapist may consider redoing MRT on this memory before going up the next step of the hierarchy. If there are ongoing secondary emotions associated with the last fear memory, then part of the session may be spent using cognitive strategies to help the client gain a shift in his/her maladaptive interpretations by considering the trauma from a post-traumatic growth perspective. a. The client will be asked to recall the traumatic memory on the current step of the fear hierarchy. a. The client will be encouraged to close her/his eyes to intensify the extinction process (by minimising distractions) if they feel safe to do so. b. The client will initially be asked to imagine being in a real or an imaginary safe place. The goal is to a) get a baseline of the client’s imagination – to gauge whether their imagery during the exposure is OK compared with baseline, b) relax them to help resistance to recall, c) train them in inducing the relaxation so they can use this to reduce any distress after recall. c. The client will then be asked to describe the scene of the traumatic memory as clearly as he/she can. This recollection will be kept no longer than 3-5 minutes, as the goal is only to activate the memory and not to start the extinction process. d. Once the memory is activated, the client will be asked to return to the safe place imagined before the recall. b. The client will be engaged in a detached mindfulness exercise for approximately 20 minutes. c. After 20 minutes the client will be asked to close her/his eyes and return to the safe place experienced earlier. d. The client will then be invited to recall the same traumatic event they recalled 20 minutes prior. The therapist will ask the client to describe the image out loud in the present tense and in first person, as though it were happening now. e. Questions will be asked, including what the client can see, hear smell, feel and sense in their body. The vividness of each experience will be heighted by asking the client to focus on aspects of the memory and focus on how vivid it was. f. According to their emotional needs, the client may then change the imagined situation into less aversive mental images. The positive effects of this approach are enhanced if clients play an active role in the new script (i.e., patients imagine themselves enacting the change), compared to a more passive approach where patients imagine third parties (e.g., the therapist) helping in the imagined situation (Arntz, 2012; Siegesleitner et al., 2020). g. At various times throughout this process, the client will be asked to rate his/her subjective units of distress (SUDS) on a scale of 0 to 10. h. These steps will be repeated until the client experiences a significant reduction in SUDS – ideally towards 1 or 2 out of 10. i. Once the client reports a significant reduction in SUDS, then the client will be asked to move his/her attention back to the safe place imagery. j. The experience of the client will be explored towards the end of the session. k. Any secondary emotions (e.g. anger, sadness, guilt) that arose from the experience will be explored from a post-traumatic growth perspective (e.g. emotions normalised and validated and then the client encouraged to consider what they have learned from experiencing the trauma). l. The client will be encouraged to keep calm and relaxed during the next 4-5 hours (i.e., up to 6 hours after the initial recall). Phase Three: Final Session a. The clients mental state during the week will be reviewed. This will be used as a measure of progress. b. Summarise i. The formulation of the presenting problem and the role of fear memories in the experience of BN and PTSD. ii. The rationale for exposure therapy and the focus on reducing the primary emotion of fear. iii. The client’s progress up the fear hierarchy c. Summarise the client’s current mental state and discuss/negotiate if the client needs any further treatment and what the options are for referrals. d. Ask the client to report on their understanding of any strategies that they can continue to apply to manage secondary emotions. e. Ask the client to discuss their experiences with the process of the therapy and what they have learned from the experience. f. Address any unresolved issues. g. End the sessions and praise the client for his/her progress and recognise the gains made.