Understanding PTSD and Eating Disorders
By Jennifer Wang-Hall, PhD
Introduction The etiology of eating disorders is multifaceted and complex. Many factors have been suggested to contribute to the development of eating disorders, including temperamental dispositions, family history, and difficulties in regulating emotions. One factor that contributes to emotion regulation difficulties is experiences of trauma, which often create strong negative emotions and intrusive thoughts that can be difficult to tolerate, frequently resulting in maladaptive attempts to regulate these emotions. One such method may be engaging in eating-disordered behaviors including restricting, bingeing, and purging. These behaviors may serve to give an individual a sense of control when traumatic experiences have left them feeling helpless and vulnerable. Living with the aftereffects of trauma and an eating disorder can be exceptionally difficult, and these symptoms are often debilitating, preventing individuals from living full and meaningful lives. Fortunately, a few evidence-based treatments have been shown to target the cognitive, behavioral, and emotional patterns frequently seen in individuals with post-traumatic stress disorder (PTSD). The purpose of this review is to provide information regarding the prevalence of traumatic experiences and PTSD in eating disorder populations, discuss available treatment options, and explore the experiences of treating clinicians.
Trauma and Its Consequences General population studies have shown that a large proportion of people have been exposed to at least one traumatic event in their lifetime (Benjet et al., 2016). Trauma comes in many forms and can be experienced by individuals of all ages, backgrounds, and circumstances. Traumatic events include, but are not limited to, childhood abuse, sexual assault, accidents, natural disasters, and intimate partner violence. In addition, trauma may include being directly involved in the event, witnessing the event, or repeated or extreme exposure to details of the event. Traumatic events may lead to a series of psychological consequences including nightmares, flashbacks, avoidance, negative mood, distorted beliefs, and hypervigilance. Many individuals experience these symptoms for a brief period of time and then the symptoms naturally resolve themselves. However, for others these symptoms persist and can lead to significant distress and impairment. When these criteria are collectively met, an individual is diagnosed with PTSD. There are many psychological conditions that frequently co-occur with PTSD, including depression, anxiety, substance abuse, and eating disorders.
Eating Disorders and PTSD Research has indicated that rates of eating disorders are higher in people who have experienced trauma and PTSD. One study indicated that up to 23 percent of patients with anorexia nervosa and up to 25 percent of patients with bulimia nervosa met criteria for PTSD (Tagay, Schlottbohm, Reyes-Rodriguez, Repic, & Senf, 2014). Among patients attending eating disorder residential treatment, up to 52 percent met criteria for PTSD (Gleaves, Eberenz, & May, 1998). While the research is mixed regarding PTSD prevalence in specific subtypes of eating disorders, some of it has suggested that bingeing and purging behaviors are more prevalent in individuals with PTSD than is restriction (Brewerton, 2004). It has been suggested that overeating may be a form of self-soothing and may numb out unpleasant feelings and intrusive thoughts related to the traumatic event. Purging behaviors are thought to have a similar function, acting as a way to expel unwanted experiences and improve mood. Although the research provides more support for the link between bulimia and PTSD, there has also been speculation that anorexic patients may be using restricting to regulate emotions, particularly those related to trauma. Restriction may result in emotional numbing and a feeling of power that may be desirable to a traumatized individual (Trim, Galovski, Wagner, & Brewerton, 2017). Given the considerable role that these behaviors may take on in regulating emotions, giving up the behaviors in order to recover from the eating disorder is exceedingly difficult.
Treatment for PTSD and Eating Disorders There are many important considerations that therapists (and their patients) must deliberate prior to beginning PTSD treatment. Brewerton (2007) describes the need for clinicians to ensure nutritional rehabilitation (most often guided by a dietitian) before proceeding with trauma treatment. Research has demonstrated that anorexia-induced starvation leads to deficits in set-shifting, attention, and decision-making (Treasure & Russell, 2011). These cognitive impairments appear to resolve with adequate weight restoration (Hatch et al., 2010). Another frequent error is failing to ensure appropriate skill acquisition prior to beginning PTSD treatment. Without adequate distress tolerance, a patient may resort to problematic coping mechanisms (bingeing, purging, restricting, substance use, self-harm, etc.) (Brewerton, 2007).
When a clinician determines that a patient is ready to begin trauma treatment, there are several evidence-based options from which to choose: cognitive processing therapy (CPT) (Resick, Monson, & Chard, 2014), prolonged exposure (PE) (Foa et al., 1999), and eye movement desensitization and reprocessing (EMDR) (Shapiro, 2001). CPT is based on the premise that people have a strong need to “make sense” of the world and that their beliefs about themselves and the world may shift (or become stronger) after a trauma in order to give themselves a sense of control. CPT emphasizes psychoeducation in the first session, providing information about the nature of PTSD and the role of avoidance in maintaining symptoms. In subsequent sessions, patients are guided through a series of cognitive exercises and given homework assignments to continue these exercises outside the treatment room. Socratic questioning is used to aid the patients in arriving at new and more balanced beliefs about the trauma, its causes, and its effects. PE is rooted in the framework of emotional processing theory. It may be especially aimed at patients who exhibit a significant degree of emotional avoidance. PE involves four therapeutic components: psychoeducation, in vivo exposure, imaginal exposure, and emotional processing (Cukor, Olden, Lee, & Difede, 2010). Patients are guided through imaginal exposures that involve revisiting memories and triggers related to the trauma, while in vivo exposures help the patient approach places, people, and activities that they may have been avoiding. These components facilitate emotional processing so that habituation may occur and avoidance can decrease. EMDR is multi-theoretical in its orientation in that it incorporates etiological events, conditioned responses, cognitions, and emotional processing (Shapiro, 2001). EMDR entails having the patient focus on emotionally distressing topics or stimuli while simultaneously attending to an external cue (eye movements, hand tapping, etc.). The goal of EMDR is to completely process a traumatic experience and the associated emotions, as well as decrease subjective distress.
Unfortunately, research examining these treatments specifically in eating disorder populations is scarce. Trim and colleagues noted that only two outcome studies have been conducted on PTSD treatment in eating disorder samples. Both studies (Mott, Menefee, & Leopolous, 2012; Mitchell, Wells, Mendes, & Resick, 2012) examined the use of CPT and showed improvement in symptoms of PTSD. To date, no research has been conducted on whether eating disorder patients have better outcomes in one of these PTSD treatments versus another (i.e., CPT, PE, EMDR). In deciding between these treatments, it should be noted that all are evidence-based and similar outcomes have been found for each (Trim et al., 2017). One consideration should be patient preference, as it has been shown to contribute to patient outcomes (Schumm, Walter, Bartone, & Chard, 2015).
Clinician Experience Recent research has examined clinicians’ perspectives and concerns with providing trauma treatment to eating disorder patients (Trottier, Monson, Wonderlich, MacDonald, & Olmsted, 2017). Trottier and colleagues used a sample of clinicians working in a wide range of settings (e.g., inpatient, outpatient, college counseling, eating disorder treatment centers) and representing a wide range of theoretical orientations. Their study found that therapists felt it was extremely important to address trauma-related symptoms and considered them to be a significant obstacle to achieving eating disorder recovery. However, they also expressed uncertainty about how to integrate trauma therapy with eating disorder treatment. In addition, therapists expressed only moderate familiarity and comfort with, and utilization of, evidence-based trauma therapies. Therapists anticipated complications including worsening self-harm, suicidality, eating disorder symptoms, and substance use. However, they also reported anticipated benefits including increased treatment retention, improved therapeutic alliance, and a decrease in relapse rate. Trottier and colleagues (2017) stated that the extent to which therapists reported concerns and uncertainty is problematic because it may impair their ability to provide evidence-based and integrated trauma treatment.
For therapists who do provide trauma treatment, there are additional concerns regarding their own well-being. In recent years, considerable attention has been given to the experience of clinicians providing trauma treatment. The literature has suggested there are costs to being exposed to another’s trauma and from the emotional investment in providing empathic support and guidance. Several terms have been used to describe the types of suffering a clinician may experience, including “secondary traumatic stress,” “vicarious traumatization,” and “compassion fatigue.” An exploration of cross-clinician variables found that clinicians with a “self-sacrificing” defense style were particularly vulnerable to vicarious traumatization (Adams & Riggs, 2008). In addition, it appears that therapist schemata related to self-safety relate to vicarious traumatization (Devilly, Wright, & Varker, 2009). Thus, therapists whose beliefs about their own safety are affected by hearing the accounts of their patients’ traumas may be most susceptible to vicarious traumatization. Given the inevitable toll that trauma work takes on therapists, it is important to consider protective and resilience factors and strategies that therapists may employ. Brewerton (2007) warns clinicians to be wary of the desire to “rescue” patients during trauma treatment. This can lead to the use of unhelpful and ineffective therapy approaches. Figley (2002) offered a model of factors contributing to compassion fatigue and suggested that disengagement (distancing oneself from the patient between sessions) may lower therapist compassion stress. Figley further suggested the bolstering of social supports and engaging with others outside of the “therapist persona.”
Conclusion In sum, a significant portion of patients with eating disorders have experienced a traumatic event, and many of these patients meet criteria for PTSD. It may be that engaging in eating disorder symptoms is a means of coping with the experiences involved in PTSD. Fortunately, evidence-based therapies for PTSD exist, although the evidence for these treatments in eating disorder populations is still emerging. There are barriers to providing these treatments, including clinician concerns and familiarity with evidence-based treatments. It is clear there is a need for further research in the field of eating disorders and PTSD. Future research should continue to explore the efficacy of PTSD treatments in patients with eating disorders, as well as ways to improve clinicians’ confidence and comfort in delivering these therapies. This is a vulnerable population for whom treatment is desperately needed. It is our responsibility as therapists to continue to explore and strengthen this field.
About the author:
Dr. Jennifer Wang-Hall is a postdoctoral fellow at the UC San Diego Eating Disorders Center. Over the last ten years, she has worked with patients with eating disorders at all levels of care. Her research has focused on examining correlates of eating disorders in order to inform future treatment directions. Jennifer is passionate about helping patients with eating disorders develop skills to create a life worth living.
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