Post Traumatic Stress Disorder (PTSD) and eating disorders often co-occur. People with eating disorders may have other mental health conditions, such as generalized anxiety disorder, social anxiety disorder, or obsessive-compulsive disorder (OCD). In fact, many individuals with eating disorders also have one or more anxiety disorders that often predate the eating disorder.
What Is PTSD?
Prior to the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), PTSD was included in the Anxiety Disorders category of the DSM. In 2013, the diagnosis of PTSD was moved to a new category of disorders called Trauma- and Stressor-Related Disorders.
A diagnosis of PTSD is made when a person experiences a traumatic event and then has great difficulty in the aftermath of that event. The traumatic incident continues to dominate their daily life. A PTSD diagnosis requires a person to have symptoms that can include upsetting and intrusive memories, nightmares, avoidance of reminders of the event, negative thoughts or feelings related to the event, difficulty concentrating, constant anxiety, and increased physiological arousal since the event. These symptoms must persist for a month or more.
What Are Eating Disorders?
Eating disorders are complex conditions that affect eating and can seriously impair health and social functioning.
The most common eating disorders are:
- Binge-eating disorder (BED): Eating large amounts of food while feeling out of control
- Bulimia nervosa: Eating large amounts of food alternating with behaviors designed to counteract the impact of this eating
- Anorexia nervosa: Eating insufficiently for one’s energy needs due to a fear of weight gain
What Is Trauma?
Trauma refers to a broad range of experiences. While initially eating disorders were often studied and believed to be linked to childhood sexual abuse, the definition of trauma has been broadened to include many other forms of victimization, including other childhood sources such as emotional abuse, emotional and physical neglect, teasing, and bullying, as well as adult experiences such as rape, sexual harassment, and assault. It also can include natural disasters, motor vehicle accidents, and combat.
Unfortunately, traumatic events are relatively common. The majority of people in the U.S. will experience at least one traumatic event in their lifetime
How PTSD Relates to Trauma
Anyone can develop PTSD at any age. Not every person who experiences trauma develops PTSD—in fact, most people will manage to process a traumatic event and move on without developing the disorder. Others will exhibit some behaviors or transient symptoms of PTSD but never develop the disorder.
Certain factors can increase a person’s likelihood of developing PTSD following trauma—these can include the type of trauma, number of traumas experienced, prior problems with anxiety and depression, poor social support, and genetic predisposition.
Trauma, including childhood sexual abuse, is a “nonspecific” risk factor for eating disorders—nonspecific because it can also precede a number of other psychiatric disorders. In the U.S., the lifetime prevalence of PTSD is estimated to be at 6.4 percent. Rates of PTSD among people with eating disorders are less clear because there are few studies. What studies do exist show the following rates for lifetime PTSD:
- Women with bulimia nervosa: 37-40 percent
- Women with BED: 21-26 percent
- Women with anorexia nervosa: 16 percent
- Men with bulimia nervosa: 66 percent
- Men with BED: 24 percent
Rates of PTSD are generally found to be higher in cases of eating disorders with symptoms of bingeing and purging, including the anorexia-binge/purge subtype.
There are different theories regarding the higher incidence of PTSD among people with eating disorders. One theory is that the trauma directly affects body image or sense of self and leads a person to attempt to modify their body shape to avoid future harm.
Another is that trauma exposure leads to emotional dysregulation (difficulty managing emotional reactions), which in turn can increase the risk for various types of psychopathology, including PTSD, borderline personality disorder, and substance use disorders. In this model, binge eating and purging are believed to be an attempt by the affected person to manage or numb their intense PTSD symptoms. When they succeed in doing so, the eating disorder behaviors are reinforced.
In any case when multiple psychiatric conditions co-occur, treatment becomes more complicated. This can certainly be true with PTSD and eating disorders. An eating disorder patient with PTSD may have more difficulty trusting their provider or allowing others to dictate treatment. Treatment for eating disorders often involves accepting direction around eating, so an unwillingness on the part of a patient with PTSD to trust the caregiver can be problematic.
There are few specific clinical guidelines for treating patients with both PTSD and eating disorders. Fortunately, there are effective treatments. Both PTSD and eating disorders can be successfully treated with cognitive-behavioral therapy (CBT), a treatment that focuses on understanding the relationship between thoughts, feelings, and behaviors.
Psychotherapy is the leading treatment for PTSD. Some of the leading evidence-based therapies for PTSD include:
- Cognitive Processing Therapy (CPT) teaches how to reframe your maladaptive beliefs about the trauma.
- Prolonged Exposure Therapy (PE) teaches how to face feelings and involves talking about the trauma.
- Trauma-Focused CBT (TF-CBT) is designed for children and adolescents, and teaches how to understand, process, and cope with trauma.
- Eye Movement Desensitization and Reprocessing (EMDR) helps one to process and understand trauma while making rapid eye movements. This treatment tends to be more controversial because it’s unclear whether the eye movements make any contribution to patients’ improvement above and beyond the associated exposure process.
Psychotherapy is also the front-line treatment for eating disorders. Enhanced cognitive therapy (CBT-E) is the protocol with the greatest evidence for the treatment of adult eating disorders. It focuses on changing behaviors which in turn helps to challenge problematic thoughts.
In the treatment of co-occurring eating disorders and PTSD, there is no consensus on whether treatment should be sequential (with eating disorder treatment first or PTSD treatment first), or concurrent/integrated (treatment for the eating disorder and PTSD provided at the same time).
If a patient is medically unstable due to an eating disorder, the eating disorder should probably be treated first until those issues have improved. Sometimes, treating one condition can help make the treatment of the other condition more effectively. For example, if a patient is using eating disorder behaviors to avoid negative feelings, PTSD exposure treatment may not be as effective.
However, one of the problems with sequential treatment is that treating one disorder can sometimes worsen the other. This can cause a self-perpetuating cycle that prevents recovery from both disorders. If a patient with an eating disorder is confronting painful trauma memories, they may increase behaviors to avoid feeling the negative emotions, and this avoidance helps maintain their PTSD. By contrast, concurrent treatment can be effective at addressing both problems simultaneously, yet no integrated treatment protocol exists for PTSD and eating disorders.
Another decision in treatment planning is which of the aforementioned evidence-based PTSD treatments should be used. Outcomes have been quite similar among the four treatments and no study has indicated which one might be most effective for people with both PTSD and eating disorders. Some professionals have pointed out that CPT may be the most closely aligned with CBT-E, so an integrated treatment could combine aspects of both of those.
For patients with more problems with emotion dysregulation and high-risk behaviors, a form of dialectical behavior therapy (DBT), a protocol for treating PTSD, is DBT-PE. This treatment combines prolonged exposure with DBT. It is a new protocol and there are not yet any studies on DBT-PE with patients with eating disorders, but some professionals believe it could be a good option for patients with eating disorders and PTSD.
The following criteria have been suggested for patients with eating disorders on when to begin PTSD treatment:
- The patient indicates readiness.
- The patient is adequately nourished and can process information.
- The eating disorder symptoms are relatively under control.
- The patient demonstrates an adequate ability to tolerate negative feelings.
Patients with PTSD and eating disorders should have a comprehensive assessment. Some patients may not feel comfortable revealing traumatic events early on in treatment, so assessment should be an ongoing process. Their therapist should develop a case formulation that helps them to understand the relationship between the eating disorder and PTSD, and can help guide when and in which order to address the different disorders.