It'd be great to think that nutritional rehabilitation was the sole key to freedom and recovery for everyone with an eating disorder. But we know there is a significantly high incidence of trauma in the past of people who struggle with eating disorders, and this can become a maintaining factor in the illness itself.
That's why we're proud to launch The Trauma Spot.
This is where we'll be looking at trauma ,especially in the context of eating disorders, how AEDRA can help and what other options are out there
Click to enquire about trauma therapy now
Post-traumatic stress disorder (PTSD) and eating disorders very 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 behaviours designed to counteract the impact of this eating
Anorexia nervosa: Eating insufficiently for one’s energy needs due to a fear of weight gain
These are also the three types of eating disorders that have most often been studied in relation to PTSD.
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 victimisation, 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 common. The majority of people 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.
Eating Disorders and PTSD
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 behaviours 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-behavioural 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 guided 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 effective. 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 behaviours, 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.
Clients are often surprised when I tell them that we won’t be actively working to bring their trauma history to the surface in therapy. It’s not that we wouldn’t ever want to do that—when the time is right, if appropriate for the client, trauma processing in a safe, supportive environment has a role to play in the journey of trauma integration.
But research has found that telling the trauma story is ineffective in bringing relief from symptoms of trauma and can even be harmful (retraumatizing). Careful preliminary work with other strategies needs to take place before working with the trauma story itself.
A heavy focus on telling the traumatic story reflects outdated notions of how trauma affects us and how we need to treat it. Traumatic memories are not stored in a way that they can be deeply accessed by verbal interactions based on cognitive or logical processes.
Trauma is stored somatically, (in the body). Its most disruptive consequences play out in sensory networks, the nervous system, and the vagus nerve that connect many parts of the body including the brain and the gut. We have to involve all of those systems to get to the root of trauma.
Trauma puts survivors on constant high alert, a survival response useful to protect against additional trauma. But this sense of alertness also blocks access to the deep roots of trauma in the body.
Traumatic memories reside as frozen experiences within. They take away spontaneity, one of the most important resources for survivors in moving on.
Start therapy with laying a foundation
If we begin therapy by focusing on the trauma story itself, the risk is high that we will add to the injury and pain, that is, retraumatize. Early work should focus instead on restoring a sense of safety, on helping the survivor to discover and draw on their resources, and on self-regulation.
Only after a client has been able to achieve a reduction in the alertness that typically follows trauma and a strengthened awareness of resources for coping with stress can we look at whether we need to deal directly with the trauma story. If we do need to deal directly with the trauma story, such preparation reduces the odds that reviewing the trauma will cause emotional flooding and retraumatization.
Trauma is complex in its impacts, and therefore treatment needs to be complex as well. In a gradual way, we need to strengthen various aspects of a survivor’s well-being: emotional, physical, cognitive, spiritual and relational.
The empowerment and resilience structure* framework I use provides such a complex, personalized and whole-person approach by designing trauma treatment around 4 fundamental stages.
The first stage is a foundation of preparation and the building a positive and powerful therapeutic relationship, enhanced by feedback informed treatment **;
The second stage focusses on psychoeducation and skills building; this involves learning or improving on a myriad of skills, including resilience, self-regulation, grounding, and containment to help the survivor rapidly develop stability, self-efficacy, anxiety management and to improve their relationships.
In the 3rd stage, we focus, if necessary, on desensitizing and integrating trauma memories for survivors still experiencing intrusions (nightmares or flashbacks); Often the skills learned in the previous stages have stopped these symptoms.
I help people who have suffered a recent loss and are experiencing uncomplicated bereavement using a passive grief-focused supportive process, and also clients who are suffering a protracted loss with complicated bereavement using an active CBT grief focussed intervention process to help clients start to remember with love.
The 4th stage We focus on posttraumatic Growth & Resilience. We work together on fostering posttraumatic growth and resiliency, moving towards a future that helps clients re-start normal adult development and lead intentional lives.
Trauma is painful. Pain is a part of life and we all carry it with us all the time. The hardest part of trauma therapy, as in many other kinds of therapy, is coming to terms with the fact that the pain that brings clients to seek help will not necessarily go away.
But, in successful therapy, the relationship of survivors to the pain of trauma changes, so that it no longer dominates consciousness and monopolizes resources for living. Trauma and the resulting pain become but one part (or parts) of the rich, ongoing tapestry of life.
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*gentry, baranowsy and rhoton, 2017