UNC Exchanges is pleased to present a three-part blog series on posttraumatic stress disorder (PTSD) and eating disorders written by our clinical post-doctoral fellow, Dr. Mary Hill. In this piece, Dr. Hill discusses the co-occurrence of PTSD and eating disorders and what we know about evidence-based care. In her next two posts, Dr. Hill will present more in-depth information about misperceptions of trauma, misperceptions of reactions to trauma, and evidence-based treatments for trauma.
by Mary Hill, PhD
Some individuals with eating disorders have a history of interpersonal trauma,1,2 and these types of trauma (e.g., physical or sexual assault) are more likely to lead to the development of posttraumatic stress disorder (PTSD) than non-interpersonal traumas (e.g., natural disaster, car accident).3 Eating disorder symptoms can help the individual distract from intrusive memories, distress, and hyperarousal associated with PTSD. Although the eating disorder may dampen PTSD symptoms in the moment, it may prolong suffering in the long-term, and PTSD symptoms may also make recovery from the eating disorder harder.4 Therefore, addressing both the trauma and eating disorder in treatment is important.
Although there are no established protocols for treating individuals with eating disorders who also have PTSD, several treatments for PTSD have been evaluated in the literature. Exposure-based interventions have consistently demonstrated the greatest research support, with prolonged exposure (PE) as the first line treatment for PTSD because of its strong body of evidence.5,6,7,8 Other exposure-based interventions have moderate strength of research evidence (e.g., trauma-focused cognitive behavioral therapy (TF-CBT) and cognitive processing therapy; CPT) and low to moderate research support (e.g., eye movement desensitization and reprocessing; EMDR).6,7 A full description and critical review of each therapy is beyond the scope of this blog, but it is worth noting that the use of EMDR is controversial, and multiple reviews have shown 1) it is no more effective for PTSD symptom reduction than standard exposure therapy and maybe less effective long term, and 2) eye movements, the central feature of treatment, have not shown added benefit.9,10 For these reasons, it is preferable for patients and practitioners to pursue well-established evidence-based treatments like PE, CF-CBT, or CPT.
Even in the absence of clear protocols for co-occurring PTSD and eating disorders, several factors should be considered when treating individuals with both disorders:
- Address safety needs. For example, it is essential to ensure physical safety if traumas are ongoing, reduce self-injury and substance misuse, and address medical instability related to the eating disorder.
- Normalize eating patterns. For individuals who are underweight, treatment providers should help establish nonrestrictive eating patterns and increase weight to improve cognitive functioning that will enable them to engage in trauma-focused therapy. Normalizing eating also includes reducing or eliminating binge eating and inappropriate compensatory behaviors.
- Promote distress tolerance skills to assist in effectively managing distress associated with trauma-related thoughts, memories, and emotions. If the eating disorder is serving to reduce distress associated with PTSD, there may be an initial worsening of PTSD symptoms when reducing eating disorder symptoms. Helping individuals learn and incorporate alternative distress tolerance skills into their behavior first may increase the likelihood of success in treatment.
Unfortunately, trauma survivors face many barriers to seeking mental health treatment. The most commonly cited barrier is concern about stigma, shame, and social rejection.11 Continued efforts to decrease stigma and address misinformation about trauma and common reactions to trauma among survivors, healthcare professionals, law enforcement, and in the community may increase individuals’ willingness to seek specialized care. In addition, making information about evidence-based treatments and how they work readily available can inform survivors that symptoms are treatable and address concerns about trauma-focused therapies.
In summary, a portion of individuals with eating disorders have trauma histories, and PTSD symptoms and eating disorder symptoms impact each other. Although there are currently no established guidelines for when and how to address trauma in eating disorders treatment, evidence-based PTSD treatments can be used in conjunction with eating disorders treatments. Additional research is needed to determine optimal methods for integrating treatment for both disorders.
- Brewerton, T. D. (2007). Eating disorders, trauma, and comorbidity: Focus on PTSD. Eating Disorders, 15, 285-304. doi: 10.1080/10640260701454311
- Reyes-Rodriguez, M. L., Von Holle, A., Ulman, T. F., Thornton, L. M., Klump, K. L., Brandt, H., … Bulik, C. M. (2011). Post-traumatic stress disorder in anorexia nervosa. Psychosomatic Medicine, 73, 491-497. doi: 10.1097/PSY0b013e31822232bb
- Forbes, D., Lockwood, E., Phelps, A., Wade, D., Creamer, M., Bryant, R. A., …O’Donnell, M. (2014). Trauma at the hands of another: Distinguishing PTSD patters following intimate and nonintimate interpersonal and noninterpersonal trauma in a nationally representative sample. Journal of Clinical Psychiatry, 75, 147-153.
- Trottier, K., Wonderlich, S. A., Monson, C. M., Crosby, R. D., and Olmsted, M. P. (2016). Investigating posttraumatic stress disorder as a psychological maintaining factor of eating disorders. International Journal of Eating Disorders, 49, 455-457. doi: 10.1002/eat.22516
- Bisson, J. & Andrew, M. (2007). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, 3, 1-122. doi: 10.1002/14651858.CD003388.pub3
- Institute of Medicine (2008). Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, D.C. The National Academic Press.
- Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Cook Middleton, J., …Gaynes, B. N. (2016). Psychological treatments for adult with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128-141. doi: https://doi.org/10.1016/j.cpr.2015.10.003
- Difede, J., Olden, M. & Cukor, J. (2014). Evidence-based treatment of post-traumatic stress disorder. Annual Review of Medicine, 65, 319-332. doi: 10.1146/annurev-med-051812-145438
- Davidson, P. R., & Parker, K. C. H. (2001). Eye movement desensitization and reprocessing (EMDR): A meta-analysis. Journal of Counseling and Clinical Psychology, 69, 305-316. Doi: 10.1037//0022-006X.69.2.305
- Herbert, J. D. & Sageman, M. (2014). “First do no harm:” Emerging guidelines for the treatment of posttraumatic reactions. In G. M. Rosen (Ed.), Posttraumatic stress disorder: Issues and controversies (pp. 213-232). Hoboken, NJ: Jon Wiley & Sons, Inc.
- Kantor, V., Knefel, M., and Lueger-Schuster, B. (2016). Perceived barriers and facilitators of mental health service utilization in adult trauma survivors: A systematic review. Clinical Psychology Review, 52, 52-68. doi: 10.1016/j.cpr.2016.12.001