Racism-Related Stress, PTSD, and CEED’s Pledge

by Mary L. Hill, PhD, Cynthia Bulik, PhD, and Jean Doak, PhD

In light of the recent, salient examples of systemic racism in our country, we at CEED are taking this time to reflect on our own practices as a clinic and use our platform to raise awareness and promote action. This post has two sections. First we discuss the impact of racism-related stress on PTSD and eating disorders in African Americans. Second, we outline what we as a program will do to change. We acknowledge that racism adversely affects individuals from all racial and ethnic minority groups. Given the events that have occurred in the United States over the past few weeks, today we focus on the impact of these events on our African American patients, students, colleagues, family members, and friends.

As previously outlined (see Co-occurrence of PTSD and Eating Disorders), PTSD and eating disorders commonly co-occur. And we know that interpersonal traumas are particularly distressing and more likely to lead to the development of PTSD than other types of trauma, like exposure to a natural disaster or being in a car accident. Experiences of racism are a unique type of interpersonal trauma. Pervasive racism and prejudice, both historically and currently, may explain why African Americans are more likely to meet diagnostic criteria for PTSD than the general population.1

African American ManWilliams and colleagues reported, “Racism-related traumatic experiences can range from frequent ambiguous microaggressions to blatant hate crimes and physical assault. Racial microaggressions are subtle, yet pervasive acts of racial discrimination perpetuated against African Americans and other groups.”2 Chronic racism-related stressors can lead to increased anxiety and hypervigilance, impact one’s sense of safety, power, and control, and make it more difficult for individuals to heal after experiencing more severe racism-related stressors and traumas. So, not only are certain acts of racism clear traumatic events, more subtle, frequent forms of racism and discrimination can exacerbate PTSD symptoms after exposure to a traumatic event.1,2  

It is also important to consider how racism-related stressors and trauma impact eating disorders among Black people. Like PTSD-related avoidance, eating disorder behaviors such as binge eating, purging, and dietary restriction can function as means of coping with distress; however, this manner of coping maintains both the distress and the eating disorder.3,4 Although very little research exists on the topic, it is reasonable to assume that eating disorder behaviors may emerge to manage racism-related stressors in African American individuals. Unfortunately, persistent misconceptions in providers about who is at risk for eating disorders (e.g., young white females) means that African Americans and males often go undetected. Moreover, stereotypes about who develops the illness can also keep people who don’t fit the stereotype from seeking care in the first place.5 However, we know that eating disorders afflict individuals regardless of size and shape, race and ethnicity, socioeconomic status, biological sex, and gender identify.6,7,8

To combat the consequences of these erroneous stereotypes, providers across the health care system should keep eating disorders on their radar screen regardless of gender, race and ethnicity, and body shape and size of the patients who walk through their doors. In working with patients of color, we should ask about the impact of racism and discrimination on mental health and continue to practice and improve cultural adaptations of evidence-based treatments.2,9,10 Regardless of our race and background, we need to be willing to initiate discussions about racism-related trauma and stress, demonstrate understanding about the consequences of racism and discrimination on mental health and validate Black people’s experience. We all need to listen and support. Our work doesn’t stop with increasing awareness. We need to actively work toward improving access to culturally competent care and collaborate with patients and families to ensure that the services delivered are appropriate and effective in order to retain individuals in care. These changes can’t just be temporary in response to a national crisis. They need to be permanent, front of mind priorities for all health care workers. The convergent crises of COVID-19 and George Floyd’s death have ripped the band-aid off of a country that had grown complacent in the face of pervasive inequalities and injustices.

At CEED, we will address this on all levels, from clinical care, to training, to research. We will increase our efforts to challenge systemic barriers that limit access to clinical care. We will continually re-examine our hiring and training practices to ensure that we are being proactive and not influenced by bias—implicit or explicit. We will encourage African American students to enter the field and to become engaged in research from early in their academic careers. We will ensure that individuals of color are appropriately represented in all of our research studies and actively seek counsel on how best to make that happen. Together with the Department of Psychiatry, we are committed to UNC Health’s Vision and Values, particularly “One Great Team,” which emphasizes building an inclusive and equitable culture that encourages and supports the diverse voices of our patients and each other. We will hold ourselves and each other accountable to this principle. We will revisit this regularly to ensure that we do not descend into complacency. We will increase our efforts to listen and learn. We welcome critiques and dialogue. We will not shrink from the difficult conversations. This is our commitment to an ongoing call to action. We can do better; we must do better.


  1. Himle, J. A., Baser, R. E., Taylor, R. J., Campbell, R. D., & Jackson, J. S. (2009). Anxiety disorders among African American, Blacks of Caribbean Descent, and Non-Hispanic Whites in the United States. Journal of Anxiety Disorders, 23, 578-590. https://doi.org/10.1016/j.janxdis.2009.01.002
  2. Williams, M. T., Malcoun, E., Sawyer, B. A., Davis, D. M., Nouri, L. B., & Bruce, S. L. (2014). Cultural adaptations of prolonged exposure therapy for treatment and prevention of posttraumatic stress disorder in African Americans. Behavioral Sciences, 4, 102-124. doi: 10.3390/bs4020102
  3. Trottier, K., Wonderlich, S. A., Monson, C. M., Crosby, R. D., & 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
  4. Harrington, E. F., Crowther, J. H., & Shipherd, J. C. (2010). Trauma, binge eating, and the “Strong Black Woman.” Journal of Consulting and Clinical Psychology, 78, 469-479. doi: 10.1037/a0019174
  5. Sonneville, K. R., & Lipson, S. K. (2018). Disparities in eating disorder diagnosis and treatment according to weight status, race/ethnicity, socioeconomic background, and sex among college students. International Journal of Eating Disorders, 51, 19-24. doi: 10.1002/eat.22846
  6. Hudson, J. I., Hiripi, E., Pope, H. G. Jr., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61, 348–358. https://doi. org/10.1016/j.biopsych.2006.03.040
  7. Lipson, S. K., & Sonneville, K. R. (2017). Eating disorder symptoms among undergraduate and graduate students at 12 U.S. colleges and universities. Eating Behaviors, 24, 81–88. https://doi.org/10.1016/j.eatbeh. 2016.12.003
  8. Swanson, S. A., Crow, S. J., Le, G. D., Swendsen, J., & Merikangas, K. R. (2011). Prevalence and correlates of eating disorders in adolescents: results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 68, 714–723. https:// doi.org/10.1001/archgenpsychiatry.2011.22
  9. Masuda, A. (Ed.) (2014). Mindfulness and Acceptance in Multicultural Competency: A Contextual Approach to Sociocultural Diversity in Theory and Practice. Oakland, CA: New Harbinger Publication.
  10. Masuda, A. (2016). Principle-based cultural adaptations of cognitive behavior therapies: A functional and contextual perspective as an example. Japanese Journal of Behavior Therapy, 42, 11-19. https://doi.org/10.24468/jjbt.42.1_11