The experience of trauma both in childhood and adulthood has been linked to numerous mental health issues, including depression, anxiety, and post-traumatic stress disorder. So it isn’t much of a surprise that researchers have also found a relationship between the experience of trauma and the development of disordered eating. Eating disorders are a salient mental health concern for adolescents and young adults, a study of over 10,000 adolescents (ages 13-18) found that the median onset age of several types of disordered eating was between 12 and 13 years old, and that eating disorders and subthreshold eating disorders affected up to 2.5% of participants in their lifetime. The same study found that of the participants diagnosed with PTSD, only 3.4% did not develop any kind of disordered eating (1). Of course, not everyone who has experienced trauma will develop an eating disorder, and not everyone who develops an eating disorder has experienced trauma. However, for those individuals who have both experienced trauma and developed an eating disorder, it may be vital to address that trauma in order to effectively treat the eating disorder. This information brief explores what is currently known about the link between trauma and eating disorders, current treatment for eating disorders, and how to incorporate trauma-focused therapies into eating disorder treatment.
The American Psychological Association (APA) defines trauma as “an emotional response to a terrible event like an accident, rape or natural disaster.” Studies on trauma and eating disorders have been particularly interested in childhood sexual, physical, and emotional abuse, as well as adult rape, assault, or other types of victimization. According to the International Society for Traumatic Stress Studies, these types of traumas are classified as interpersonal or intentional trauma, and tend to have the greatest adverse effects (2).
According to the National Child Traumatic Stress Network (NCTSN) childhood trauma can affect attachment and relationships, the physical health of both the body and the brain, emotional responses and behavior, and thinking and learning. Trauma can also lead to dissociation, where children mentally separate from themselves or their experiences, as a coping mechanism, and a self-concept that includes low self-worth and helplessness (3).
The APA defines eating disorders as “abnormal eating habits that can threaten your health or even your life.” The APA recognizes three main types of eating disorders: anorexia nervosa, bulimia nervosa, and binge eating disorder.
Anorexia nervosais often characterized by a distorted body image in which people see themselves as overweight even when dangerously thin. People with anorexia nervosa participate in extreme restrictive or purging behaviors, including refusal to eat or eating extremely limited amounts and compulsive exercising.
Bulimia nervosais characterized by a cycle in which people eat excessive amounts of food (binge) and then use methods like laxatives, vomiting, or excessive exercising to purge their bodies of food and calories.
Binge eating disorder is characterized by frequently eating excessive amounts of food, like those with bulimia nervosa. However, unlike those with bulimia nervosa, people dealing with binge eating disorder don’t purge their bodies after their binging episodes.
People may also be diagnosed with“eating disorders not otherwise specified”(EDNOS) if they have disordered eating behavior (including the behaviors noted in the three disorders above), but do not meet the official diagnostic criteria for anorexia nervosa, bulimia nervosa, or binge eating disorder(4)
Eating disorders affect not only a patient’s health, but also their school or work, family life, social life, and myriad other aspects of their day to day routine (1). Physical problems associated with anorexia include low iron levels in the blood (anemia), brittle or fragile bones from loss of tissue (osteoporosis), and heart and brain damage. Bulimia nervosa can lead to throat and tooth problems from purging, acid reflux, and heart attacks and binge eating disorder can lead to high blood pressure, diabetes, and other health problems associated with obesity (4).
There seems to be a clear linkage between traumatic experiences and certain types of disordered eating behavior, in particular several studies have suggested that post-traumatic stress disorder (PTSD) is related to binging and purging behaviors (5-7). In one study, 41% of participants with bulimia also met the criteria for subthreshold or threshold PTSD (8) and in another 13.7% of patients with anorexia also met criteria for PTSD, with the purging subtybe of anorexia being significantly more likely to meet PTSD criteria than those with restrictive anorexia nervosa (9). Much of the research done on this relationship has focused on child abuse, specifically emotional, sexual, and physical abuse (5, 10), and these traumatic experiences have been associated with increased severity of ED symptoms (10). However, the National Women’s Study extended their research to other traumatic experiences, including sexual assault during adulthood, sexual harassment, teasing, and bullying, and found that these experiences may also increase the likelihood of developing disordered eating (6). While few studies on this relationship have been longitudinal, most assume that there is at least some type of causal or temporal relationship between trauma and disordered eating, as the traumatic experiences (often from childhood) occur before the onset of the ED in a vast majority of cases (9, 5).
Why is this linkage so common? According to the National Child Traumatic Stress Network (NCTSN), childhood trauma can contribute to feelings of low self-worth, low self-esteem, and helplessness, and according the APA these factors can contribute to the onset of eating disorders (3-4). Some researchers have suggested that childhood abuse victims have a more difficult time distinguishing their emotions from feelings of hunger and satiety which can lead disordered eating behaviors (5), and others determined that poor emotional awareness coupled with body dissatisfaction strongly predicted disordered eating (11). Perhaps related to this relationship, other proposed mechanisms for the relationship between trauma and ED have to do with emotion regulation. Several researchers have suggested that patients may engage in disordered eating behaviors, such as purging, as a means of avoidance and to decrease the hyperarousal associated with PTSD’s intrusive thoughts. Through this mediating relationship, ED behaviors are reinforced because they have the desired effect, and therefore continue (7, 12-14).
Like many mental illnesses, eating disorders can be extremely difficult to treat. A 2013 systematic review of eating disorder treatment literature found that often times less than half of participants reached remission from treatment (15). Resistance in eating disorder treatment is quite common, as patients use “safety behaviors” that protect them from gaining the weight there are so terrified of, or resist change because their ED behavior is their main coping mechanism and without it they are unsure how to handle unwanted feelings (16). Typically, patients who are ashamed of their behaviors, find them problematic, or feel they are not part of who they want to be are easier to treat than those who feel some amount of pride in their behaviors or feel that their disordered eating is congruent with them as a person. Patients with bulimia nervosa and binge eating disorder tend to fall into the former category, while those suffering with anorexia nervosa tend to fall into the latter (16).
Different treatment options are used for different types of patients with different disorders and levels of motivation to change. The most effective and long-lasting treatment course is usually some form of psychotherapy, though some medications have also been shown to be helpful in certain patients. Treatment must not only address the psychological and interpersonal issues surrounding the disorder, but must also, of course, take into account the nutritional and medical symptoms associated with eating disorders (17). Many patients benefit from outpatient therapy which may include group or family therapy in addition to individual sessions (18). Family based therapy, which involves changes on the parent and family level as well as at an individual level, has been shown to be particularly helpful for patients with anorexia nervosa (16-17). Unsurprisingly, this type of therapy has also proven to be helpful in patients with little motivation to change their behavior who are often anorexic patients rather than those with bulimia or binge eating disorder (16). Cognitive-behavioral therapy, which helps patients change unrealistically negative thoughts, and interpersonal therapy, which helps patients improve their relationships and address conflicts in a healthy way, have both shown promise in treating patients with bulimia. Some research on dialectical behavior therapy, which is a skills-based treatment, has also shown promise for its use in patients with eating disorders, though further research is needed in this area (19).
Comorbidity of PTSD and an eating disorder can pose a major challenge in treatment (6, 12). If the eating disorder is serving as a coping mechanism for PTSD symptoms, then patients may relapse or may not make a successful recovery when they find they can’t cope with their past traumatic experiences anymore. One potential solution to this challenge is to use trauma focused or trauma informed therapy, which involves directly talking about traumatic events with the goal of perceiving the trauma and its meaning in new ways (13). While there hasn’t been much research on the use of this method for eating disorders, it has been shown to be an effective model for providing traumatized children and adolescents, and their caregivers, with a multitude of skills including those for stress management, relaxation, and coping with intrusive thoughts. The therapy does this through psychoeducation and both individual and joint parent-child sessions, in which the parent and child are gradually exposed to the traumatic experience. This type of therapy is not for every child who has experienced trauma, but it is certainly helpful for those who are experiencing issues related to that trauma, including PTSD and potentially eating disorders (20). Many researchers agree that PTSD and traumatic experiences need to be assessed in eating disorder treatment for the best chance at a full and successful recovery (6, 7, 12, 21). Whether the best course of action is to treat the symptoms concurrently or separately remains to be seen, and relies largely on the individual patient. Future directions for research would benefit from randomized control trials that incorporate trauma focused therapy into already established eating disorder treatment, perhaps this approach would lead to higher success rates and less resistance in treatment.