Due to the high comorbidity between disordered eating after a traumatic experience, understanding the association between the two is pertinent to the conceptualization of a person experiencing such stressors. There is an increasing amount of literature suggesting that many of those with eating disorders (ED) also have a history of psychological trauma (Mitchell et al., 2012). Not all survivors of trauma have eating disorder pathology and not all people with eating disorders have a history of trauma; however, there is a known association between the two. In one clinical sample of women diagnosed with an eating disorder, nearly 70% reported exposure to a traumatic event (Hepp et al., 2007). In this same sample, 50% reported symptoms indicative of a diagnosis of posttraumatic stress disorder (PTSD). As for the general population, a national survey of 4,008 American women found that 69% reported experiencing trauma (Gold, 2008). Of that sample, roughly 12% endorsed a lifetime history of PTSD and around 5% endorsed PTSD in the previous six months. Despite the similarities in exposure to trauma between the general population and the disordered eating population, according to these samples, clients with disordered eating are at least four times more likely to have a PTSD diagnosis.
Persin (2016) describes how trauma may impact self-worth and self-esteem. She theorized that trauma experiences lower the capacity to tolerate or regulate emotions, and thus contributes to the manifestation of disordered eating. The trauma may be separate from the disordered eating, exacerbate pathology, or be intertwined. For example, trauma separate from disordered eating could be seen when eating pathology is present prior to the traumatic experience. Trauma can exacerbate pathology as those with eating disorders have greater sensitivity to social cues (Rorty & Yager, 1996), which could contribute to symptoms such as paranoia or negative self-attributions often seen in PTSD. Trauma and disordered eating can also be intertwined; food, hunger, or bodily discomfort could be used as a physical manifestation of emotional pain. For example, restricting food could be self-punishment for feeling as though the trauma was their fault. As such, treatment must be individualized and tailored to the client to assess the thoughts, feelings, and desires occurring in addition to the behaviors.
People with eating disorders have an elevated risk of physical illness, regardless of their body size (Harrop, 2019; Mitchell & Crow, 2006). Typical health complications include gastrointestinal problems, osteoporosis, dermatological issues, and nutritional abnormalities. These health concerns are seen in populations with trauma as well (Kendall-Tackett, 2009). Thorough assessment of both trauma and eating disorder pathology can aid clinicians in dissecting symptomology to provide appropriate care, as disordered eating and trauma can present in physical illness as well. Consultation with medical care providers is critical with these populations as discrepancies between clinical presentation and diagnostic criteria can lead to misdiagnosis. For example, other presentations, like atypical anorexia, may not satisfy the low weight criteria of anorexia nervosa and take a longer time to identify, leading to worse prognosis (LeBow et al., 2015). Due to this delay, people may not receive care as quickly, which can lead to decreased functioning, especially when comorbid with trauma. Other specified feeding or eating disorder (OSFED) is just as harmful as other eating disorders and client care may be impacted by weight stigma (Veillette et al., 2018). The complexity of trauma and eating disorders can be difficult to parcel out, so understanding the various factors regarding origin pathology, onset of symptoms in relation to the traumatic event, and possible treatment routes is valuable.
When trauma is comorbid with anorexia nervosa (AN), the trauma typically occurs prior to the restriction (Reyes-Rodriguez et al., 2011). Emotional abuse or neglect is the most common form of trauma within AN subtypes, while physical abuse is the least prevalent. One study conducted by Reyes-Rodriguez and colleagues (2011) considered the different types of sexual trauma within AN. Overall, 76% of participants in the sample reported experiencing sexual assault; nearly 41% experienced childhood sexual assault, whereas 35% experienced it in adulthood. This suggests that the developmental time period in which the assault occurred has a small impact on the manifestation of AN. Traumatic experiences, specifically sexual, physical, and emotional childhood trauma, are typically associated with AN-binge purge type (BP; Jaite et al., 2011). Guillaume et al. (2016) found that individuals with AN, no matter their subtype, were also more prone to experience psychiatric disorders like major depressive disorder, bipolar disorder, and substance use disorder. This is important to consider because understanding the driving force behind the disorder is critical to treatment. Understanding the traumatic antecedents which occurred prior to the development of the eating disorder can help the therapist complete a thorough conceptualization and incorporate trauma work into the client’s treatment plan.
Despite inconsistent research findings, bulimia nervosa (BN) appears to be one of the most common eating disorders among individuals with a trauma history (Backholm & Isomaa, 2013). Individuals who have EDs with purging behaviors are more likely to have experienced childhood abuse than individuals with restricting behaviors (Smith et al., 2016). About 30% of adults with BN symptoms report a history of childhood sexual abuse and over 50% of women with BN report a history of physical abuse. Guillaume et al. (2016) noted that individuals with BN were also more likely to have a higher number of suicide attempts after a traumatic event than individuals with AN after a traumatic event. There is also a correlation between both childhood abuse and neglect and suicide attempts among women with BN.
Binge Eating Disorder
Within individuals with binge eating disorder (BED), about 91% of women and 98% of men had reported at least one traumatic event in their lifetime (Mitchell et al., 2012). A history of dissociation is also present within this population; in one study, about 23% of patients with BED reported experiences of dissociation (Palmisano et al., 2017). It is theorized that dissociation may be a function of BED as the frequency of binges is associated with the level of dissociation (La Mela et al., 2010). When individuals with BED experience dissociation, binge eating may occur as a result of a separation between sensory experience and observation of mind (Eshtehardi, 2014). Essentially, there is a lack of experiential presence or awareness of bodily sensations. Moreover, responding to internal cues of when to stop eating may become difficult. Dissociation can lead to emotional numbing, detachment, and lowered awareness to surroundings (Gold, 2008). As such, treatment can include mindfulness, such as grounding techniques, to encourage intuitive or mindful eating.
Other Specified Feeding or Eating Disorder
Current research suggests that other specified feeding or eating disorder (OSFED) is the most prominent type of disordered eating after a traumatic experience. In a study with 845 participants with trauma exposure and eating disorder pathology, 20% met criteria for AN, 33% met criteria for BN, 8% met criteria for BED, and the rest met criteria for OSFED (Backholm & Isomaa, 2013). OSFED, previously known as eating disorder not otherwise specified, is diagnosed when disordered eating pathology does not meet the criteria for a specific disorder (APA, 2013). Most individuals do not meet criteria for AN, BN, or BED, but they may satisfy criteria for an eating disorder which places them in the OSFED category (Striegal-Moore & Bulik, 2007). For example, an individual with OSFED may meet all the criteria diagnostically for AN except the significantly low weight requirement, or a person may satisfy the criteria for bulimia with the exception of bingeing being present. Despite the prevalence of OSFED within the trauma population, this diagnosis is often considered exclusion criteria when recruiting participants for research purposes. The dearth of information for this disorder with comorbid trauma makes reviewing the literature difficult (Backholm & Isomaa, 2013).
Clinical Presentations and Treatment Implications
Survivors of early sexual trauma or other types of abuse report experiencing negative beliefs and thoughts about themselves (Cooper et al., 1998). Such negative beliefs can be seen through extremely negative and focused thoughts about weight and shape. Ultimately, these distorted thoughts have a causal effect on behaviors seen in disordered eating. Traumatic experiences influence negative beliefs about the self, which is associated with a higher risk of eating disorder behavior. Additionally, dissociation plays a role in behaviors such as overeating and compulsive exercise, as it interferes with self-awareness and can contort body image (Jaite et al., 2011). Dissociative eating after a traumatic experience may lead to purging, as seen in BN and AN-BP (Jaite et al., 2011). It is suggested that trauma directly influences eating disorder behavior and that disordered eating can serve as a coping mechanism for trauma-related thoughts and feelings (Brewerton & Brady, 2014). Factors relevant to this process could be experienced bodily (e.g., sensation numbness), socially (e.g., family dynamics and shame), or cognitively (e.g., self-efficacy).
Patients with clinically significant eating disorders have greater sensitivity to social cues, which could be associated with the need to ascribe to socially acceptable behavior, such as societal ideals of thinness and beauty (Rorty & Yager, 1996). A common thread between eating disorder pathology and trauma is the social-affective concept of shame.Through the use of maladaptive behaviors and harsh self-criticism, the function of restrictive eating disorder pathology for some may be to become more socially valued through becoming thinner or engaging in actions that are associated with thinness. Furthermore, the maintenance of PTSD symptoms are related to shame and persistent self-criticism. This can lead to feelings of paranoia that there is an ongoing social-evaluative threat. Additionally, shame is associated with feelings of worthlessness and powerlessness, which are often seen in those who have a history of abuse and disordered eating. Shame, like experiences of trauma, may be difficult to disclose in clinical populations out of fear of being exposed and rejected (Øktedalen et al., 2014).
Environmental factors also play a role in the development of disordered eating. Family behavior after a traumatic event occurs, specifically in terms of empathetic responses, is associated with levels of dissociation and desire for control seen in disordered eating (de Groot & Rodin, 1999). Similarly, disordered eating can be viewed as a method to calm and relieve anxiety, or numb uncomfortable feelings linked with trauma (Harned & Fitzgerald, 2002). According to this conceptualization, disordered eating facilitates a feeling of control over life events (Meyer, 2008). Since many traumatic events lead individuals to feel out of control, this is one hypothesized mechanism that links trauma to higher levels of disordered eating.
Dialectical behavioral therapy (DBT) and acceptance and commitment therapy (ACT) are effective and promising treatments for eating disorders (Shumlich, 2017). Eating disorders are often resistant to treatment, but these third-wave cognitive behavioral therapies address aspects of eating disorder pathology other than the behavior, such as emotion regulation in DBT and experiential acceptance in ACT. It is shown that therapy with environmental and pragmatic change strategies (Hayes et al., 2004), such as DBT and ACT, improve emotion regulation skills. This can assist with interpersonal deficits and provide skills for coping with impulsivity (Shumlich, 2017), which can reduce both disordered eating and trauma symptomatology. In order to better understand disordered eating and comorbid trauma, more research is needed to enhance conceptualization and treatment outcomes.
- Individuals with disordered eating are more likely to have a trauma history. Therefore, it is important for eating disorder specialists to provide trauma-informed care when necessary and incorporate trauma into the conceptualization of the client. More information on trauma informed care can be found here: http://www.traumainformedcareproject.org
- It is more likely that an individual with trauma will present with OSFED after a traumatic experience, rather than AN, BN, or BED. Therefore, it is important to consider eating disorder behaviors and symptoms, rather than one’s body weight, size, or shape.
- Shame and self-criticism are socially-informed issues that are common among these two comorbid disorders.
- Dissociation may be occurring during binge eating episodes, so thorough assessment is important to investigate dissociative symptoms during disordered eating pathology.
- Environmental and relational factors play a large part in disordered eating and trauma pathology. As such, interventions that incorporate interpersonal effectiveness and communication skills may improve treatment outcomes.
Cite This Article
Ross-Nash, Z., & Brochu, P. (2020, October). The importance of trauma-informed care in eating disorder treatment. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/the-importance-of-trauma-informed-care-in-eating-disorder-treatment
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association.
Backholm, K., & Isomaa, R., (2013). The prevalence and impact of trauma history of eating disorder patients. European Journal of Psychotraumatology, 4(1). https://doi.org/10.340240.22482
Brewerton, T.D., & Brady, K.T. (2014). The role of stress, trauma, and PTSD in the etiology and treatment of eating disorders, addictions, and substance use. In T.D Brewerton & A.B. Dennis (Eds.), Eating disorders, addictions, and substance use disorders (pp. 379-404). http://doi.org/10/1007/978-3-642-45378-6_17
Cooper, M., Todd, G., & Wells, A. (1998). Content, origins, and consequences of dysfunctional beliefs in anorexia nervosa and bulimia nervosa. Journal of Cognitive Psychology: An International Quarterly, 12(1), 213-230.
De Groot, J., & Rodin, G. M. (1999). The relationship between eating disorders and childhood trauma. Psychiatric Annals, 29(4), 225-228. https://doi.org/10.3928/0048-5713-19990401-10
Eshtehardi, S. (2014). Voices caught within: The embodied experience of women with binge eating disorder (Order No. 3627472). Available from ProQuest Dissertations & Theses Global. (1559188819). Retrieved from http://search.proquest.com.ezproxylocal.library.nova.edu/docview/1559188819?accountid=6579
Gold, S. N. (2008). The relevance of trauma to general clinical practice. Psychological Trauma: Theory, Research, Practice and Policy, S(1), 114-124. https://doi.org/10.1037/1942-9681.S.1.114
Guillaume, S., Jaussent, I., Maimoun, L., Ryst, A., Seneque, M., Villain, L., Hamroun, D., Lefebvre, P., & Renard, E. (2016). Associations between adverse childhood experiences and clinical characteristics of eating disorders. Scientific Reports, 6, 35761. https://doi.org/10.1038/srep35761
Harrop, E. (2019). 3201 Patient Perceptions of Healthcare Provider Interactions among Higher-Weight Women with Eating Disorders: Opportunities for Earlier Screen, Improved Referral, and Increase Clinician Rapport. Journal of Clinical and Translational Science, 3(S1), 151-151. Doi:10.1017/cts.2019.343
Harned, M. S., & Fitzgerald, L. F. (2002). Understanding a link between sexual harassment and eating disorder symptoms: A mediational analysis. Journal of Consulting and Clinical Psychology, 70(5), 1170-1181. http://doi.org /10.1037/0022-006X.70.5.1170
Hayes, S.C., Strosahl, K.D., Wilson, K.G., Bissett, R.T., Pistorello, J., Toarmino, D.,… McCurry, S.M. (2004). Measuring experiential avoidance: A preliminary test of a working model. Psychological Record, 54, 553-578. https://doi.org/10.1007/BF03395492
Hepp, U., Spindler, A., Schnyder, U., Kraemer, B., & Milos, G. (2007). Post-traumatic stress disorder in women with eating disorders. Eating Weight Disorders, 12(1), 24-27. https://doi.org/10.1007/bf03327778
Jaite, C., Schneider, N., Hilbert, A., Pfeiffer, E., Lehmukuhl, U., & Salbach-Andrae, H. (2011). Etiological role of childhood emotional trauma and neglect in adolescent anorexia nervosa: a cross-sectional questionnaire analysis. Psychopathology, 45(1), 61-66. https://doi.org/10.1159/000328580
Kendall-Tackett, K. (2009). Psychological trauma and physical health: A psychoneuroimmunology approach to etiology of negative health effects and possible interventions. Psychological Trauma: Theory, Research, Practice, and Policy, 1(1), 35–48. https://doi.org/10.1037/a0015128
La Mela, C., Maglietta, M., Castellini, G., Amoroso, L, Lucarelli, S. (2010). Dissociation in eating disorders: relationship between dissociative experiences and binge-eating episodes. Comprehensive Psychiatry, 51(4), 393-400.doi:10.1016/j.comppsych.2009.09.008
Lebow, J., Sim, L. A., & Kransdorf, L. N. (2015). Prevalence of a history of overweight and obesity in adolescents with restrictive eating disorders. Journal of Adolescent Health, 56, 19–24. https://doi.org/10.1016/j.jadohealth.2014.06.005
Mitchell, J., & Crow, S. (2006). Medical complications of anorexia nervosa and bulimia nervosa. Current Opinion in Psychiatry, 19(4). 438-443. https://doi.org/10.1097/01.yco.0000228768.79097.3e
Mitchell, K.S., Mazzeo, S.E., Schlesinger, M.R., Brewerton, T.D., & Smith, B.N. (2012). Comorbidity of partial and subthreshold PTSD among men and women with eating disorders in the national comorbidity survey-replication study. International Journal of Eating Disorders, 45, 307-315. http://doi.org/10/1002/eat.20965
Meyer, S. B. (2008). Functional analysis of eating disorders. Journal of Behavior Analysis in Health, Sports, Fitness and Medicine, 1(1), 26-33. http://doi.org/10.1037/h0100365
Øktedalen, T., Hagtvet, K. A., Hoffart, A., Langkaas, T. F., & Smucker, M. (2014). The trauma related shame inventory: Measuring trauma-related shame among patients with PTSD. Journal of Psychopathology and Behavioral Assessment, 36(4), 600-615. http://doi.org/10.1007/s10862-014-9422-5
Palmisano, G. L., Innamorati, M., Sarracino, D., Bosco, A., Pergoloa, F., Scaltrito, D., (2017). Trauma and dissociation in obese patients with and without binge eating disorder: A case- control study. Congent Psychology 5(1). DOI: 10.1080/23311908.2018.1470483
Reyes-Rodríguez, M. L., Von Holle, A., Ulman, T. F., Thornton, L. M., Klump, K. L., Brandt, H., Crawford, S., Fichter, M. M., Halmi, K. A., Huber, T., Johnson, C., Jones, I., Kaplan, A. S., Mitchell, J. E., Strober, M., Treasure, J., Woodside, D. B., Berrettini, W. H., Kaye, W. H., & Bulik, C. M. (2011). Posttraumatic stress disorder in anorexia nervosa. Psychosomatic medicine, 73(6), 491–497. https://doi.org/10.1097/PSY.0b013e31822232bb
Rorty, M., & Yager, J. (1996) Histories of childhood trauma and complex post-traumatic stress sequelae in women with eating disorders. Psychiatric Clinics of North America, 19, 773-791. http://doi.org/10.1016/S0193-953X(05)70381-6
Shumlich, E. J. (2017). Dialectical behaviour therapy and acceptance and commitment therapy for eating disorders: Mood intolerance as a common treatment target. Canadian Journal of Counselling and Psychotherapy, 51(3), 217-229.
Smith, C. E., Pisetsky, E. M., Wonderlich, S. A., Crosby, R. D., Mitchell, J. E., Joiner, T. E., & Peterson, C. B. (2016). Is childhood trauma associated with lifetime suicide attempts in women with bulimia nervosa? Eating and Weight Disorders, 21(2), 199-204. http://doi.org /10.1007/s40519-015-0226-8
Veillette. L. A. S., Serrano, J. M., & Brochu, P. M. (2018) What’s weight got to do with it? Mental health trainees’ perceptions of a client with anorexia nervosa symptoms. Frontiers Psychology, 9, 2574. https://doi.org/10.3389/fpsyg.2018.02574