The Links Between PTSD and Eating Disorders
Published on Psychiatric Times
(http://www.psychiatrictimes.com)
The Links Between PTSD and Eating Disorders
May 01, 2008 | Comorbidity In Psychiatry [1], Dissociative Identity Disorder [2], Traumatic Stress
Disorders [3], Major Depressive Disorder [4], PTSD [5], Addiction [6], Alcohol Abuse [7], Amnesia [8]
By Timothy D. Brewerton, MD [9]
Despite an abundance of studies linking both traumatic experiences and anxiety disorders with
eating disorders, relatively little has been reported on the prevalence of associated posttraumatic
stress disorder (PTSD) or partial PTSD in patients with eating disorders.
Despite an abundance of studies linking both traumatic experiences and anxiety disorders with
eating disorders, relatively little has been reported on the prevalence of associated posttraumatic
stress disorder (PTSD) or partial PTSD in patients with eating disorders. The National Women's Study,
dating back more than 10 years, remains the only detailed study of crime victimization histories,
resultant PTSD, and associated psychiatric comorbidity, including eating disorders, in a
representative sample of women in the United States.1 This article presents the case for a link
between PTSD and eating disorders. The prevalence of comorbid PTSD and eating disorders is
discussed with an explanation of a mechanism that may explain the connection, followed by
treatment options and reasons for caution.
Prevalence
In the National Women's Study, both current and lifetime PTSD prevalence were found to be
significantly higher in persons with bulimia nervosa than in those without bulimia nervosa (current:
21% vs 4%, P < .001; lifetime: 37% vs 12%, P < .001). Those who met DSM-IV criteria for binge
eating disorder also had a significantly higher lifetime prevalence of PTSD (22%) compared with
control participants (P < .01), although there was no significant difference in current PTSD
prevalence. One of the critical findings from this study was that prevalence of bulimia nervosa was
significantly greater in individuals with histories of rape with PTSD (10.4%) than in those with
histories of rape without PTSD (2.0%) and in those with no history of rape (2.0%). These findings
strongly imply that it is abuse resulting in PTSD (rather than abuse per se) that significantly
increases the chances of later developing bulimia nervosa.2 Lifetime PTSD also predicted the
associated comorbidities of major depression and alcohol abuse/dependence with bulimia
nervosa.3 None of the study participants with anorexia nervosa had a history of PTSD.
Studies of clinical samples also indicate higher than expected rates of PTSD in patients with eating
disorders. In one report, 74% of 293 women attending residential treatment indicated that they had
experienced a significant trauma, and 52% reported symptoms consistent with a diagnosis of current
PTSD based on their responses on a PTSD symptom scale.4 Forty-seven percent of 112 patients with
anorexia nervosa and 62% of patients with bulimia nervosa met PTSD criteria. It was not clear from
this study what percentage of the anorexia nervosa patients also binged and/or purged. However,
taken together, the overall research literature has linked histories of trauma and PTSD with bulimic
disorders, including bulimia nervosa, binge eating disorder, and anorexia nervosa of the
binge-eating/purging type, as opposed to anorexia nervosa of the restricting type.2,5-9
In a clinical sample of 44 patients who recovered from bulima nervosa, 20 abused patients showed a
trend toward more frequent diagnoses of PTSD over their life span and more frequent substance
dependence than did the 24 nonabused patients.10 Lipschitz and colleagues11 reported on the
associated comorbidity among 74 adolescent inpatients. PTSD was the most common diagnosis
(36%), and eating disorders were significantly more frequent in the PTSD group (25%) than in the
non-PTSD group (6%, P < .03). In addition, hospitalized adolescent males with PTSD were more likely
to have comorbid eating disorders, other anxiety disorders, and somatization. Unfortunately, the
types of eating disorders in these patients were not described.
In a large national sample of 24,041 hospitalized female veterans, those inpatients with an eating
disorder diagnosis had higher rates of anxiety disorders, especially PTSD, as well as borderline
personality disorder (BPD).12 The point prevalence of PTSD in women inpatients with an eating
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The Links Between PTSD and Eating Disorders
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disorder was 25% compared with 8% in inpatients who did not have an eating disorder. The authors
noted that there was very little overlap between those with PTSD and BPD in that only 12.5% of the
inpatients with BPD also had a diagnosis of PTSD.
In a study of 2436 women at a long-term residential treatment center, the rates of PTSD significantly
differed across eating disorder diagnoses (P < .05), with the highest rates occurring in patients with
anorexia nervosa binge-eating/purging type (25%) and the lowest rates occurring in patients with
anorexia nervosa restricting type (10%). Intermediate PTSD rates were found in those with bulimia
nervosa (23%) and in those with eating disorder not otherwise specified (23%).13
Thompson and associates14 investigated rates of PTSD symptoms and other psychopathology in 97
women who: (1) had been sexually abused in childhood only; (2) had been raped in adulthood only;
(3) had been both sexually abused during childhood and raped during adulthood; or (4) had never
been sexually abused. All participants were assessed using the Structured Clinical Interview for
DSM-IV and the Modified PTSD Symptom Scale Self-Report. Women who reported sexual trauma,
regardless of age, were significantly more likely to exhibit psychopathology than controls, including
higher rates of both PTSD and eating disorders. Rates of PTSD diagnosis were 6 to 7 times higher in
the 3 trauma groups than in the control group, and rates of an eating disorder diagnosis were 5
times higher.
In a study of 257 female patients evaluated at an anxiety disorders clinic who had principal
diagnoses of an anxiety disorder (PTSD, generalized anxiety disorder, panic disorder,
obsessive-compulsive disorder, or so-cial phobia), only PTSD and social phobia were significantly
related to eating disorder symptoms. These 2 anxiety disorders accounted for significant, unique
variance in eating disorder pathology.15
All of the above studies took place in the United States, where PTSD rates are high; however, 2
studies completed in Europe provided a very different perspective. In Switzerland, Hepp and
colleagues16 assessed the frequency of comorbid PTSD in 277 women with DSM-IV-defined eating
disorders, including 84 with anorexia nervosa, 152 with bulimia nervosa, and 41 with eating disorder
not otherwise specified using the Structured Clinical Interview for DSM-IV.16 None of the participants
had current PTSD, and only 4 participants (1.4%) met lifetime criteria for PTSD. However, the authors
noted that Switzerland has an extremely low base rate of PTSD in the general population. In a Zurich
cohort of over 4500 adults, the 12-month prevalence using DSM-IV criteria was found to be 0% for
PTSD, 2.2% for subthreshold PTSD in females, and 0.26% for subthreshold PTSD in males.17
In a study undertaken in Great Britain, 164 consecutive referrals to the Eating Disorders Unit at the
Maudsley Trust Hospitals who met criteria for anorexia nervosa (n = 90), bulimia nervosa (n = 54),
or eating disorder not otherwise specified (n = 20) were assessed for PTSD using the Structured
Clinical Interview for DSM-III-R.18 In the overall sample only 4% met criteria for current PTSD and 11%
met criteria for lifetime PTSD. Patients with anorexia nervosa had PTSD rates (10%) similar to those
of patients with bulimia nervosa (13%) and those who had eating disorder not otherwise specified
(10%).
Reasons for a link
The potential reasons for an association between severe trauma, PTSD, and bulimic disorders,
especially bulimia nervosa, have been discussed in detail elsewhere.2,5,8,9 It has been hypothesized
that eating disordered behaviors, particularly purging behaviors, serve to facilitate avoidance of
traumatic material and to numb the hyperarousal and emotional pain associated with traumatic
memories and thoughts. Purging may also promote forgetting parts or all of a traumatic event (ie,
dissociative amnesia). Several studies have reported higher rates of dissociative symptoms in
bulimic patients than in controls, and in the National Women's Study, 27% of patients with bulimia
nervosa endorsed forgetting all or part of traumatic memories compared with 11% of participants
who did not have an eating disorder.8 Thus, bulimia often serves as a maladaptive coping strategy in
the same way substance abuse does in relationship to trauma and PTSD.2,3,19
Treatment
Treatment approaches for PTSD and trauma-related disorders have advanced considerably over the
past several years. The most empirically validated treatments for PTSD include cognitive-behavioral
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therapy (CBT) with prolonged exposure (PE), eye movement desensitization reprocessing (EMDR),
and pharmacotherapy,20-25 although CBT with PE appears to be the most effective and long-lasting
modality. Psychodynamic psychotherapy that involves the processing of traumatic material may also
be useful.24,26 Dialectical behavior therapy can be effective in BPD and other trauma-related
diagnoses characterized by affective dysregulation, including PTSD, bulimia nervosa, impulse control
disorders, and dissociative disorders.23,25,27-31
There are no published treatment studies or guidelines specifically involving patients with eating
disorders and PTSD. The principles of treatment for such patients are based on practice guidelines
for the individual conditions. The American Psychiatric Association has published guidelines for both
eating disorders and PTSD. An attempt to combine these principles into an integrated approach for
the traumatized patient with a comorbid eating disorder has been detailed elsewhere.2,5 In addition,
a case formulation approach has been described that can be used to integrate empirically supported
treatments for various comorbid conditions, including PTSD and eating disorders.32,33
In the case formulation approach, the clinician applies hypotheses about potential mechanisms that
cause and perpetuate dysfunctional behaviors. This is combined with the adoption of empirically
validated treatments for each case that includes hypothesis testing and continuous collection of data
to assess progress and process. A critical component of this approach is to determine the functional
mechanisms that link problem behaviors or disorders.2 In other words, what is the function of the
symptom? For example, a common hypothesis is that bulimic behaviors, such as self-induced
vomiting and laxative abuse, act to facilitate or promote numbing and avoidance of trauma-related
memories, dreams, feelings, thoughts, and behaviors, and decrease or blunt associated
hyperarousal.
To the degree that this theory is verified by the patient, this makes way for learning healthier coping
strategies to effectively deal with the underlying issues without the adverse consequences. In this
integrated line of attack, evidence-based treatments for eating disorders, such as CBT for PTSD, can
be woven into a phasic deployment of interventions that are modified to the needs of the individual.
CBT is clearly the most empirically supported form of psychotherapy for eating disorders and for
most forms of trauma-related comorbidity, including PTSD, major depression, other anxiety
disorders, and substance use disorders. Consequently, CBT has nearly universal application in this
highly comorbid group and can serve as the foundation on which other therapeutic interventions
may be supplemented, such as interpersonal psychotherapy, pharmacotherapy, family therapy, or
psychodynamic psychotherapy.
Although CBT for PTSD has a number of key ingredients, such as anxiety reduction skills training,
rec-ord keeping, cognitive therapy, and relapse prevention, the inclusion of prolonged exposure with
cognitive reprocessing appears to be critical to the successful resolution of PTSD.21,22,34-36 EMDR
seems to include most of these components and can be an acceptable treatment alternative for
PTSD.37 Studies indicate that EMDR is as efficacious as CBT with PE as well as fluoxetine, at least in
the short term.38,39 More recent comparison studies indicate that CBT with PE may have more lasting
benefit than EMDR (B. Rothbaum, unpublished data, January 2008).
Diagnostic issues and complications
There are several issues that may arise in the course of evaluating and treating the traumatized
patient with an eating disorder. To some extent, this depends on the level of skill, training, and
experience of the clinician, but these patients are challenging to even the most seasoned clinicians.
A common mistake made by therapists inexperienced in the treatment of eating disorders is to not
fully appreciate the need for nutritional rehabilitation (relative normalization of weight and eating)
before beginning actual exposure work. Another error is to fail to properly teach and demonstrate
anxiety reduction skills or stress inoculation training before tackling traumas directly. In either case,
it is easy for patients to become so overwhelmed with emotionally laden material that they are
unable to process physiologically, psychologically, or both, and they, in turn, revert back to their
familiar coping methods involving self-destructive but nevertheless numbing and avoidant
disordered eating behaviors.
Some clinicians may not be familiar with the empirically based treatments for PTSD and/or bulimia
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The Links Between PTSD and Eating Disorders
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nervosa, particularly CBT, and require specialized supervision and/or training before real progress
can be made. In these situations, the clinician would do well to consider making a referral to
someone who specializes in this area in order to better serve the patient's needs. Another common
mistake is to not continue the "prolonged" exposure long enough until there is true extinction of
hyperarousal and avoidance responses. Clinicians who are not versed in behavior therapy may
unintentionally and unconsciously collude with the avoidance of the patient.
Vicarious traumatization can be a valid concern for therapists who are doing trauma work, and it is
important to acknowledge that patients' recounting of their traumatic experiences may trigger
therapists' own issues. The control and processing of both negative and positive countertransference
is especially critical in this work given the dangers of retraumatization.
In general, patients will show a relative readiness (or decreased resistance) to commence more
intensive trauma work when their eating disorder symptoms are under sufficient control, their brains
are being well-nourished (thereby normalizing neurotransmitter function),40 and they have mastered
some anxiety reduction skills. Patients are consequently much better able to adequately process
painful experiences and integrate them emotionally and cognitively.
Given the significant trust issues that these patients often have, it is common for them to not feel
safe enough to disclose abuse or important details about their abuse until they have progressed well
into their course of therapy. Previous threats to patients made by perpetrators not to disclose abuse
may remain operative in the form of maladaptive beliefs. As a result, an occasional re-assessment of
any relevant trauma history can be productive.
It is important to note that once nutritional and weight stabilization occurs, delayed PTSD may
emerge de novo or previously diagnosed PTSD may get worse in the absence of the patient's usual
avoidance and numbing strategies. Sometimes patients do not begin to even recognize that they
have been abused until the precise definitions of abuse and neglect have been explained to them.
Once their cognitive set changes in such a way that they can perceive past traumatic experiences as
abusive, delayed PTSD symptoms may appear. Recovering patients may even remember earlier
traumatic events or significant details of events that they had previously forgotten once full
nutritional stabilization has taken place and they feel safer, stronger, and more supported.
It is important for therapists to contain any "rescue" fantasies that they may harbor and refrain from
using techniques designed to recover memories, such as hypnosis or amobarbital interviews,
because these are fraught with dangers such as the induction of false memories. Traumatized eating
disorder patients may be particularly vulnerable to this given their high degree of hypnotizability.41 In
addition, if any previous traumatic events are reported by patients, it is imperative that clinicians
recognize and observe all reporting laws mandated by their discipline and national, state, and local
governments.
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[2] http://www.psychiatrictimes.com/dissociative-identity-disorder
[3] http://www.psychiatrictimes.com/traumatic-stress-disorders
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