Introduction, The etiology of eating disorders is multifaceted and complex. Many factors have been suggested to contribute to the development of eating disorders, including temperamental dispositions, family history, and difficulties regulating emotions. One factor contributing to emotion regulation difficulties is experiences of trauma, which often create strong negative emotions and intrusive thoughts that can be difficult to tolerate, frequently resulting in maladaptive attempts to regulate these emotions. One such method may be engaging in eating-disordered behaviors, including restricting, bingeing, and purging. These behaviors may give an individual a sense of control when traumatic experiences leave them helpless and vulnerable. Living with the aftereffects of trauma and an eating disorder can be exceptionally difficult, and these symptoms are often debilitating, preventing individuals from living full and meaningful lives. Fortunately, a few evidence-based treatments have been shown to target the cognitive, behavioral, and emotional patterns frequently seen in individuals with post-traumatic stress disorder (PTSD). This review aims to provide information regarding the prevalence of traumatic experiences and PTSD in eating disorder populations, discuss available treatment options, and explore the experiences of treating clinicians.
Trauma and Its Consequences General population studies have shown that many people have been exposed to at least one traumatic event in their lifetime (Benjet et al., 2016). Trauma comes in many forms and can be experienced by individuals of all ages, backgrounds, and circumstances. Traumatic events include, but are not limited to, childhood abuse, sexual assault, accidents, natural disasters, and intimate partner violence. In addition, trauma may include being directly involved in the event, witnessing the event, or repeated or extreme exposure to details of the event. Traumatic events may lead to psychological consequences, including nightmares, flashbacks, avoidance, negative mood, distorted beliefs, and hypervigilance. Many individuals experience these symptoms for a brief time, and then the symptoms naturally resolve themselves. However, these symptoms persist for others and can lead to significant distress and impairment. When these criteria are collectively met, an individual is diagnosed with PTSD. Many psychological conditions frequently co-occur with PTSD, including depression, anxiety, substance abuse, and eating disorders.
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Eating Disorders and PTSD Research has indicated that eating disorders are higher in people who have experienced trauma and PTSD. One study indicated that up to 23 percent of patients with anorexia nervosa and 25 percent with bulimia nervosa met the criteria for PTSD (Tagay, , Reyes-Rodriguez, Repic, & Senf, 2014). Among patients attending eating disorder residential treatment, up to 52 percent met the criteria for PTSD (Gleaves, Eberenz, & May 1998). While the research is mixed regarding PTSD prevalence in specific subtypes of eating disorders, some have suggested that bingeing and purging behaviors are more prevalent in individuals with PTSD than restriction (Brewerton, 2004). It has been suggested that overeating may be a form of self-soothing and may numb out unpleasant feelings and intrusive thoughts related to the traumatic event. Purging behaviors are thought to have a similar function, acting to expel unwanted experiences and improve mood. Although the research supports the link between bulimia and PTSD, there has also been speculation that anorexic patients may be using restricting to regulate emotions, particularly those related to trauma. Restriction may result in emotional numbing and a feeling of power that may be desirable to a traumatized individual (Trim, Galovski, Wagner, & Brewerton, 2017). Given the considerable role, these behaviors may take in regulating emotions, giving up the behaviors to recover from the eating disorder is exceedingly difficult.
Treatment for PTSD and Eating Disorders There are many important considerations that therapists (and their patients) must deliberate prior to beginning PTSD treatment. Brewerton (2007) describes the need for clinicians to ensure nutritional rehabilitation (most often guided by a dietitian) before proceeding with trauma treatment. Research has demonstrated that anorexia-induced starvation leads to deficits in set-shifting, attention, and decision-making (Treasure & Russell, 2011). These cognitive impairments appear to resolve with adequate weight restoration (Hatch et al., 2010). Another frequent error is failing to ensure appropriate skill acquisition before beginning PTSD treatment. Without adequate distress tolerance, patients may resort to complex coping mechanisms (bingeing, purging, restricting, substance use, self-harm, etc.) (Brewerton, 2007).
When a clinician determines that a patient is ready to begin trauma treatment, there are several evidence-based options from which to choose: cognitive processing therapy (CPT) (Resick, Monson, & Chard, 2014), prolonged exposure (PE) (Foa et al., 1999), and eye movement desensitization and reprocessing (EMDR) (Shapiro, 2001). CPT is based on the premise that people have a strong need to “make sense” of the world and that their beliefs about themselves and the world may shift (or become stronger) after trauma to give themselves a sense of control. CPT emphasizes psychoeducation in the first session, providing information about the nature of PTSD and the role of avoidance in maintaining symptoms. In subsequent sessions, patients are guided through a series of cognitive exercises and given homework assignments to continuing these exercises outside the treatment room. Socratic questioning is used to aid the patients in arriving at new and more balanced beliefs about the trauma, its causes, and its effects. PE is rooted in the framework of emotional processing theory. It may be especially aimed at patients who exhibit significant emotional avoidance. PE involves four therapeutic components: psychoeducation, in vivo exposure, imaginal exposure, and emotional processing (Cukor, Olden, Lee, & Difede, 2010). Patients are guided through imaginal exposures that involve revisiting memories and triggers related to the trauma.
In contrast, in vivo exposures help the patient approach places, people, and activities they may have been avoiding. These components facilitate emotional processing so that habituation may occur and avoidance can decrease. EMDR is multi-theoretical in its orientation in that it incorporates etiological events, conditioned responses, cognitions, and emotional processing (Shapiro, 2001). EMDR entails having the patient focus on emotionally distressing topics or stimuli while simultaneously attending to an external cue (eye movements, hand tapping, etc.). The goal of EMDR is to completely process a traumatic experience and the associated emotions and decrease subjective distress.
Unfortunately, research examining these treatments specifically in eating disorder populations is scarce. Trim and colleagues noted that only two outcome studies had been conducted on PTSD treatment in eating disorder samples. Both studies (Mott, Menefee, & Leopolous, 2012; Mitchell, Wells, Mendes, & Resick, 2012) examined the use of CPT and showed improvement in symptoms of PTSD. To date, no research has been conducted on whether eating disorder patients have better outcomes in one of these PTSD treatments versus another (i.e., CPT, PE, EMDR). In deciding between these treatments, it should be noted that all are evidence-based, and similar outcomes have been found for each (Trim et al., 2017). One consideration should be a patient preference, as it has been shown to contribute to patient outcomes (Schumm, Walter, Bartone, & Chard, 2015).
Clinician Experience Recent research has examined clinicians’ perspectives and concerns with providing trauma treatment to eating disorder patients (Trottier, Monson, Wonderlich, MacDonald, & Olmsted, 2017). Trottier and colleagues used a sample of clinicians working in a wide range of settings (e.g., inpatient, outpatient, college counseling, and eating disorder treatment centers) representing a wide range of theoretical orientations. Their study found that therapists felt it extremely important to address trauma-related symptoms and considered them a significant obstacle to achieving eating disorder recovery. However, they also expressed uncertainty about integrating trauma therapy with eating disorder treatment. In addition, therapists expressed only moderate familiarity and comfort with and utilization of evidence-based trauma therapies. Therapists anticipated complications, including worsening self-harm, suicidality, eating disorder symptoms, and substance use. However, they also reported anticipated benefits, including increased treatment retention, improved therapeutic alliance, and decreased relapse rate. Trottier and colleagues (2017) stated that the extent to which therapists reported concerns and uncertainty is problematic because it may impair their ability to provide evidence-based and integrated trauma treatment.
For therapists who do provide trauma treatment, there are additional concerns regarding their well-being. In recent years, considerable attention has been given to the experience of clinicians providing trauma treatment. The literature has suggested there are costs to being exposed to another’s trauma and from the emotional investment in providing empathic support and guidance. Several terms have been used to describe the types of suffering a clinician may experience, including “secondary traumatic stress,” “vicarious traumatization,” and “compassion fatigue.” An exploration of cross-clinician variables found that clinicians with a “self-sacrificing” defense style were particularly vulnerable to vicarious traumatization (Adams & Riggs, 2008). In addition, it appears that therapist schemata related to self-safety relate to vicarious traumatization (Devilly, Wright, & Varker, 2009). Thus, therapists whose beliefs about their safety are affected by hearing the accounts of their patients’ traumas may be most susceptible to vicarious traumatization. Given the inevitable toll that trauma work takes on therapists, it is important to consider protective and resilience factors and strategies that therapists may employ. Brewerton (2007) warns clinicians to be wary of the desire to “rescue” patients during trauma treatment. This can lead to the use of unhelpful and ineffective therapy approaches. Figley (2002) offered a model of factors contributing to compassion fatigue and suggested that disengagement (distancing oneself from the patient between sessions) may lower therapist compassion stress. Figley further suggested bolstering social supports and engaging with others outside the “therapist persona.”
Conclusion In sum, a significant portion of patients with eating disorders have experienced a traumatic event, and many of these patients meet the criteria for PTSD. It may be that engaging in eating disorder symptoms is a means of coping with the experiences involved in PTSD. Fortunately, evidence-based therapies for PTSD exist, although the evidence for these treatments in eating disorder populations is still emerging. There are barriers to providing these treatments, including clinician concerns and familiarity with evidence-based treatments. There is a need for further research in the field of eating disorders and PTSD. Future research should continue to explore the efficacy of PTSD treatments in patients with eating disorders and ways to improve clinicians’ confidence and comfort in delivering these therapies. This is a vulnerable population for whom treatment is desperately needed. Our therapists are responsible for continuing to explore and strengthen this field.
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