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Trauma and Eating Disorders

* TW: This blog post discusses trauma and abuse. Reader discretion is advised.

It is important to identify risk factors connected to eating disorders and comorbid conditions, as well as appropriate treatments. To facilitate full recovery for individuals diagnosed with various eating disorders, risk factors and comorbidities must also be addressed. One such risk factor related to eating disorders that has been repeatedly identified is the presence of trauma (Brewerton, 2004). Considerable data has supported this significant relationship between various types of trauma and specific eating disorders (Afifi, et al., 2017). According to the Substance Abuse and Mental Health Services Administration (SAMHSA), millions of individuals in the United States experience concurrent mental health diagnoses or addiction disorders (SAMHSA, 2014). Treating one mental health diagnosis and not a co-occurring addiction or other mental health disorder would not only waste already limited mental health resources but would severely impact patient outcomes in a negative way, as well as prevent advancements in assessment and treatment related research (Brewerton, 2004). In order to provide adequate care to patients diagnosed with eating disorders as a result of trauma related conditions, it is essential to identify treatment practices that address these multiple conditions. Understanding the prevalence of these trauma conditions and their relationship with specific eating disorder subtypes can better address the needed individualized treatment plan.

Considering what types of trauma are related to increased eating disorder risk can be an important consideration for future preventative interventions. Currently, child maltreatment is associated with eating disorder risk and includes trauma subcategories such as physical, sexual and emotional abuse, as well as emotional and physical neglect (Afifi, et al., 2017). While eating disorders can be diagnosed at any age, the majority of eating disorder psychopathology occurs beginning in adolescence (The National Eating Disorders Association, 2018). Because of this, when considering trauma’s connection to eating disorder risk, trauma is assessed related to general child maltreatment (Molendijk, et al., 2017). While a practical solution to eating disorder risk would be to decrease the prevalence of child maltreatment, a more realistic and immediate approach would be to prioritize assesses trauma related prevalence concurrently with eating disorder assessments due to the statistically significant association (Molendijk, et al., 2017).

When not sufficiently identified or treated, child maltreatment can commonly be diagnosed as PTSD later in life (NEDA, 2018). PTSD is a mental health diagnosis that can develop after various forms of traumatic exposure and present with symptoms such as hyperarousal or avoidance behaviors, negative re-experiencing symptoms and abnormal psychological or behavioral episodes (NEDA, 2018). Numerous studies have identified a significant association with PTSD and eating disorder prevalence in multiple eating disorder subtypes (Brewerton, 2017). These concurrent diagnoses can be explained through shared risk factors (Brewerton, 2017). These risk factors include a family history of psychological disorders, absence of social support, previous traumatic experiences, or child maltreatment, as well as identifying as female (Brewerton, 2017). Additionally, personality characteristics associated with eating disorders and PTSD include perfectionism and neuroticism, whereas behaviors associated with these two disorders include obsessive-compulsiveness, behavioral inhibition, novelty seeking and harm avoidance (Brewerton, 2017).

Anorexia Nervosa

Individuals diagnosed with AN are significantly more likely to report harmful childhood experiences (Grilo, et al., 1999), report experiences of sexual trauma in childhood (Connors, et al., 1993) or be diagnosed with PTSD (Reyes-Rodríguez, et al., 2011). Evidence that merits a more in-depth consideration includes Madowitz findings that combined 32 articles related to sexual trauma and eating disorder risk (Madowitz, et al., 2015). Eating disorders and AN specifically were connected to sexual assault, abuse, or trauma, depending on the language used (Madowitz, et al., 2015). For example, study participants reported a need to cope and achieve feelings of control following sexual trauma related experiences that are also seen within eating disorder related behaviors (Madowitz, et al., 2015). Madowitz and colleagues also provided two main characteristics that are connected to sexual trauma experiences and the increased severity of AN; these characteristics include negative body perceptions and psychopathology (Madowitz, et al., 2015). Reported sexual abuse among individuals receiving inpatient treatment for AN were reported to have more significant psychopathology (Carter, et al., 2006).

Bulimia Nervosa

Mitchell and colleagues found that trauma in the form of PTSD, as well as subthreshold PTSD is connected to a higher prevalence of binge eating disorder, as well as BN in both male and females (Mitchell, et al., 2012). Supporting this evidence, Reyes-Rodriguez and colleagues provided more evidence to this effect, stating that roughly 37 percent of individuals diagnosed with BN also reported PTSD symptoms (Reyes-Rodríguez, et al., 2011). A strong relationship has been found on several occasions connecting sexual abuse to BN prevalence (Solmi, et al., 2020). Most recently, all subtypes of child maltreatment but most significantly, emotional abuse, was significantly connected to BN psychopathology (Monteleone, et al., 2021). A strong relationship has been found with numerous research groups connecting sexual abuse to BN prevalence (Solmi, et al., 2020).

Binge Eating Disorder

While BED has similar characteristics compared to AN and BN, the eating behaviors and body related attitudes in BED are distinct. Individuals diagnosed with BED are likely to experience increased anxiety and psychopathology, as well be diagnosed with PTSD, mood, anxiety and drug use disorders (Grilo, et al., 2012). Additionally, sexual abuse and physical neglect posed the strongest association with BED, however these findings were found to vary depending on gender (Afifi, et al., 2017). For example, when considering women, sexual abuse and emotional abuse are most related to BED psychopathology, whereas sexual abuse and physical neglect were most related to men (Afifi, et al., 2017).

Practical Implications and Future Directions

While evidence clearly supports a unified approach to treatment for eating disorders and trauma disorders, as well as evidence of interventions that have used these approaches (Brewerton, 2016), barriers to approach implementation should be considered (Brewerton, 2019). A lack of trauma informed treatment adherence can be explained through clinicians reporting feeling uncomfortable applying these findings in everyday practice (in treating eating disorders) (Brewerton, 2019). Other barriers to implementing trauma informed treatment approaches with co-occurring disorders are also related to barriers associated with trust issues commonly found in patients reporting traumatic experiences (Brewerton, 2016). Additionally, weight restoration and nutritional stabilization might exacerbate PTSD symptoms due to limiting eating related coping strategies; this could be one of many factors related to therapy resistance (Brewerton, 2016). If you or someone you know identifies with the information shared in this post, please reach out to the Carruth Center or WVU Dining to be connected with clinicians that can support you.