Links Between Eating Disorders and Traumatic Experiences


Taking part in supporting the Eating Disorders Awareness Week__

Eating disorders can be difficult to understand and a challenge to treat. As they are extremely dangerous to a person’s health, eating disorders are associated with high mortality rates. Among all eating disorders, anorexia nervosa has the highest rate of mortality.

It is well established that trauma and eating disorders are highly correlated. A national study with a sample of 3,006 women found that of people with bulimia nervosa:

• 26.8% reported aggravated assault.

• 36.9% had a history of posttraumatic stress (PTSD).

Research shows most people with anorexia nervosa, bulimia nervosa, and binge eating (BED) have a history of interpersonal (relationship) trauma. This pattern holds true for both men and women. Interpersonal trauma can happen in parent-child or intimate partner relationships. Domestic violence, emotional abuse, sexual abuse, and neglect often cause long-lasting effects.

Possible reasons for the link between trauma and eating disorders

The underlying link between PTSD and eating disorders may involve difficulty in regulating uncomfortable emotions. Binging and purging may function as a way to manage emotions and give the individual a sense of control. However, more research investigating potential causal mechanisms between trauma and eating disorders is needed.

What are the implications of treatment for eating disorders?

Clinicians and programs that treat eating disorders should be alert for signs of PTSD or complex posttraumatic stress (C-PTSD). Similarly, clinicians treating people with PTSD should be alert for potential comorbid eating issues. The effects of treatment can be bidirectional. Treatment for PTSD and C-PTSD may improve outcomes for eating disorders; treatment for eating disorders may have beneficial effects on PTSD symptoms.

Treatment for trauma and eating disorders

If you have an eating disorder, it is important to seek treatment immediately. Your condition can have a serious impact on your physical health and may put your life in danger. If you have a history of trauma or if you feel that you are having difficulty managing your emotions, you may consider finding a therapist who is experienced in treating trauma as well as eating disorders. Addressing the underlying trauma may be an important part of sustainable, long-term recovery.

When you are in therapy for PTSD or C-PTSD, if you have an eating disorder, make sure that your therapist is aware of the disordered eating. If you have experienced trauma and are receiving care for an eating disorder, your therapist should know about your history of trauma.

Simultaneous therapy for trauma and eating disorders

Simultaneous treatment for eating disorders and trauma will likely increase the effectiveness of therapy. If treatment is sought for only the eating disorder, the underlying trauma will not be addressed, and the healing will not be complete.

Studies have also shown individuals with eating disorders often have a susceptibility to stress. Those with anorexia nervosa and/or bulimia nervosa are likely to experience high levels of anxiety sensitivity. In other words, they have a fear of sensations and behaviors they associate with anxiety. For example, they may fear the sensation of losing control and exaggerate inhibitions. These fears can make it difficult for them to feel safe and relaxed.

The overlap between eating disorders and PTSD is significant. If you are experiencing trauma as well as an eating disorder, you will likely benefit from an informed, integrated approach. If you have an eating disorder, your best chance of recovery lies in addressing the underlying trauma simultaneously with the eating disorder.

Common comorbidities with eating disorders:

  • depression.

  • bipolar disorder.

  • panic and anxiety disorders.

  • post-traumatic stress disorder(PTSD)

  • obsessive compulsive disorder (OCD)

  • obsessive compulsive personality disorder (which is different from OCD)

  • borderline personality disorder.

  • sleep disorders.

Unrelated to trauma: Disordered Eating on the Autism Spectrum

Broadly relates to various characteristics, including Behavioral Rigidity, which is a characteristic of many psychopathologies, including autism. In the difficulty in transitioning between activities, environments, or even internal aspects of the same task, behaviour rigidity is often reflective of deficits in self-regulation. Another common characteristic is related to Sensory Abnormalities, which affect hearing, vision, touch, and smell. For all of these systems, atypical sensory functioning is likely to contribute significantly to eating pathologies, though there still is only limited research. A review of olfaction for individuals with ASD found 'possible involvement' of impairment of sensory systems, suggesting more study is merited. Early tactile sensitivities have also been proposed as a contributor to specific food preferences. Some individuals with ASD have eating issues that may become very clinically significant.

Depending on severity, along a spectrum of varied symptoms, sensory experiences such as smells, tastes, textures, noises and body sensations may be uncomfortable and perceived as harmful to those with ASD. When these individuals consistently avoid aversive sensory experiences, they may consume a limited variety of foods. This can cause low energy, malnutrition, arrested growth or weight loss. The result is an eating disorder known as avoidant/restrictive food intake disorder, commonly called ARFID.

Types of Eating Disorders

Food is one of the many mediums through which our emotions and distress can be expressed, so you may have a very difficult relationship with food which impacts on your mental health, but does not fit into any of the current categories of diagnosis. It is also possible to experience more than one eating disorder, or to experience some symptoms from each disorder.

If your problems with eating aren't easy for your doctor to categorise, they might not give you a specific diagnosis. But even if you don't have a diagnosis, or prefer to think about your experiences in a non-medical way, you may find it helpful to understand some of the feelings and behaviours that can be associated with specific eating disorders.

Bulimia nervosa

If you experience bulimia, you may find that you eat large amounts of food in one go because you feel upset or worried (binging). You may then feel guilty or ashamed after binging and want to get rid of the food you have eaten (purging).

You might feel:

  • ashamed and guilty

  • that you hate your body or that you are fat

  • scared of being found out by family and friends

  • depressed or anxious

  • lonely, especially if no one knows about your eating problems

  • very low and upset

  • like your mood changes quickly or suddenly

  • like you're stuck in a cycle of feeling out of control and trying to get control back

  • numb, like feelings are blocked out by bingeing or purging

You might do:

  • eat lots of food in one go (binge)

  • go through cycles of eating, feeling guilty, purging, feeling hungry and eating again throughout the day

  • eat foods that you think are bad for you when you binge

  • starve yourself in between binges

  • eat in secret

  • crave certain types of food

  • try to get rid of food you've eaten (purge) by making yourself sick, using laxatives or exercising excessively

Might happen to your body:

  • you might stay roughly the same weight, or you might go from being overweight to underweight quite often

  • you may be dehydrated, which can cause bad skin

  • if you menstruate, your periods might become irregular or stop altogether

  • if you make yourself sick, your stomach acid can harm your teeth and you can get a sore throat

  • if you use laxatives, you could develop irritable bowel syndrome (IBS), stretched colon, constipation and heart disease.

Anorexia nervosa

If you get an anorexia diagnosis, this is because you are not eating enough food to get the energy you need to stay healthy. Sometimes people assume anorexia is just about slimming and dieting, but it is much more than this. At its core it is often connected to very low self-esteem, negative self-image and feelings of intense distress.

You might feel:

  • like you can't think about anything other than food

  • like you want to disappear

  • that you have to be perfect

  • like you are never good enough

  • lonely, especially if no one knows about your eating problems

  • that by eating you lose the control you feel you need

  • that you are hiding things from your family and friends

  • that you are fat and your weight loss isn't enough

  • very frightened of putting on weight

  • angry if someone challenges you

  • tired and disinterested in things

  • depressed or suicidal

  • anxious

  • a high or sense of achievement from denying yourself food or over-exercising

  • panicky around meal times

You might do:

  • reduce your food intake or stop eating altogether

  • count calories of all your food and spend a lot of time thinking about them

  • hide food or secretly throw it away

  • avoid foods that feel dangerous, like those with high amounts of calories or fat

  • read recipe books and cook elaborate meals for people but not eat them yourself

  • use drugs that say they reduce your appetite or speed up your digestion

  • think about losing weight all the time

  • exercise a lot and have strict rules about how much you need to do

  • make rules about food, like listing 'good' and 'bad' foods or only eating things that are a certain colour

  • develop very structured eating times

  • check and weigh your body all the time

Might happen to your body:

  • you might weigh less than you should or lose weight very fast

  • you might become physically underdeveloped (in particular if anorexia starts before puberty)

  • you may feel weak and move slowly

  • you may feel very cold all the time

  • if you menstruate, your periods might become irregular or stop altogether

  • your hair might thin or fall out

  • you might develop fine fuzzy hair on your arms and face (called 'lanugo')

  • you might lose interest in sex or not be able to have or enjoy it

  • you may find it hard to concentrate

  • your bones may become fragile and you might develop problems like osteoporosis

Binge eating disorder

If you have binge eating disorder you might feel that you can't stop yourself from eating, even if you want to. It is sometimes described as compulsive eating. If you experience binge eating disorder, you might rely on food to make you feel better or to hide difficult feelings.

You might feel:

  • out of control and as if you can't stop eating

  • embarrassed or ashamed

  • lonely and empty

  • very low, even worthless

  • unhappy about your body

  • stressed and anxious

You might do:

  • pick at food all day, eat large amounts all at once (bingeing)

  • eat without really thinking about it, especially when you are doing other things

  • regularly eat unhealthy food

  • eat for comfort when you feel stressed, upset, bored or unhappy

  • hide how much you are eating

  • eat until you feel uncomfortably full or sick

  • try to diet but find it hard

Might happen to your body:

  • you might put on weight

  • you might develop health problems associated with being overweight, such as diabetes, high blood pressure or joint

  • and muscle pain

  • you might experience breathlessness

  • you might feel sick a lot

  • you might experience sugar highs and crashes (having bursts of energy followed by feeling very tired)

  • you might develop health problems such as acid reflux and irritable bowel syndrome (IBS)

Other specified feeding and eating disorder (OSFED)

OSFED is a diagnosis that is becoming more common. In the past you may have been given a diagnosis of eating disorder not otherwise specified (EDNOS) – but this is not usually used any more.

If you are given a diagnosis of OSFED it means that you have an eating disorder but you do not meet all the criteria for a diagnosis of anorexia, bulimia or binge eating disorder. This does not mean that your eating disorder is less serious, it just means that it does not fit into current diagnostic categories. You might experience any of the behaviours, feelings and body changes associated with other eating disorders.

Getting a diagnosis of OSFED can help you access treatment and support.

Other diagnoses related to disordered eating
  • Rumination disorder. If you have rumination disorder you will regularly regurgitate your food (but you do not have a physical health problem to explain it). You might re-chew, re-swallow or spit out the food you regurgitate.

  • Pica. If you have pica, you will regularly eat things that are not food and have no nutritional value (for example chalk, metal or paint). This can potentially be very harmful.

  • Avoidant/restrictive food intake disorder (ARFID). If you have ARFID you will feel a very strong need to avoid food in general or certain foods because of their smell, taste or texture. The idea of eating can fill you with anxiety. ARFID does not tend to be connected to issues with body image – it is an anxiety about the process of eating itself.

Treatments

Talking about your eating problems can be scary, but if you'd like treatment and support, the first step is usually to visit your doctor (GP) or seek personal therapy. They should be able to refer you to more specialist services:

  • Cognitive behavioural therapy for eating disorders (CBT-ED). This is an adapted form of CBT specifically for treatment of eating disorders, including anorexia. There are alternative forms of CBT for bulimia nervosa (CBT-BN) and binge eating disorder (CBT-BED). For anorexia, you should be offered up to 40 sessions, with twice weekly sessions in the first two or three weeks. For bulimia and binge you should be offered at least 20 sessions, and may be offered twice weekly sessions at first.

  • Focal Psychodynamic Therapy (FPT).

  • Family therapy. This means working through issues as a family with the support of a therapist and exploring the dynamics or situations that might have prompted the feelings underlying an eating disorder. It can help your family understand your eating problems and how they can support you. Family therapy is often offered to people with anorexia, especially younger people.

  • Maudsley Anorexia Nervosa Treatment for Adults (MANTRA). This treatment helps you work towards recovery by helping you understand what keeps you attached to anorexia, and gradually learn alternative ways of coping. This should be done at a pace that suits you and your needs. You should be offered at least 20 sessions.

  • Specialist Supportive Clinical Management (SSCM). This is not a type of talking treatment, but talking treatment may be included within it. During SSCM you will have weekly meetings where you receive support for weight gain, physical health checks, education and advice. You will also have a chance to talk about key issues you are experiencing and think more about your symptoms and behaviour.

  • Admission to a clinic: You may need to go into hospital or to a clinic if your doctor or care team feel you are very unwell or underweight, if other kinds of treatment haven’t worked, or if your home environment is making it hard for you to stay well.


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© 2020 by Rozie Pilkington

London Borough of Bromley