Eating Disorders and Posttraumatic Stress Disorder (PTSD)

What is Posttraumatic Stress Disorder (PTSD)?

Posttraumatic Stress Disorder (PTSD) is a serious mental health condition that can develop when someone has been exposed to one or more traumatic events. According to the DSM-5 TR, traumatic events include situations where there is a real or perceived threat of death, serious injury, and/or sexual violence. These events can include those that are directly experienced by someone, witnessing someone else being exposed to trauma, hearing secondhand that a traumatic event has happened to a loved one, and/or repeatedly listening to details of other people’s traumatic experiences (e.g., first responders).¹

Research on Eating Disorders and PTSD

PTSD is a significant risk factor for the development of an eating disorder and co-occurs with eating disorders at a much higher rate than the general population. For example, while it is estimated that 6.8% of adults and up to 8% of adolescents in the United States will meet the diagnostic criteria for PTSD at some point in their lives, studies have found that on average 25% of people with eating disorders experience co-occurring PTSD.^1,2 Prevalence rates for PTSD are even higher among those with bulimia nervosa (BN), with studies showing up to 45% of subjects having both disorders.³

Research has also found that those with eating disorders and co-occurring PTSD experience more complex and severe eating disorder symptoms, are more likely to have binge-purge types of eating disorders (e.g., binge eating disorders (BED), bulimia nervosa (BN) etc.), drop out of treatment, have other co-occurring mental illnesses, increased risk of suicidality and poorer treatment outcomes than those without PTSD.^4,5 For example, a study of hospital patients with BN and other specified food or eating disorders (OSFED) found that those with PTSD were over 2 times more likely to leave treatment early than those without PTSD.⁶

What are the Signs and Symptoms of PTSD?

PTSD is diagnosed after a person is exposed to trauma and subsequently experiences one or more of the below symptoms:¹

• Intrusive, recurrent and involuntary symptoms (e.g., distressing dreams, flashbacks, or intense emotional distress when exposed to trauma related triggers)
• Avoidance symptoms (e.g., avoidance of trauma-related feelings, thoughts, memories, people, situations, activities or objects)
• Negative changes in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred (e.g., amnesia, negative beliefs about oneself, others, or the world, feelings of self-blame, constantly expecting the worst, having difficulty experiencing positive feelings)
• Hyperarousal and reactive symptoms (e.g.,, irritability or angry outbursts, exaggerated startle, self-destructive behaviors, problems concentrating, insomnia, being overly watchful and anxious)

PTSD is diagnosed only when a person has experienced these symptoms for more than one month and it leads to significant impairment of functioning in important areas of life.¹ While half of those with PTSD will likely recover within 3 months of experiencing a traumatic event, for many it can become a chronic condition, particularly when the disorder is not adequately addressed and treated.^1,7 Sadly, PTSD is often underdiagnosed or misdiagnosed with one study finding that it took an average of 4.5 years for subjects to be diagnosed after the initial onset of symptoms.⁸ Such delays in seeking help have been found to prolong and exacerbate the symptoms of PTSD. Like PTSD, individuals with eating disorders are also underdiagnosed and can go years without receiving necessary treatment. For example, studies have found that on average it can take up to 5.6 years for someone with an eating disorder to be diagnosed and receive treatment.⁹

What is the Link Between Eating Disorders and PTSD?

Despite the evidence that there is a strong correlation between PTSD and eating disorders, it is unclear exactly how these two conditions are related and why there is such a high co-occurrence between them. One possibility for this connection is that eating disorders and their associated symptoms may predispose someone to develop PTSD after experiencing trauma. Several studies have shown that people with eating disorders are more likely to have a pre-existing anxiety disorder, perceive threat or hostile intent from others, be preoccupied with negative consequences, are sensitive to punishment, have difficulty adapting to change, and have a heightened reaction to stress and trauma, all of which could serve to increase their risk of developing PTSD after experiencing trauma.^1,10

Researchers have also proposed that eating disorders could develop as a way for someone to self-medicate and cope with the unmanageable feelings associated with their PTSD. Studies have shown that binge eating and/or purging behaviors can be a way in which individuals manage their PTSD symptoms by decreasing feelings of anxiety, hyperarousal (extreme anger, paranoia and irritability), and by allowing them to numb or avoid intrusive thoughts about the traumatic event(s).^2,11,12 Others have argued that PTSD related negative thinking may cause or exacerbate symptoms of low self-esteem, perfectionism, and poor body image which then lead to engaging in disordered eating behaviors.¹³ Studies have also shown that the traumatic events and subsequent PTSD symptoms often occur before someone shows signs of an eating disorder, which supports evidence that trauma and PTSD may have a causal relationship to the development of eating disorders.¹⁰

Conversely, other researchers have suggested that rather than one disorder causing the other, the symptoms of both PTSD and eating disorders maintain or exacerbate each other. For example, avoidance of PTSD symptoms like hyperarousal by binging, purging, and/or restriction may serve to maintain both eating disorders and co-occurring PTSD.¹⁴ Since these behaviors can reinforce each other, it can be difficult to break this cycle of disordered eating and avoidance of PTSD related symptoms. As a result, traumatic experiences and their harmful consequences are not effectively processed and can continue to cause harm. In this way, trauma, PTSD, and eating disorders can be very much intertwined.

What are the Risk Factors for Eating Disorders and PTSD?

While there is still debate over exactly how eating disorders and PTSD are related, researchers have identified several factors that may increase one’s risk of developing both an eating disorder and PTSD:¹⁰

• Having a close relative with a mental health condition. Having family members like a parent or sibling with a mental illness has been shown to increase one’s risk of developing PTSD and eating disorders.^15,16
• Personal history of trauma. All types of childhood maltreatment (e.g., emotional abuse, physical abuse, sexual abuse and/or neglect) as well as other types of traumatic events that may occur later in life have been found to increase one’s risk of PTSD and eating disorders.⁴
• Experiencing multiple traumatic events. People who have experienced multiple traumatic events are more likely to develop both PTSD and eating disorders.^4,10
• Being female. Females have an increased risk of developing an eating disorder as well as PTSD compared to males.^10,17
• LGBTQIA+ individuals. Studies have found that LGBTQIA+ folks experience higher rates of trauma and are more likely to develop subsequent PTSD and co-occurring eating disorders than their cisgender/heterosexual counterparts.^18,19
• Being a veteran. Research has found an increased co-occurrence of eating disorders and PTSD among veterans.¹⁷ These studies have identified several factors that have been shown to increase the risk of developing both eating disorders and PTSD among veterans including; sexual trauma or harassment, experiencing combat exposure, as well as the strict weight and physical fitness requirements in the armed forces.²⁰ For example, studies have found that female and male veterans who experienced military sexual trauma were approximately twice as likely to have an eating disorder compared to those without a history of sexual trauma.²⁰
• Severity of trauma. The severity of the trauma(s) someone has experienced increases the risk for both the development of PTSD and eating disorders as well as leading to more severe eating disorder and PTSD symptoms.¹⁰
• Genetics. Twin studies have shown that there are several common genetic factors that contribute to the development of eating disorders and PTSD.²¹
• Lack of social support. Low social support or the perception of a lack of social support has been associated with higher rates of eating disorder and PTSD symptoms and poorer treatment outcomes.⁴
• Co-occurring mental health conditions. Several mental health diagnoses are associated with both eating disorders and PTSD and may serve as a risk factor in the development of both disorders including; obsessive compulsive disorder, avoidant personality disorder, and pre-existing anxiety or mood disorders.¹⁰
• Personality traits. People with PTSD and eating disorders share many common personality traits that have been identified as a shared risk factor for both disorders. These include perfectionism; a higher level of harm avoidance characterized by excessive fear or worry, shyness, doubt and pessimism; a tendency to have negative thoughts and feelings; sensation seeking; and heightened inhibition (self-restraint and the inability to act in a relaxed way). For example, sensation seeking and a lack of inhibition have been identified as a common trait for those with binge eating and purging behaviors as well as people who have experienced trauma.^22,23,24

How are Eating Disorder and PTSD Treated?

Individuals with an eating disorder and PTSD require assessment and treatment for both conditions using a trauma-informed, integrated approach.^10,14 If the trauma is not addressed during the treatment of an eating disorder, then it may impede recovery of both disorders.¹³ Important factors contributing to the success of treatment can include positive reactions by family members and close friends to disclosure about traumatic events, as well as strong support from family and friends. Although the best approach to address PTSD in the context of an eating disorder remains elusive, work so far has focused primarily on cognitive processing therapy (CPT) to address PTSD symptomology integrated with traditional treatment for the eating disorder.^25,26 Future research is likely to shed light on how best to treat this comorbid combination.¹³

Learn more about the treatment process here.

Learn more about finding treatment providers in your area here.

To learn more about treatment options for PTSD go to the National Center for PTSD.