Eating Disorders and Posttraumatic Stress Disorder (PTSD)

Reviewed by Timothy D. Brewerton, MD

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

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

Warning Signs of Posttraumatic Stress Disorder (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

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.

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 You can learn more about eating disorders and veterans here>
  • 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

Treatment Considerations


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.

Sources


[1] American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR. American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787

[2] Ferrell, E. L., Russin, S. E., & Flint, D. D. (2020). Prevalence estimates of comorbid eating disorders and posttraumatic stress disorder: A quantitative synthesis. Journal of Aggression, Maltreatment & Trauma, 31(2), 264–282. https://doi.org/10.1080/10926771.2020.1832168

[3] Brewerton T. D. (2023). The integrated treatment of eating disorders, posttraumatic stress disorder, and psychiatric comorbidity: a commentary on the evolution of principles and guidelines. Frontiers in psychiatry, 14, 1149433. https://doi.org/10.3389/fpsyt.2023.1149433

[4] Brewerton T. D. (2022). Mechanisms by which adverse childhood experiences, other traumas and PTSD influence the health and well-being of individuals with eating disorders throughout the life span. Journal of eating disorders, 10(1), 162. https://doi.org/10.1186/s40337-022-00696-6

[5] Scharff, A., Ortiz, S. N., Forrest, L. N., Smith, A. R., & Boswell, J. F. (2021). Post-traumatic stress disorder as a moderator of transdiagnostic, residential eating disorder treatment outcome trajectory. Journal of clinical psychology, 77(4), 986–1003. https://doi.org/10.1002/jclp.23106

[6] Trottier K. (2020). Posttraumatic stress disorder predicts non-completion of day hospital treatment for bulimia nervosa and other specified feeding/eating disorder. European eating disorders review: the journal of the Eating Disorders Association, 28(3), 343–350. https://doi.org/10.1002/erv.2723

[7] Goldstein, R. B., Smith, S. M., Chou, S. P., Saha, T. D., Jung, J., Zhang, H., Pickering, R. P., Ruan, W. J., Huang, B., & Grant, B. F. (2016). The epidemiology of DSM-5 posttraumatic stress disorder in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. Social psychiatry and psychiatric epidemiology, 51(8), 1137–1148. https://doi.org/10.1007/s00127-016-1208-5

[8] Jeffrey Schein, Christy Houle, Annette Urganus, Martin Cloutier, Oscar Patterson-Lomba, Yao Wang, Sarah King, Will Levinson, Annie Guérin, Patrick Lefebvre & Lori L. Davis. (2021). Prevalence of post-traumatic stress disorder in the United States: a systematic literature review. Current Medical Research and Opinion, 37(12), 2151-2161. https://doi.org/10.1080/03007995.2021.1978417

[9] Ali, K., Farrer, L., Fassnacht, D. B., Gulliver, A., Bauer, S., & Griffiths, K. M. (2017). Perceived barriers and facilitators towards help-seeking for eating disorders: A systematic review. The International journal of eating disorders, 50(1), 9–21. https://doi.org/10.1002/eat.22598 

[10] Brewerton, Timothy. (2019). An Overview of Trauma-Informed Care and Practice for Eating Disorders. Journal of Aggression Maltreatment & Trauma, 28(4), 445-462. https://doi.org/10.1080/10926771.2018.1532940

[11] Mitchell, K. S., Singh, S., Hardin, S., & Thompson-Brenner, H. (2021). The impact of comorbid posttraumatic stress disorder on eating disorder treatment outcomes: Investigating the unified treatment model. The International journal of eating disorders, 54(7), 1260–1269. https://doi.org/10.1002/eat.23515

[12] Brewerton T. D. (2007). Eating disorders, trauma, and comorbidity: focus on PTSD. Eating disorders, 15(4), 285–304. https://doi.org/10.1080/10640260701454311

[13] Convertino, A. D., & Mendoza, R. R. (2023). Posttraumatic stress disorder, traumatic events, and longitudinal eating disorder treatment outcomes: A systematic review. The International journal of eating disorders, 56(6), 1055–1074. https://doi.org/10.1002/eat.23933

[14] Vanzhula, I. A., Calebs, B., Fewell, L., & Levinson, C. A. (2019). Illness pathways between eating disorder and post-traumatic stress disorder symptoms: Understanding comorbidity with network analysis. European eating disorders review: the journal of the Eating Disorders Association, 27(2), 147–160. https://doi.org/10.1002/erv.2634

[15]  Tortella-Feliu, M., Fullana, M. A., Pérez-Vigil, A., Torres, X., Chamorro, J., Littarelli, S. A., Solanes, A., Ramella-Cravaro, V., Vilar, A., González-Parra, J. A., Andero, R., Reichenberg, A., Mataix-Cols, D., Vieta, E., Fusar-Poli, P., Ioannidis, J. P. A., Stein, M. B., Radua, J., & Fernández de la Cruz, L. (2019). Risk factors for posttraumatic stress disorder: An umbrella review of systematic reviews and meta-analyses. Neuroscience and biobehavioral reviews, 107, 154–165. https://doi.org/10.1016/j.neubiorev.2019.09.013

[16] Redgrave, G. W., Coughlin, J. W., Heinberg, L. J., & Guarda, A. S. (2007). First-degree relative history of alcoholism in eating disorder inpatients: relationship to eating and substance use psychopathology. Eating behaviors, 8(1), 15–22. https://doi.org/10.1016/j.eatbeh.2006.01.005

[17] Barakat, S., McLean, S. A., Bryant, E., Le, A., Marks, P., National Eating Disorder Research Consortium, Touyz, S., & Maguire, S. (2023). Risk factors for eating disorders: findings from a rapid review. Journal of eating disorders, 11(1), 8. https://doi.org/10.1186/s40337-022-00717-4 

[18] Brewerton, T. D., Suro, G., Gavidia, I., & Perlman, M. M. (2022). Sexual and gender minority individuals report higher rates of lifetime traumas and current PTSD than cisgender heterosexual individuals admitted to residential eating disorder treatment. Eating and weight disorders: EWD, 27(2), 813–820. https://doi.org/10.1007/s40519-021-01222-4

[19] Mensinger, J. L., Granche, J. L., Cox, S. A., & Henretty, J. R. (2020). Sexual and gender minority individuals report higher rates of abuse and more severe eating disorder symptoms than cisgender heterosexual individuals at admission to eating disorder treatment. The International journal of eating disorders, 53(4), 541–554. https://doi.org/10.1002/eat.23257

[20] Touma, D. A., Quinn, M. E., Freeman, V. E., & Meyer, E. G. (2023). Eating Disorders in U.S. Active Duty Military Members and Veterans: A Systematic Review. Military medicine, 188(7-8), 1637–1648. https://doi.org/10.1093/milmed/usac180

[21] Afari, N., Gasperi, M., Dochat, C., Wooldridge, J. S., Herbert, M. S., Schur, E. A., & Buchwald, D. S. (2021). Genetic and environmental influences on posttraumatic stress disorder symptoms and disinhibited eating behaviors. Eating disorders, 29(3), 226–244. https://doi.org/10.1080/10640266.2020.1864587

[22] Lie, S. Ø., Bulik, C. M., Andreassen, O. A., Rø, Ø., & Bang, L. (2021). Stressful life events among individuals with a history of eating disorders: a case-control comparison. BMC psychiatry, 21(1), 501. https://doi.org/10.1186/s12888-021-03499-2

[23] Chen, C. Y., Lin, S. H., Li, P., Huang, W. L., & Lin, Y. H. (2015). The role of the harm avoidance personality in depression and anxiety during the medical internship. Medicine, 94(2), e389. https://doi.org/10.1097/MD.0000000000000389

[24] Brewerton, T. D., Cotton, B. D., & Kilpatrick, D. G. (2018). Sensation seeking, binge-type eating disorders, victimization, and PTSD in the National Women’s Study. Eating behaviors, 30, 120–124. https://doi.org/10.1016/j.eatbeh.2018.07.001

[25] Brewerton, T. D., Gavidia, I., Suro, G., & Perlman, M. M. (2023). Eating disorder patients with and without PTSD treated in residential care: discharge and 6-month follow-up results. Journal of eating disorders, 11(1), 48. https://doi.org/10.1186/s40337-023-00773-4

[26] Trottier, K., Monson, C. M., Wonderlich, S. A., & Crosby, R. D. (2022). Results of the first randomized controlled trial of integrated cognitive-behavioral therapy for eating disorders and posttraumatic stress disorder. Psychological medicine, 52(3), 587–596. https://doi.org/10.1017/S0033291721004967