Eating Disorders and Trauma

Reviewed by Timothy D. Brewerton, MD

Traumatic events, which are events that cause psychological, physical, and/or emotional pain or harm, have been found to be a significant risk factor for the development of a variety of psychiatric disorders, including eating disorders —particularly those involving symptoms of binging and purging, such as binge eating disorders (BED), bulimia nervosa (BN) and anorexia nervosa-binge/purge type (AN-BP).1,2,3

Three major national representative studies in the United States have shown that individuals with eating disorders have significantly higher rates of trauma than individuals without an eating disorder. These include the National Women’s Study, the National Comorbidity Survey Replication, and the National Epidemiologic Survey on Alcohol and Related Conditions; the highest rates of lifetime trauma among those with eating disorders were found to be 54%, 100%, and 74% respectively.4 Another study of young adults in the United States found that those who experienced multiple forms of childhood trauma were almost twice as likely to report disordered eating behaviors compared to those without a history of childhood trauma.5

Research has consistently shown that trauma is not only a risk factor for the development and/or perpetuation of eating disorders, but that individuals with eating disorders and a history of trauma are more likely to have other co-occurring mental illnesses, increased risk of suicidality and dropping out of treatment earlier than those without a history of trauma.4 Much of the research has focused on how trauma during childhood impacts the risk of having an eating disorder. For example, a meta-analysis found that those who have experienced childhood abuse have more complex and severe eating disorder symptoms and develop eating disorders at an earlier age when compared to peers without a history of childhood abuse.3,6

While there is less research into the impact of trauma during adulthood, studies have found that adults who have experienced trauma are also more likely to develop an eating disorder. For example, a study of female college students found that those who had experienced sexual violence within the past year were more likely to engage in purging behaviors than those who had not experienced sexual violence.6 Furthermore, research on active duty military and veteran populations have consistently found that those who were exposed to military related trauma are more likely to develop an eating disorder, to experience more severe eating disorder symptomology, and to have co-occurring mental illnesses (i.e. posttraumatic stress disorder (PTSD), substance use disorder (SUD), depression and sleep disorders etc.).7 Several studies have also found that both female and male veterans who experienced military sexual trauma were twice as likely to have an eating disorder compared to those without a history of military sexual trauma.7,8 While the majority of research has historically included primarily female subjects and did not look at how gender identity and sexual orientation impact the prevalence of trauma and eating disorders, more recent studies have found that LGBTQIA+ folks report higher rates of abuse and more severe eating disorder symptoms than their cisgender counterparts.9,10

You can learn more about eating disorders in LGBTQIA+ populations here>

Trauma and Coping


Most people will be exposed to at least one traumatic event at some point in their lives. Typically in the aftermath of a traumatic event, individuals will experience feelings of exhaustion, confusion, sadness, anxiety, agitation, numbness, dissociation (state of feeling disconnected), and/or have difficulty feeling or expressing emotions.11 In most cases these initial reactions will resolve and the trauma does not lead to long term negative consequences.11 However, for some the trauma will lead to serious psychological impairments and impact their ability to function in major areas of life. In such cases trauma may lead to a diagnosis of posttraumatic stress disorder (PTSD), however studies have shown this occurs in only one third of those who experience a severe traumatic event.12

Like eating disorders, there is a combination of biological, psychological, and social factors that can increase one’s risk of developing long term negative consequences of trauma (i.e. PTSD and its associated symptoms). These factors can include having a family and/or personal history of mental health conditions, experiencing multiple and/or more severe traumatic event(s) and a lack of social support.11

How we cope with distressing events can play an important role in whether or not a traumatic event leads to long term negative consequences. Individuals who use an avoidant coping style have been shown to have an increased risk of developing trauma related symptoms and PTSD:13

  • Avoidant coping: associated with changes in behaviors to avoid thinking, feeling or doing things that are distressing such as distraction, self-isolation or suppressing emotions. This style of coping can result in more negative mental health outcomes and functioning.14
  • Approach coping: associated with a problem-solving style which can include trying to think of the positive aspects of a distressing situation and seeking help from others with similar experiences. This style of coping is associated with better mental health outcomes and functioning. 14

You can learn more about PTSD and eating disorders here>

Connection Between Trauma and Eating Disorders


Despite the evidence that there is a strong correlation between trauma and eating disorders, it is unclear exactly how these issues relate to one another. One possibility for this connection is that eating disorders could develop as a way for someone to self-medicate and cope with the unmanageable feelings associated with the traumatic event(s).6,15 Studies have shown that traumatic events often occur before someone shows signs of an eating disorder, which support the hypothesis that trauma may be a significant risk factor in the development of eating disorders.13

Researchers have also proposed that trauma may cause or exacerbate symptoms of low self-esteem, self-criticism, perfectionism, impulsiveness, compulsiveness, dissociation, and poor body image, which can then lead to engaging in disordered eating behaviors.16,17 For example, individuals who have experienced sexual abuse commonly experience feelings of body dissatisfaction in the aftermath of trauma and researchers have suggested that these individuals may engage in eating disorder behaviors to reduce their body dissatisfaction by attempting to alter their body.18 In another study, low self-esteem caused by abuse was found to be a contributing factor in the development of binge eating disorder and night eating syndrome among the subjects.2

Other researchers have proposed rather than trauma directly leading to the development of eating disorders, trauma and eating disorders serve to maintain or exacerbate each other. They hypothesize that by engaging in disordered eating behaviors to avoid or numb the trauma related negative thoughts and feelings, traumatic experiences and their harmful consequences are not effectively processed and continue to cause harm.13 In this way trauma and eating disorders are believed to create a cycle in which the disordered eating and trauma symptoms reinforce each other and become intertwined.

Treatment Considerations


Individuals with an eating disorder and a history of trauma require assessment and treatment for both these issues using a trauma-informed, integrated approach.4 If the trauma is not addressed during the treatment of an eating disorder, then it may impede the recovery process.14 It is important to seek help from a professional as soon as possible since eating disorders can have serious mental and physical health consequences and early treatment has been shown to greatly improve treatment outcomes.19

Learn more about the treatment process here.

Learn more about finding treatment providers in your area here.

Sources


[1] Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. (Report No. 14-4884.) Substance Abuse and Mental Health Services Administration. https://ncsacw.acf.hhs.gov/userfiles/files/SAMHSA_Trauma.pdf

[2] 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 

[3] Molendijk, M. L., Hoek, H. W., Brewerton, T. D., & Elzinga, B. M. (2017). Childhood maltreatment and eating disorder pathology: a systematic review and dose-response meta-analysis. Psychological medicine, 47(8), 1402–1416. https://doi.org/10.1017/S0033291716003561

[4] 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

[5] Hazzard, V. M., Bauer, K. W., Mukherjee, B., Miller, A. L., & Sonneville, K. R. (2019). Associations between childhood maltreatment latent classes and eating disorder symptoms in a nationally representative sample of young adults in the United States. Child abuse & neglect, 98, 104171. https://doi.org/10.1016/j.chiabu.2019.104171

[6] Trottier, K., & MacDonald, D. E. (2017). Update on Psychological Trauma, Other Severe Adverse Experiences and Eating Disorders: State of the Research and Future Research Directions. Current psychiatry reports, 19(8), 45. https://doi.org/10.1007/s11920-017-0806-6

[7] 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

[8] Blais, R. K., Brignone, E., Maguen, S., Carter, M. E., Fargo, J. D., & Gundlapalli, A. V. (2017). Military sexual trauma is associated with post-deployment eating disorders among Afghanistan and Iraq veterans. The International journal of eating disorders, 50(7), 808–816. https://doi.org/10.1002/eat.22705

[9] 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

[10] 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

[11] Center for Substance Abuse Treatment. (2014). Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Substance Abuse and Mental Health Services Administration. Available from: https://www.ncbi.nlm.nih.gov/books/NBK207191/

[12] 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

[13] Jenzer, T., Meisel, S. N., Blayney, J. A., Colder, C. R., & Read, J. P. (2020). Reciprocal processes in trauma and coping: Bidirectional effects over a four-year period. Psychological trauma: theory, research, practice and policy, 12(2), 207–218. https://doi.org/10.1037/tra0000500

[14] American Psychological Association. (n.d.). Avoidance coping. Apa Dictionary of Psychology. https://dictionary.apa.org/avoidance-coping. Accessed on 9/15/23

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

[16] 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

[17] Brustenghi, F., Mezzetti, F. A. F., Di Sarno, C., Giulietti, C., Moretti, P., & Tortorella, A. (2019). Eating Disorders: the Role of Childhood Trauma and the Emotion Dysregulation. Psychiatria Danubina, 31(Suppl 3), 509–511. https://www.psychiatria-danubina.com/UserDocsImages/pdf/dnb_vol31_noSuppl%203/dnb_vol31_noSuppl%203_509.pdf

[18] Convertino, A. D., Morland, L. A., & Blashill, A. J. (2022). Trauma exposure and eating disorders: Results from a United States nationally representative sample. The International journal of eating disorders, 55(8), 1079–1089. https://doi.org/10.1002/eat.23757

[19] Groth, T., Hilsenroth, M., Boccio, D., & Gold, J. (2019). Relationship between Trauma History and Eating Disorders in Adolescents. Journal of child & adolescent trauma, 13(4), 443–453. https://doi.org/10.1007/s40653-019-00275-z