Getting to the Root Cause to Treat Eating Disorders
Eating disorders are rarely solely related to abnormal or disturbed eating habits. In fact, eating disorders are rarely even about food. As an integrative medicine practitioner with over thirty years of experience in treating eating disorders, knowing the root cause of eating disorders like bulimia, binge eating disorder, and anorexia is critical to developing an effective treatment plan for patients.
In my practice, I’ve encountered numerous factors that have been contributing factors in the development of binge eating, anorexia, and bulimia. In many cases, the root cause involved untreated and unresolved trauma. Additionally, trauma, when left unresolved, can also contribute to the development of other psychiatric disorders and even physical diseases.
The Undeniable Relationship between Eating Disorders, Trauma, and PTSD
Recent studies validate the importance of assessing trauma and post-traumatic stress disorder (PTSD) in treating eating disorders. A relationship between eating disorders, particularly bulimia nervosa and binge eating disorder, and trauma has been discovered among participants in various studies (Brewerton 2007).
While child sexual abuse has long been recognized as a risk factor for eating disorders and can also manifest in other psychiatric disorders, recent studies indicate other types of trauma can also lead to eating disorders. A recent study found that “the vast majority of women and men with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) reported a history of interpersonal trauma” (Mitchell et al. 2012). Approximately one-third of women with bulimia, 20% with binge eating disorder and 11.8% with non-bulimic/non binge eating disorders met criteria for lifetime PTSD. Overall, the most significant finding was that rates of eating disorders were generally higher in people who experienced trauma and PTSD (Mitchell et al. 2012).
Types of Trauma that Can Lead to Eating Disorders
A study in 2007 showed that there are many types of trauma that can be associated with eating disorders including neglect, sexual assault, sexual harassment, physical abuse and assault, emotional abuse, emotional and physical neglect (including food deprivation), teasing, and bullying (Brewerton 2007). Furthermore, according to a study in 2001, “Women who reported sexual trauma were significantly more likely to exhibit psychopathology than controls, including higher rates of both PTSD and EDs [eating disorders]” (Brewerton 2007).
The exact mechanism for why trauma contributes to the development of an eating disorder is unclear. What is known is that trauma can cause disruption in the nervous system which may make it difficult for individuals to manage their emotions and so they turn to eating disorder behaviors or other addictions as a way to manage these uncomfortable emotions. Sexual trauma may specifically cause body image issues, partly related to the self-critical view that can develop after sexual trauma. Some victims may wish to be thin to reduce their attractiveness or may gain weight in the case of those with binge eating disorder to accomplish the same goal (Dunkley et al. 2010; Sack et al. 2010; Yehuda 2001).
Is There a Correlation Between PTSD and Eating Disorders?
Another significant finding in a study with over 24,000 US veterans, conducted by Striegel-Moore, Garvin, Dohm & Rosenheck in 1999, found higher rates of anxiety disorders, including PTSD and borderline personality disorder in women with eating disorders (Brewerton 2007).
The prevalence of BN [bulimia nervosa] “rates were significantly higher only in subjects with histories of rape with PTSD compared with subjects with histories of rape without PTSD and those subjects with no history of rape. These results suggest that it is PTSD, rather than an abuse history per se, that best forecasts the emergence of BN” (Brewerton 2007).
These studies suggest there is some type of link between eating disorders and PTSD. Could PTSD directly cause eating disorder behaviors, or could there be a genetic or biological trait that predisposes someone who experiences PTSD to develop an eating disorder? If there is a direct correlation between eating disorders and PTSD, could this mean that by not diagnosing PTSD in relation to eating disorders hinders treating both the symptoms of PTSD and the eating disorder itself?
What PTSD and Eating Disorders Have in Common
When looked at more closely, PTSD and eating disorders share some similar characteristics. They both have high rates of dissociation. Eating disorder behaviors may be a way to distance oneself from disturbing thoughts, emotions, or memories associated with PTSD (Mitchell et al. 2012). It’s possible to see the psychological symbolism of these behaviors in sufferers of eating disorders. Purging can be seen as a way to get rid of something unwanted (emotion, memory, or symptom) while bingeing can be seen as a way to fill a void. We know logically that we cannot fill an emotional void with food and we cannot get rid of unwanted feelings, memories, or symptoms by emptying our stomachs. Yet, both provide relief for the sufferer in either managing the symptoms of PTSD or as a coping mechanism in dealing with an unresolved (and possibly subconscious) trauma.
Along with the shared characteristics between PTSD and eating disorders, there are also similar genetic and biological factors that might explain this correlation. However, even while there may be additional factors for this relationship between eating disorders and PTSD, studies continue to show that women and men with trauma and PTSD have higher rates of eating disorders than the general population (Mitchell et al. 2012). This suggests that, at the very least, eating disorders are much more complicated to treat than originally believed. This added layer of complexity must be understood in order to treat eating disorders, trauma, and PTSD effectively when two or more are present concurrently.
One of the reasons PTSD is hard to diagnose in patients with eating disorders is that the Diagnostic and Statistical Manual of Mental Disorders-5 does not include a diagnosis for partial PTSD, meaning that while some symptoms may be present, no diagnosis can be given unless all criteria are met. This limits the ability of professionals to properly diagnose patients who suffer from both PTSD and eating disorders or even draw a connection between the two.
The Proper Care and Feeding of Eating Disorders
If you suffer from an eating disorder, this doesn’t necessarily mean you’ve been traumatized. However, if you suffer from an eating disorder and you have a history of neglect, trauma, or abuse, it is important for you to get help for trauma while getting treatment for your eating disorder. Trauma symptoms like loss of focus, nightmares, being easily startled or feeling you have to be on red alert all the time, anxiety, depression, insomnia, and/or hallucinations, may indicate a history of trauma or PTSD. Seeking proper treatment and care is critical to your health and well-being. While medication can be helpful in treating PTSD symptoms, trauma therapy is the cornerstone of effective treatment.
There are several forms of therapy available to treat eating disorders. Cognitive-behavioral therapy (CBT) with prolonged exposure is the most recognized and effective methods in treating eating disorders, and many forms of trauma-related disorders. Eye movement desensitization and reprocessing (EMDR) has also been shown to be effective especially in combination with CBT. Some types of medications can also be beneficial in treating mood and anxiety disorders associated with trauma and eating disorders but are best used in combination with therapy. There are medications for some of the symptoms of PTSD such as nightmares and flashbacks.
The first step in recovery is to get help. You do not have to suffer in silence or alone and there are ways to effectively cope with and heal from trauma, PTSD, and eating disorders. Find a therapist who specializes in treating eating disorders, trauma, and PTSD to ensure you meet with a professional who can address these needs. The therapy should also include some type of nutritional plan to help restore your body’s ability to heal as the disruptive eating habits may have left your body malnourished. As you begin to take steps to nourish the body, you will be better able to deal with therapy for trauma and the symptoms associated with trauma. A great indicator that you have the right therapist is you will be able to go at your own pace and learn effective and healthy coping mechanisms to deal with anxiety, discomfort, and emotions that surface. If you try therapy and you don’t feel secure or safe, don’t give up. It may take some time to find a therapist who has the appropriate experience, the tools, and the right bedside manner to help you recover.
Mitchell KS, Mazzeo SE, Schlesinger MR, Brewerton TD, Smith BN. Comorbidity of partial and subthreshold PTSD among men and women with eating disorders in the National Comorbidity Survey-Replication Study. The International Journal of Eating Disorders. 2012;45(3):307-315. doi:10.1002/eat.20965.
Brewerton, Timothy D. Eating disorders, trauma, and comorbidity: focus on PTSD. The Journal of Treatment & Prevention. 2007;15(4): 285-304. doi:10.1080/10640260701454311
Sack M, Boroske-Leiner K, Lahmann C. Association of nonsexual and sexual traumatizations with body image and psychosomatic symptoms in psychosomatic outpatients. Gen Hosp Psychiatry. 2010 May-Jun; 32(3):315-20.
Yehuda RJ. Biology of posttraumatic stress disorder. Clinical Psychiatry. 2001; 62 Suppl 17():41-6.
Dunkley DM, Masheb RM, Grilo CM. Childhood maltreatment, depressive symptoms, and body dissatisfaction in patients with binge eating disorder: the mediating role of self-criticism. International Journal of Eating Disorders. 2010 Apr; 43(3):274-81.
Dr. Carolyn Coker Ross is an internationally known author, speaker, expert, and pioneer in the use of Integrative Medicine for the treatment of Eating Disorders, Obesity, and Addictions. She is a graduate of Andrew Weil’s Fellowship Program in Integrative Medicine. She is the former head of the eating disorder program at internationally renowned Sierra Tucson. Dr. Ross is a consultant for treatment centers around the US. She is the author of three books including one of the first books on Binge Eating Disorder: The Binge Eating and Compulsive Overeating Workbook and her recent book, The Emotional Eating Workbook. Her newest book, The Food Addiction Recovery Workbook will be released on September 1, 2017. Dr. Ross currently has a private practice in Denver and San Diego specializing in Integrative Medicine for treating eating disorders, addictions, mood and anxiety disorders, and obesity.