Exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury or threat to one’s physical integrity is included in the description of the diagnosis for Post Traumatic Stress Disorder (PTSD). Sexually traumatic events for children may include developmentally inappropriate sexual experiences without threat of actual violence or injury. Physical and/or sexual abuse, incest, and rape are all included in the events hailing the diagnosis of PTSD, according to the DSM-IV.
With respect to PTSD and eating disorders, the National Eating Disorders Association (NEDA) states that, “Post Traumatic Stress Disorder (PTSD) is often a co-occurrence with persons who suffer from an eating disorder. Those who have experienced traumatic events may engage in an eating disorder to self-manage the feelings and experiences related to PTSD.” It is believed that 30% of people with eating disorders of all types i.e. anorexia nervosa, bulimia, binge and/or compulsive eating have been sexually abused.
Studies have demonstrated statistically-significant links between patients who suffered abuse and the later development of an eating disorder. In a piece on the Psychiatric Times, trauma expert Timothy D. Brewerton, MD, reported that “74% of 293 women attending residential treatment indicated that they had experienced a significant trauma, and 52% reported symptoms consistent with a diagnosis of current PTSD based on their responses on a PTSD symptom scale.”
In a 2011 study, Reyes-Rodriquex found that AN (anorexia nervosa) and PTSD co-occur and traumatic events tend to occur prior to the onset of AN. From a final sample of 753 women with AN, 13.7% (n=103) met DSM-IV criteria for PTSD. The sample mean age was 29.5 years. The majority of participants with PTSD reported the first traumatic event before the onset of AN (64.1%, n=66). The most common traumatic events reported by those with a PTSD diagnosis were sexual related traumas during childhood (40.8%) and during adulthood (35.0%).
In a more recent meta-analysis review of studies (18 study results) on PTSD and EDs (eating disorders) through May of 2016, Brewerton found that childhood maltreatment (i.e. emotional, sexual and/or physical) prevalence was high in each type of ED (totalN= 13,059, prevalence rates 21–59%) relative to healthy (N=19 15,092, prevalence rates 1–35%) and psychiatric (N= 7,736, prevalence rates 5–46%) control groups. ED patients were more likely to be diagnosed with a co-morbid psychiatric disorder and to be suicidal relative to ED subjects who were not exposed to childhood maltreatment. ED subjects also reported an earlier age at ED onset.
It is critical to note that it must not be assumed that individuals who have eating disorders have had a history of prior trauma, sexual, and/or physical abuse. Contrarily, an individual who has been sexually or physically abused is at an increased risk for the development of an eating disorder.
Further clinical studies are necessary. Anecdotal reporting by clinicians and research outcomes suggest that PTSD in ED patients is underdiagnosed.
Diagnostic Criteria for Eating Disorders & PTSD
The criteria below are specific to adults, adolescents, and children older than six years.
Diagnostic criteria for PTSD includes a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and re-activity. The sixth criterion concerns duration of symptoms; the seventh assesses functioning; and, the eighth criterion clarifies symptoms as not attributable to a substance or co-occurring medical condition. These criteria are seen in eating disorder patients with PTSD.
The diagnostic features associated with PTSD are of particular importance in the understanding of the etiology of eating disorders. The DSM-IVR states, “The traumatic event can be re-experienced in various ways. Commonly the person has recurrent and intrusive recollections of the event…In rare instances, the person experiences dissociative states that last from a few seconds to several hours…during which components of the event are relived and the person behaves as though experiencing the event at the moment. Intense psychological distress or physiological reactivity often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event…” Eating disorders mimic the repetitive nature of abuser and victim.
The DSM-5 includes in its description, “The essential feature of PTSD is the development of characteristic symptoms following exposure to one or more traumatic events.” For some individuals, “Fear based re-experiencing, emotional, and behavioral symptoms may predominate.” For others, “arousal and reactive-externalizing symptoms (i.e. eating disorders,) are prominent…”
How is an Eating Disorder a Response to PTSD?
One of the primary purposes of eating disorder symptomatology is to avoid and cope with painful, disquieting or uncomfortable feelings or affect. The eating disorder serves both to distance oneself from these feelings or states as well as to relieve them. From an abuse perspective, the eating disorder is a clever, albeit, destructive means to accomplish both distance and numbing as well as a means to relive the painful past events through a recreation of it through the eating disorder symptomatology.
In effect, the individual with the eating disorder assumes roles of both the victim and abuser. They are typically at the mercy of the eating disorder symptomatology, which can be quite sadistic (i.e. laxative abuse, starvation, binge eating until exhausted and physical-ly in pain) as well as simultaneously assuming the role of the abuser who is in effect doing the harm, perpetrating the assault, to her own body. This paradigm fits with the relationship between the individual who is physically and/or sexually abused and the abuser, only this time, the sufferer is able to assume “control” by taking on both roles. The individual therefore is able to maintain recurrent and intrusive abusive events through the use of the eating disorder while simultaneously enabling herself to dissociate, distract and sooth the pain through the obsession with food.
Triggering events of the traumatic event can initiate extreme present day psychological distress for the sufferer of PTSD. In this vein, feelings of shame, humiliation, and guilt, whether perceived or actual events, can initiate a symptomatic response by the eating dis-order sufferer. However, with eating disorders, these “feelings” are typically projected onto the body.
For example, a woman presently suffering with bulimia and a history of incest attends a party and perceives that a man across the room is looking at her. Assuming that the man is gazing appropriately and is seeking to make eye contact, the sufferer converts his attention into fearing that the man is actually looking at her critically because she believes she is fat and undesirable. The woman leaves the party feeling ashamed of her body and disgusted. She binges and purges when she returns home.
Upon analysis, the woman reports the shame, disgust, and guilt she felt as a child when her father initiated his abuse by looking longingly at her. Her feelings of love for her father became distorted as she sought his affection and was disgusted, horrified, and terrified in the same breath. These feelings later became projected on to her body as an adult. The shame, disgust, and guilt she feels now is experienced as believing she is fat and disgusting because of her eating disorder behavior. She feels guilty over eating too much and shameful about her eating disorder, a “secret,” not unlike the secret of the incest.
Memories of the abuse remain repressed for some eating disorder sufferers. The eating disorder symptomatology further ensures the psychic coma; the eating disorder consumes an enormous amount of time, psychological energy, and focus. Literally, there is no time to think about anything else.
What is important to keep in mind is that assumptions cannot be made about the development of an eating disorder; the casual factors are unique to the individual sufferer. Clearly, for all eating disorder sufferers there is a unique constellation of causes, of one kind or another, which has led to the development of their specific symptomatology.
The impact of relationships and parenting in the development of self-concept and self-esteem, family dynamics, biological depression and anxiety, cultural and societal pressures about weight and body image, physical and/or sexual abuse, are all contributors in the development of eating disorders. All are significant. Which one(s) apply is unique to the individual. PTSD is indeed a condition, which affects some or perhaps many individuals who have been victims of abuse, the manifestations of which may find expression through an eating disorder.
Judy Scheel, Ph.D., LCSW, CEDS has been treating eating disorders for more than twenty years. She founded and was the Executive Director for Cedar Associates, a private outpatient treatment program in NY. She currently practices in North Carolina and maintains a small practice in NY. She founded Cedar Associates Foundation, Inc, a not for profit organization dedicated to education, prevention, and research of eating disorders. She authored the book, When Food is Family: A Loving Guide to Treat Eating Disorders. She maintains a blog on eating disorders for Psychology Today.