Trauma is very common, with approximately 89.7% of individuals experiencing at least one traumatic event in their lifetime. Many people with eating disorders have experienced such adversity during their lifetime. Some people have experienced sexual or physical abuse as a child, sexual or physical abuse during adulthood, or other experiences that are life-threatening or in which physical safety has been threatened. These kinds of events are often referred to as traumatic. People who experience traumatic events may develop distressing symptoms related to their trauma, and approximately 8.3% go on to develop post-traumatic stress disorder (PTSD). However, even if not all the criteria for PTSD are met, the symptoms can be highly distressing and deserving of treatment. There are four types of trauma symptoms:
- Re-experiencing symptoms: having nightmares or flashbacks about the traumatic event, feeling as though the trauma is happening all over again
- Avoidance: avoiding reminders of the event, including thoughts, feelings, and people, places, or things tied to the trauma; keeping busy or distracting oneself with TV or video games to avoid thinking about the trauma; using drugs or alcohol to try to forget the trauma
- Thoughts and emotions related to the trauma: feeling numb, detached, fearful, angry, or guilty after the trauma; developing negative beliefs related to the trauma, like blaming oneself for the trauma or believing that the world is a dangerous place
- Increased agitation and reactivity: feeling irritable or jumpy following the trauma; having difficulty sleeping or concentrating; behaving recklessly; engaging in self-destructive habits, like harming oneself or abusing drugs or alcohol
For many people who have experienced trauma, these symptoms can be upsetting and can interfere with their daily lives. For trauma survivors who also have an eating disorder, these symptoms can play a role in disordered eating behaviors, making them an important target of treatment. For example, some trauma survivors may find themselves engaging in binge eating, purging, or excessive exercise to distract themselves from thoughts or memories of the trauma. Individuals may also rationalize using eating disorder behaviors, like restricting food intake and purging behaviors (like self-inducing vomiting), as a method of self-punishment. Both eating disorders and PTSD are serious mental health concerns that should be treated by a professional. Because it can be difficult to identify the appropriate treatment for trauma and eating disorders, the article below discusses options for treatment.
What Type of Treatment can Help People with Eating Disorders who also have Trauma Symptoms?
When choosing a type of treatment, you and your provider can decide together which approach best fits your circumstances and preferences. The recommended, first-line approaches to treating trauma symptoms are Cognitive Processing Therapy and Prolonged Exposure. Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) are two cognitive-behavioral therapies, which means they help you learn skills to handle your thoughts, emotions, and behaviors. You learn different ways to view the emotions and thoughts you experience as the result of trauma and practice responding in a healthier way. Other types of treatment that may be considered include Eye Movement Desensitization and Reprocessing Therapy (EMDR) or using psychiatric medication to treat the accompanying depression and anxiety that often occur at the same time as eating disorders and PTSD.
How does Trauma-Focused Treatment Work?
Cognitive Processing Therapy focuses on teaching you how to reframe your thoughts about the trauma by helping you to explore your understanding of why the trauma happened and its effects on how you view yourself, other people, and the world. Cognitive Processing Therapy will help you to identify and change the impact of the trauma on your beliefs about yourself, other people, and the world by finding patterns in your thoughts, feelings, and behaviors. Prolonged Exposure focuses on teaching you how to process traumatic memories; with your treatment provider, you revisit your trauma experiences via imaginal exposures (i.e., recounting traumatic memories by writing or talking about them). The goal with Prolonged Exposure is to learn new ways to respond to things that are feared or avoided by coming to a more realistic, balanced understanding about what is dangerous. By facing your fears, you will be better able to cope with things that remind you of the trauma.
How Effective is Trauma-Focused Treatment?
Both Cognitive Processing Therapy and Prolonged Exposure have strong research support. Cognitive Processing Therapy has been shown to significantly reduce trauma symptoms and related symptoms like anxiety and depression. Nearly all studies of Prolonged Exposure show that it is highly effective for reducing trauma symptoms, symptoms of depression and anxiety, and feelings of anger and guilt about the trauma, as well as improving general health and work and social functioning.
When Should I start Trauma-Focused Treatment?
There are three options for the timing of treatment:
- Trauma-focused treatment before eating disorder treatment: If your trauma symptoms are more distressing or are impacting your life more negatively than your eating disorder symptoms, your provider may recommend that you start working on reducing trauma symptoms first. In fact, treating trauma symptoms first may improve eating disorder symptoms if you are using eating disorder behaviors to cope with trauma symptoms. This approach could help you be more successful with using eating disorder treatment skills later. However, trauma treatment first is likely not a good choice if you have medical consequences of eating disorder symptoms (for example, low weight, electrolyte balance issues). Also, this is likely not a good choice if you use eating disorder behaviors to avoid trauma-related memories, feelings, and flashbacks.
- Eating disorder treatment before trauma-focused treatment: If you are experiencing very frequent eating disorder symptoms or medical consequences (like low body weight or concentration difficulties due to poor nutrition), your provider may recommend that you work on eating disorder symptoms before starting trauma-focused treatment. This approach is helpful because you need to be physically and cognitively well enough to be able to process information during trauma-focused treatment.
- Integrated (simultaneous) trauma-focused and eating disorder treatment: Some providers offer treatment for trauma symptoms and eating disorder symptoms together. Integrated treatment can be especially helpful if you have previously sought treatment for your eating disorder or trauma symptoms and experienced a worsening of symptoms of the other disorder.
Different people may benefit from each option. You and your treatment provider should work together to determine the order of treatment that is best for you. For some people, other psychological symptoms may need to be addressed before beginning trauma treatment. For example, your treatment provider may suggest a different treatment approach first if you are harming yourself (or are at risk to harm yourself), are at risk for harming other people, you are in a circumstance that is currently dangerous (for example, living with an abusive parent or partner), or you have other psychological symptoms that might interfere with treatment (for example, substance use, frequent feelings of detachment from reality).
What are the Risks of Treatment?
Both Cognitive Processing Therapy and Prolonged Exposure may bring up temporary feelings of discomfort or distress during the course of treatment. In Cognitive Processing Therapy, these feelings might come up when talking or thinking about anxiety-provoking images, memories, or situations, while in Prolonged Exposure these feelings may come up during imagined or real-life exposures to images, memories, or situations.
How Long Does Treatment Usually Last?
Cognitive Processing Therapy usually takes place in weekly, 60-minute sessions over the course of three months. Prolonged Exposure typically involves 90-minute sessions that may happen once or twice per week over the course of two to three months. However, the length of treatment is different for each person.
How can People with Trauma Symptoms and Eating Disorder Symptoms find a Treatment Provider?
Finding a treatment provider willing to treat both eating disorders and trauma is important for individuals interested in pursuing trauma-focused treatment integrated into treatment for their eating disorder. Information on finding a treatment provider can be found here. The American Psychological Association offers a tool that can help locate providers specializing in the treatment of eating disorders and trauma across the country. When selecting a treatment provider, some questions to ask include:
- Does this provider deliver treatment for the eating disorder and trauma at the same time?
- What type(s) of trauma treatment does this provider have experience with?
- Does this provider have experience treating co-occurring trauma and disordered eating?
About The Authors:
Emily Presseller, B.A., Kelsey Clark, B.A., and Helen Burton Murray, M.S., are with The WELL Center, Drexel University.
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Written – 2019