Women with bulimia nervosa are three times more likely to struggle with PTSD than women without eating disorders, according to a study by Dansky and colleagues (1997). In that study, 37% of individuals with bulimia nervosa had lifetime PTSD, compared to 12% of women without eating disorders. That’s almost two in five.
Treating eating disorders is hard, but treating eating disorders with comorbid conditions is way harder. There is no consensus, it seems, as to what disorder(s) to treat first, or whether they should be treated simultaneously:
Brewerton (2004) suggests that eating problems should be addressed prior to treating PTSD because bingeing and purging contribute to a state of physical and emotional dysregulation. Fairburn (2008), however, suggests that significant comorbid disorders be treated prior to beginning CBT for eating disorders.
The issue is quite complex,
For example, the presence of severe depression, of which hopelessness and difficulty concentrating are core criteria, may present a barrier to treatment of the eating disorder. Furthermore, if eating is used to escape from or avoid intrusive memories or strong emotions, it may be more difficult to treat the disordered eating symptoms without addressing the PTSD first. The treatment approach may then depend upon the conceptualization of the comorbid relationship between PTSD and the eating disorder and their overlapping symptoms.
Personally, I don’t think there needs to be a consensus. The answer will vary for every person. (The gut reaction that EDs must be treated first because of their physical consequences doesn’t apply to everyone. Certainly, substance dependence can be more dangerous.) But there’s no doubt that in most cases, even if the treatment of one disorder is prioritized initially, in the end, treatment needs to be comprehensive and deal with everything.
Wouldn’t it be great, though, if one treatment or therapy could help both disorders simultaneously?
With disorders that have a lot of overlap in associated features and symptoms, such as PTSD and bulimia nervosa, there is reason to believe that treatments that lead to improvements in one disorder would improve the other as well.
WHAT ARE THESE COMMON FEATURES?
Emotion dysregulation, impulsivity, and alexithymia (difficulty in identifying and describing one’s emotions) are common among PTSD and bulimia nervosa sufferers.
In PTSD, emotional dysregulation may be related to “hyperarousal, anger, avoidance, and emotional numbing” (Litz & Gray, 2002). Similarly, in bulimia nervosa, bingeing and purging may be a mechanism by which individuals attempt to regulate negative affect and anxiety. The attempt to over-regulate one’s emotional state through avoidance seems to be present in both disorders.
Impulsivity in particular is associated with both bingeing and purging (I’ve written about that here) and PTSD (Miller & Resick, 2007).
Deficits in interoceptive awareness (the ability to distinguish between feelings and sensations) and alexithymia are also associated with PTSD and eating disorders. (To be more precise, IA has been studied in trauma, not PTSD.) This suggests that perhaps the same vulnerabilities that predispose an individual to develop an eating disorder (or bingeing and purging in AN or BN) also predispose them to PTSD.
COGNITIVE BEHAVIOURAL THERAPY & COGNITIVE PROCESSING THERAPY
Cognitive behavioural therapy (CBT) is considered an evidence-based treatment for bulimia nervosa. Similarly, an adaptation of CBT, called cognitive processing therapy (CPT, more on it here), is commonly used to treat PTSD. Briefly, the focus of these therapies is on learning to recognize and identify maladaptive thoughts and beliefs, and then gaining the skills necessary to challenge them and ultimately alter behaviour.
So…. could treating one disorder help with symptoms of the other, too?
In this study, the authors hypothesized that a decrease in PTSD symptoms following CPT treatment would be associated with “improvements in interoceptive awareness, impulse regulation, and disordered eating attitudes/behaviors.” In other words, treating PTSD will improve features commonly associated with bulimia nervosa.
The authors did a secondary analysis of a previous study on the use of CPT in treating PTSD (Resick et al., 2008).
Looking at the raw data for the psychometric tests assessing PTSD and eating disorders, though the numbers decreased from pretreatment to posttreatment for things like interoceptive awareness, ineffectiveness, and impulse regulation, the decreases were not dramatic. (The posttreatment values still fell within the standard deviation of the pretreatment scores.)
Nonetheless, improvements on the Posttraumatic Stress Diagnostic Scale were significantly associated with decreases in both PTSD and eating disorders (as assessed by the Eating Disorder Inventory-2).
More specifically,
The current report found that mean scores on most [Eating Disorder Inventory 2] subscales were significantly lower at posttreatment relative to baseline, although some of these changes were relatively small. Further, reductions in Interoceptive Awareness, Interpersonal Distrust, Impulse Regulation, Ineffectiveness, and Maturity Fears scores were associated with change in PTSD symptom scores over the course of treatment. Thus, CPT contributes to decreases in symptoms common to both PTSD and eating disorders, although specific eating behaviors were not impacted.
The authors hypothesized that a component of CPT, such as the focus on identifying thoughts/feelings and how those thoughts lead to negative emotions and behaviours, would be helpful in treating those components of bulimia nervosa, all of which makes sense to me.
Taken together, results support the hypothesis that PTSD/eating disorder comorbidity is due, at least in part, to their common symptoms, e.g., emotion dysregulation, impulsivity, and deficits in interoceptive awareness/alexithymia.
Moreover,
It is possible that some women in this study used bingeing and purging to cope with their PTSD symptoms; however, bulimia scores did not significantly decrease following treatment. Because standard CPT does not specifically address disordered eating behaviors, more therapy may be needed to achieve statistically and clinically significant change for specific attitudes and behaviors.
All of which means that in a clinical setting, deciding which disorder to treat first may become less and less of an issue. To me, this makes intuitive sense, particularly for disorders that are characterized by similar symptoms/underlying cognitive processes. Of course, treating patients with comorbid PTSD and BN, will require PTSD-specific and BN-specific treatments, but at least in the beginning, both can be tackled (not necessarily in equal degrees) at once. After all, mental health disorders don’t occur in a vacuum, they are intertwined.
Because this research was a secondary analysis from a previous study and because the researchers only began administering the EDI-2 after the study began, the sample size is quite small (65 individuals). Another big issue is that there is no control group: no group with comorbid PTSD and BN that did not receive the CPT treatment (again, this is because it is a re-analysis of a study that asked a different question). Moreover, the study only focused on interpersonal trauma (such as abuse, rape, torture) and not other types of trauma (for example, vehicle accident), which may limit the generalizability of the findings.
Finally, the sample was limited to women, and the average age was 35 (range between 18 – 74). In terms of ethnicity, 62% were Caucasian, 34% African American, 1.3% were American Indian/Alaskan Native, 0.7% were Asian, and 2% identified as other.
The authors acknowledge these limitations and conclude with acknowledging that this is only the beginning,
Finally, this study was the first to examine the impact of PTSD treatment on symptoms common to both PTSD and eating disorders. However, this is only a small step toward investigation of treatment approaches for these comorbid disorders. Future research should continue to explore the comorbidity of PTSD and eating disorders among diverse groups.
I must admit, it is unsettling that there’s so little research (it seems) on treating comorbid conditions in eating disorder patients. How generalizable are the findings from a sample with no/limited comorbidities when that’s not the reality in a clinical setting?
Thoughts? What do you think about treating EDs with comorbid disorders like PTSD? If you have comorbid disorders, what has helped or hindered your recovery process from both/either?
References
Mitchell, K.S., Wells, S.Y., Mendes, A., & Resick, P.A. (2012). Treatment improves symptoms shared by PTSD and disordered eating. Journal of Traumatic Stress, 25 (5), 535-42 PMID: 23073973
Thanks so much for posting this. I am a 35 year old female with Complex PTSD and BED, among other things. I didn’t know I had a “named” ED until a month and a half into EMDR therapy for my PTSD. The treatment of one revealed the other and I have had no direct treatment for the BED but am celebrating my 120th day binge free today. I absolutely believe that treating one helps the other indirectly. I am more in control of myself and really don’t have the need to numb anymore. I would love to take part in some of this research as a subject.
First – congrats on 120 days binge free! That’s amazing!!! I’m glad you agree and have had positive experiences with treatment. I’m very happy to hear that :-). In terms of being involved in research, check out any universities or research centers that are nearby–if you live in a metropolitan area. They usually have web pages where they post info about studies and how to get involved.
It continues to blow my mind that courses of treatment emphasize food intake before even beginning with CBT, DBT, etc…I feel EXTREMELY fortunate that my support group facilitators and therapist viewed EDs as a understandable response to my underlying anxiety disorder and somewhat OCD tendencies.
Something that was interesting, to me, was the realization that I have deep-rooted anxiety about acceptance and love. I couldn’t fathom that anyone would care about me or appreciate being around me and that I needed to constantly “work” for affection. The ED was a nice way to focus on some sort of self-improvement, ironically by having the most “pure” body I could. I realize, though I don’t always internalize this, that I was acting in stark contrast to all the women I love and admire. Working towards self-empowerment and treating my body as if it is something for ME; so I can accomplish my goals, rather than some vessel for the appreciation of someone else, was definitely a turning point. I still struggle, but suppressing the urges to engage in my ED got a LOT easier after that.
Whew, sorry for the long rant!
Also, Kudos to Cindy on 120 days! Jeez! That’s fantastic!
Yeah. I think they have to come together — talk therapy and normalizing food intake. If someone is at a very low weight, then of course food stuff should be prioritized, but after your are medically stable, bring on the psychotherapy.
Not a long rant at all! Everything you wrote makes sense to me!
I feel fortunate too that I have an amazing psychiatrist that works with me as opposed to against me.
When I was being treated simultaneously for bulimia (or, y’know, having an ED – my ED behaviors have varied over the years so the diagnosis is kind of arbitrary…) and PTSD, my group therapist and individual therapist decided it could be beneficial to use group therapy to focus primarily on my ED and individual to focus on PTSD issues. I don’t think this was the best approach, though no other alternative really presented itself. Not to sound self-important or anything like that, but due to my experience with facial trauma I often felt as if my ED and body image issues were on a whole ‘nother level compared to the other girls in group. I often found myself holding back because I felt as if my personal reality would bring everyone else down or that my truth would somehow make the others feel as if I were invalidating their experiences (does that make sense?). I was often resentfully thinking: “Well, fuck, at least you only have your body to worry about; try having a broken face, too.”
The dissociation I felt in relation to PTSD brought my eating disorder and self-image to a place that had previously never been realized. When you no longer really relate to the reflection you see in the mirror, it becomes that much easier to disregard how you may be mistreating your body (at least that has been my experience – though it’s admittedly been a rollercoaster). PTSD is such a multi-faceted disorder with so many possible causes for onset… Each experience of trauma is so, so different that I would think it would have to take SO MANY STUDIES to be able to implement methods of treatment that address one disorder without often feeling like the other isn’t getting enough attention… Idon’tknow.
I DO know, however, that I have found my ED much easier to talk about compared to issues surrounding the PTSD, but I imagine that’s for obvious reasons…? I definitely-absolutely use my ED as a means of covering up/numbing out the PTSD and the related flashbacks/anxiety attacks… It’s all tangled together yet separate and confusing…
Thanks for this post, Tetyana.
Thank you so much for this post, it rings so many bells for me too. I have complex PTSD and anorexia B/P type. I look back and see the eating disorder already beginning in early childhood – and the signs of trauma are already evident in pre-school.
They have always co-existed for me. There is no separating them. They are so tangled up, I cannot even tell which came ‘first’. And the thing is, that’s how things that are co-morbid often materialize in people – our lives just don’t exist in neat, separate compartments. Even in the lives of perfectionists. What happens to us, affects us as a whole, our whole lives are touched. Our personalities and experiences shape every part of our lives. There just isn’t such thing as ‘this is the part of me that has trauma’ and ‘this is the part of me that has an eating disorder’. And yet it seems that in my life anyway, professionals have usually tried to treat them that way. As though they were completely separate problems. I’ve mostly been in ED treatment for over 16 years and in that time, have repeatedly asked for help with the trauma issues and until recently, had them brushed off as unimportant or even probably not existing. It seems a couple of the professionals who brushed me off for years even expressed surprise when I started letting them know how recent trauma therapy (finally!) was going, at what I’d been through and how much it had affected me – despite me being trying to tell THEM just that for years.
The main thing I’ve come up against has been the myth that ‘You cannot work on your real problems or do real therapy until you are weight restored’. I believed them. I was recently told otherwise by my psychologist who said, even if you only retain a little bit of the session content it’s WORTH IT and better than nothing. Now that I’m working on trauma issues, I can see just how much they have affected me – and worsened my eating disorder, which in turn has worsened the ability to cope with the PTSD.
Abuse didn’t cause my ED but it sure worsened it, for example I had issues with even putting food in my mouth, swallowing and keeping it in my stomach as a result of sexual abuse, and this in turn was complicated by being force fed repeatedly and quite harshly – having a crowd of nurses sitting on me 7 times a day to force bolus-feed me through a NG tube, or being restrained on my back in bed to be TPN fed etc. Even being locked in a psych HDU for long periods, doors slamming, patients being violent etc – everything over the years has just retraumatised me over and over. And all they had to do was listen to WHY I was having some problems and help me overcome them. Instead it seems to be that most professionals see the disclosure of trauma in relation to being treated for your ED as an excuse being trotted out to hold things up, hold up inevitable weight gain for eg.
ED helps me to get away from it all. I dissociate a lot just to cope with everyday life, starvation further heightens that sense of unreality, and numbs me to an inner silence, more a vacuum. It makes me sleep for long periods in which I for years have had dreams of a place that’s far better than this world, where I prefer to be, and that leads to me living almost in my sleep because I don’t want to come back to ‘this world’, I want to stay there. Bingeing and purging helps when nothing else will – helps me cope day to day, I’m a mess unless I at least know when my next binge is coming. Purging started as a way of trying to get someone else’s bodily fluids out of me, and has continued not just as an ED way of purging but always as a way of feeling less dirty. It also reduces anxiety big time, although not for long.
Dealing with one or the other, never worked for me, because the other problem will worsen in response. If I deal with the ED behaviors, I find the trauma stuff comes up more strongly as the ED is helping me cope with it. If I deal with the trauma stuff alone, ED worsens as it’s been my only way of surviving for so long. They need to be tackled together.
At the end of it all, I’m pretty shattered and so many pieces to have to pick up to put together again. But I’ve finally met a therapist who CAN and who wants to, and it’s an incredibly amazing and hopeful feeling to know that someone gets it and is going to hang in there with you to the end, too.
<3