by Carolyn Coker Ross, MD, MPH, CEDS
The Undeniable Relationship between Eating Disorders, Substance Use Disorders, Trauma and PTSD
Recent studies validate the importance of assessing trauma and Post-Traumatic Stress Disorder (PTSD) in treating eating disorders (ED) and substance use disorders (SUD). A relationship between eating disorders, particularly bulimia nervosa and binge eating disorder, and trauma has been discovered among participants in various studies (Brewerton 2007). Regarding SUD and trauma, 33.2% of those with SUD also were diagnosed with PTSD and among individuals with PTSD, one-fourth also were diagnosed with alcohol use disorder (Brady et al., 2000). Other studies have found an association between childhood sexual abuse and substance use disorders (Tonmyr and Shields, 2017; Draucker and Mazurcyk, 2013).
While child sexual abuse has long been recognized as a risk factor for ED and SUD and can also manifest in other psychiatric disorders, recent studies indicate other types of trauma can also be implicated. 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). In individuals with SUD, the rates of PTSD may be as high as 60-80% in veterans and 50-60% of individuals in a community sample had a history of emotional, sexual or physical abuse or neglect (Keane et al., 1988l Medrano et al., 1999). SUD and PTSD can lead to poorer social functioning, higher rates of suicide attempts, and less improvement during treatment (McCauley 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 ED and SUD 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 found, “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).
What PTSD, Substance Use Disorders and Eating Disorders Have in Common
When looked at more closely, PTSD, ED and SUD share some similar characteristics. All 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 ED and / or SUD. 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 or with alcohol or drugs and we cannot get rid of unwanted feelings, memories or symptoms by emptying our stomachs or by numbing ourselves with substances. 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, SUD and ED, 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 ED, SUD and PTSD, studies continue to show that women and men with trauma and PTSD have higher rates of ED and SUD 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 (McCauley et al., 2012).
Treatment of PTSD, ED and SUD
Studies show that treatment of PTSD in those with ED or SUD is associated with a number of positive outcomes. Early and ongoing treatment in veterans with SUD and PTSD is associated with higher rates of remission at 5 years after treatment. Both exposure therapy and cognitive behavior therapy have been found to be successful for treatment of SUD/PTSD (Ouimette, et al. 2003; Berenz et al., 2012). Research has shown that satisfactory treatment of eating disorder clients who have PTSD is dependent on addressing symptoms of trauma and PTSD (Brewerton, 2007).
As more research becomes available, it is clear that trauma has an serious impact on the severity of both eating disorder or substance use disorder symptoms and that effective treatment must include treatment of the underlying trauma.