Psychological treatment for patients with eating disorders (EDs) can vary widely based on diagnosis. Psychotherapeutic interventions can be implemented throughout the continuum of care from hospital-based settings to outpatient treatment. Cognitive-behavioral therapy (CBT) has been found efficacious in the treatment of bulimia nervosa (BN) as well as binge-eating disorder (BED).1–3 Effective treatments for anorexia nervosa (AN) have proven to be more challenging to establish due to the frequency of treatment resistance and nonadherence.4 With these findings, many clinicians in the ED field use a variety of interventions with patients with AN to target the multitude of complexities within this disorder. These can range from CBT, the Maudsley model of AN treatment for adults, and family-based treatment for AN.5
Psychiatric comorbidity is high among patients with EDs, particularly mood, anxiety, and substance use disorders.6,7 The presence of comorbidity in patients with an ED can increase the severity and chronicity of the ED, possibly resulting in increased treatment resistance.8 With this type of clinical presentation, detailed treatment considerations must be made to address multiple symptoms. This is particularly crucial for patients with an ED presenting with a co-occurring diagnosis of posttraumatic stress disorder (PTSD).
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5)9 classifies PTSD in a new category of trauma- and stressor-related disorders as opposed to the previous classification as an anxiety disorder. A key feature of PTSD is exposure to a traumatic event, which is followed by the presence of seven other symptom criteria. These include symptoms categorized under avoidance, arousal, and the reexperiencing of events. Traumatic events can include, but are not limited to, sexual assault, violence, and childhood sexual abuse. The disturbances experienced by the person with PTSD must cause significant distress and impairment.
Although a trauma history is not a causal factor for an ED, experiencing a traumatic event can serve as a risk factor for developing subsequent eating pathology.10,11 It is not uncommon for patients presenting with a primary diagnosis of an ED to report having also experienced a traumatic event in the past. This is supported by a 2012 study that found men and women who have experienced a traumatic event or have been diagnosed with PTSD have higher rates of EDs.11 In examining the correlation among traumatic events, PTSD, and EDs, many studies have found that people presenting with BN or AN with a binge/purge subtype are more likely to have experienced a traumatic event.10,11
Psychotherapists working with this population can face challenges in determining how and when to treat each of these disorders during the course of treatment. Tagay et al.12 propose that to successfully treat EDs, the comorbid PTSD must be treated to ensure positive outcomes and to prevent further psychopathologies. Due to the dangerous nature of nutritional instability seen in patients with EDs, many clinicians may initially target the ED symptomology over any other comorbidity. However, because EDs and PTSD can share overlapping symptoms (such as avoidance and emotional numbing), treating both simultaneously may prove to be advantageous for sustained recovery. Results from a 2017 pilot study on treatment for co-occurring EDs and PTSD suggest that the use of cognitive processing therapy (CPT), an empirically based protocol for PTSD treatment, may be beneficial in treating coexisting ED and PSTD symptomology.13 The aim of this article is to explore the bidirectional relationship between EDs and PTSD and identify the unique treatment considerations for this population. Specifically, the use of CPT as a trauma therapy within the ED population is explored.
The negative impact that EDs can have on psychosocial functioning, interpersonal relationships, and physical health should not be understated. EDs have markedly high mortality rates, with AN having a higher risk of death than BN and BED.14 Adding to this troubling fact is an additional barrier of the often ego-syntonic nature of EDs and the lack of motivation of patients to change. Restriction and overexercising are particularly difficult behaviors for ED patients to cease due to the likelihood of anticipated weight loss. Additionally, a 2013 review of the neurobiology of AN found through functional magnetic resonance imaging that people with AN experience a reduction in anxious mood when refusing food.15 Not only does food restriction result in the sought-after weight loss seen in patients with AN, but it also serves as a maladaptive coping mechanism for difficult emotions.
Although patients with an ED diagnosis can receive psychiatric, nutritional, and psychotherapeutic care on an outpatient basis, many will seek higher levels of care during their recovery process. Due to the severity of ED symptoms, many people with these diagnoses will seek professional intervention from multiple disciplines within the medical field. Treatment, although crucial, can interrupt many aspects of a person's life. Inpatient or residential levels of care are often necessary when medical stabilization, nutritional rehabilitation, and cessation of compensatory behaviors is required.16 The length of stay in these levels of care is heavily contingent on the patient's insurance coverage as well as their financial means. However, any time spent in a hospital or hospital-like setting can affect a patient's personal and professional life. People who do seek higher levels of care in their recovery process will have to continue with intensive treatment with an outpatient team after completing inpatient or residential care. When a client presents with additional disorders, the treatment process can be further elongated if the clinician treats them consecutively instead of concurrently.
Posttraumatic Stress Disorder
Similar to EDs, PTSD also has a profoundly negative impact on a person's general well-being. The impairment from the symptoms affects a person's social and occupational functioning and requires psychotherapeutic treatment. Exposure to a stressful or traumatic event does not guarantee a PTSD diagnosis, but the reaction to the event can be influenced by a person's general coping ability. Researchers propose that people with avoidant coping styles have more difficulty integrating a stressful experience than those with problem-solving styles.17 Those people who do develop PTSD can then be consumed with intrusive memories of the trauma, intense negative affect, and emotions such as fear, horror, and anxiety.18 This experience of the world can result in significant impairments to a person's functioning.
When a person faces these painful symptoms of PTSD, they may develop maladaptive means to cope with the experiences. Briere and Scott19 have found that restriction, bingeing, and purging, in particular, can serve to facilitate avoidance and decrease arousal from re-experiencing the traumatic event. There is also a crossover with substance use disorders, as people may use substances to manipulate a hyperactive autonomic nervous system triggered by PTSD.20 These coping strategies can complicate the treatment protocol, often leaving clinicians to prioritize between the comorbidities.
Treatment for Patients with Comorbid Eating Disorders and Posttraumatic Stress Disorder
There does not yet exist a formal consensus on how to treat comorbid PTSD and EDs. Historically, clinicians have hypothesized that treating them consecutively yields better results.21 This is due in part to the imminent physical dangers common in EDs but also due to the cognitive impairments seen as a result of the nutritional instability in patients with ED. However, EDs and PTSD share many commonalities that can be addressed simultaneously in therapeutic work. These commonalities include emotion dysregulation, impulsivity, and low interoceptive awareness.21 Due to the bidirectional nature of these two disorders, patients can at times experience heightened symptoms in one disorder while making progress in the other.22 This is further evidence for the necessity of an integrated psychotherapeutic intervention for the patient population with ED/PTSD.
Recent research has begun to explore the concurrent treatment of EDs and PTSD with promising results.13 By using a cognitive-based treatment, clinicians can target the problem behaviors seen in both disorders. This intervention can be implemented on an outpatient basis for PTSD. However, special considerations must be made within the patient population with ED/PTSD that account for the frequent nature of admissions to higher levels of care beyond outpatient care. Admission to hospital-based programs can interrupt the course of psychotherapy with the existing outpatient clinician as the patient acclimates to the protocol used at a treatment center. Therefore, it is important for the treatment protocol for patients with ED/PTSD to be easily adapted to both community-based and hospital-based clinicians.
Cognitive Processing Therapy
CPT is a 12-session, evidence-based treatment protocol for PTSD that is shown to be effective in many populations such as female survivors of sexual violence, survivors of childhood sexual abuse, and military veterans.23–25 The main aims of CPT are to assist the person in identifying how the traumatic event(s) influenced or changed thoughts and beliefs, to decrease emotional numbing, and to improve overall functioning.26 This is accomplished through psychoeducation, Socratic questioning, and homework for the patient to complete outside of the sessions. Successful courses of CPT have been shown to result in improvements in participants' depression, shame, anger, and cognitive distortions.27
There are many factors that make CPT an ideal protocol for comorbid EDs and PTSD. The manualized nature of CPT enables multiple clinicians to use the protocol throughout a patient's treatment process. The main role the clinician takes in a cognitive-based therapeutic approach such as CPT is to offer an objective perspective that assists the patient in reframing the traumatic experience(s).28 If a person's ED symptoms require admission to multiple levels of care, clinicians at each step can easily continue the CPT sessions. CPT can also be effective in addressing the problematic cognitions that maintain both PTSD and ED symptoms.21 Through the use of worksheets, patients are able to challenge maladaptive beliefs about themselves and others. By mastering the ability to subsequently modify these beliefs surrounding the trauma, patients with comorbid EDs can use this process to challenge their existing beliefs about their weight, shape, and body size that lead to ED behaviors.
Despite the many benefits of implementing CPT for the patient population with comorbid ED/PTSD, some clinicians may be apprehensive to treat the disorders simultaneously. Clinical experience can lead providers to anticipate that a patient's ED behaviors may increase in severity as they work through their trauma. These concerns also expand to fears of worsening self-injury and interference with ED symptom improvements.13 This should not be a barrier to implementation, however, because as the client progresses through the CPT sessions, the skills they learn to manage the emotions and cognitions attached to the trauma can easily be used in ED recovery. By learning to cope with emotions and to restructure maladaptive beliefs, the patient can make progress in recovering from both diagnoses simultaneously.
Future research is needed to fully explore the implementation of CPT for this unique population. Currently, CPT has few exclusion criteria and can be implemented with a varied population of patients. The protocol has modifications for patients with low IQs as well as for patients with severe self-harm.29 Although its application for a variety of populations makes CPT ideal for incorporating into ED treatment planning, future studies should examine how the protocol can be adjusted to further target symptoms shared by both PTSD and ED patients. Considerations for its appropriateness for ED patients with low body mass index or significant medical instability should be examined. Longitudinal research will be beneficial in exploring if and how CPT can serve to sustain recovery from both disorders. Such research can only serve to benefit the field by establishing the gold standard for ED/PTSD treatment.
- Waller G, Gray E, Hinrichsen H, Mountford V, Lawson R, Patient E. Cognitive-behavioral therapy for bulimia nervosa and atypical bulimic nervosa: effectiveness in clinical settings. Int J Eat Disord.2014;47(1):13–17. doi:. doi:10.1002/eat.22181 [CrossRef]
- Wilson GT, Fairburn CC, Agras WS, Walsh BT. Cognitive-behavior therapy for bulimia nervosa: time course and mechanisms of change. J Consult Clin Psychol.2002;70(2):267–274. doi:. doi:10.1037/0022-006X.70.2.267 [CrossRef]
- Kass AE, Kolko RP, Wilfley DE. Psychological treatment for eating disorders. Curr Opin Psychiatry.2013;26(6):549–555. doi:. doi:10.1097/YCO.0b013e328365a30e [CrossRef]
- Thomson-Brenner H. Improving psychotherapy for anorexia nervosa: introduction to the special section on innovative treatment approaches. Psychotherapy. 2016;53(2):220–222. doi:/. doi:10.1037/pst0000050 [CrossRef]
- Zeeck A, Herpertz-Dahlmann B, Friederich HC, et al. Psychotherapeutic treatment for anorexia nervosa: a systematic review and network meta-analysis. Front Psychiatry. 2018;9(158):1–14. doi:. doi:10.3389/fpsyt.2018.00158 [CrossRef]
- Ulfvebrand S, Birgegård A, Norring C, Högdahl L, von Hausswolff-Juhlin Y. Psychiatric comorbidity in women and men with eating disorders results from a large clinical database. Psychiatry Res. 2015;230:294–299. doi:. doi:10.1016/j.psychres.2015.09.008 [CrossRef]
- Blinder BJ, Cumella EJ, Sanathara VA. Psychiatric comorbidities of female inpatients with eating disorders. Psychosomatic Med.2006;68(3):454–462. doi:. doi:10.1097/01.psy.0000221254.77675.f5 [CrossRef]
- Fairburn CG, Brownell KD. Eating Disorders and Obesity: A Comprehensive Handbook. 3rd ed. New York, NY: Guilford Press; 2017.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
- Brewerton TD. Eating disorders, trauma, and comorbidity: focus on PTSD. Eat Disord. 2007;15:285–304. doi:. doi:10.1080/10640260701454311 [CrossRef]
- 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. Int J Eat Disord. 2012;45(3):307–315. doi:. doi:10.1002/eat.20965 [CrossRef]
- Tagay S, Schlottbohm E, Reyes-Rodriguez ML, Repic N, Senf W. Eating disorders, trauma, PTSD and psychosocial resources. Eat Disord. 2014;22(1):33–49. doi:. doi:10.1080/10640266.2014.857517 [CrossRef]
- Trottier K, Monson CM, Wonderlich SA, Olmsted MP. Initial findings from Project Recover: overcoming co-occurring eating disorders and posttraumatic stress disorder through integrated treatment. J Trauma Stress. 2017;30(2):173–177. doi:. doi:10.1002/jts.22176 [CrossRef]
- Arcelus J, Mitchell AJ, Wales J, Nielson S. Mortality rates in patients with anorexia nervosa and other eating disorders. Arch Gen Psychiatry. 2011;68(7):724–731. doi:. doi:10.1001/archgenpsychiatry.2011.74 [CrossRef]
- Kaye WH, Wierenga CE, Bailer UF, Simmons AN, Bischoff-Grethe A. Nothing tastes as good as skinny feels: the neurobiology of anorexia nervosa. Trends Neurosci. 2013;36(2):110–120. doi:. doi:10.1016/j.tins.2013.01.003 [CrossRef]
- Treat TA, Gaskill JA, McCabe EB, Ghinassi FA, Luczak AD, Marcus MD. Short-term outcome of psychiatric inpatients with anorexia nervosa in the current care environment. Int J Eat Disord. 2005;38(2):123–133. doi:. doi:10.1002/eat.20160 [CrossRef]
- Brewerton TD, Brady K. The role of stress, trauma, and PTSD in the etiology and treatment of eating disorders, addictions, and substance use disorders. In: Brewerton TD, Dennis AB, eds. Eating Disorders, Addictions and Substance Use Disorders: Research, Clinical and Treatment Perspectives. New York, NY: Springer; 2014:379–404. doi:10.1007/978-3-642-45378-6_17 [CrossRef]
- Litz BT, Gray MJ. Emotional numbing in posttraumatic stress disorder: current and future research directions. Aust N Z J Psychiatry. 2002;36(2):198–204. doi:. doi:10.1046/j.1440-1614.2002.01002.x [CrossRef]
- Briere J, Scott C. Assessment of trauma symptoms in eating-disordered populations. Eat Disord. 2007;15(4):347–358. doi:. doi:10.1080/10640260701454360 [CrossRef]
- Brady KT, Back SE, Coffey SF. Substance abuse and posttraumatic stress disorder. Curr Direct Psychol Science. 2004;13(5):206–209. doi:. doi:10.1111/j.0963-7214.2004.00309.x [CrossRef]
- Mitchell KS, Wells SY, Mendes A, Resick PA. Treatment improves symptoms shared by PTSD and disordered eating. J Trauma Stress. 2012;25(5):535–542. doi:. doi:10.1002/jts.21737 [CrossRef]
- Trottier K, Monson CM, Wonderlich SA, MacDonald DE, Olmsted MP. Frontline clinicians' perspectives on and utilization of trauma-focused therapy with individuals with eating disorders. Eat Disord. 2017;25(1):22–36. doi:. doi:10.1080/10640266.2016.1207456 [CrossRef]
- Resick PA, Schnicke MK. Cognitive processing therapy for sexual assault victims. J Consult Clin Psychol.1992;60(5):748–756. doi:10.1037/0022-006X.60.5.748 [CrossRef]
- Chard KM, Weaver TL, Resick PA. Adapting cognitive processing therapy for child sexual abuse survivors. Cogn Behav Pract. 1997;4(1):31–52. doi:. doi:10.1016/S1077-7229(97)80011-9 [CrossRef]
- Monson CM, Schnurr PP, Resick PA, Friedman MJ, Young-Xu Y, Stevens SP. Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. J Consult Clin Psychol. 2006;74(5):898–907. doi:. doi:10.1037/0022-006X.74.5.898 [CrossRef]
- Resick PA, Monson CM, Chard KM. Cognitive Processing Therapy for PTSD: A Comprehensive Manual. New York, NY: Guilford Press; 2017.
- Resick PA, Galovski TE, Uhlmansiek MO, Scher CD, Clum GA, Young-Xu Y. A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. J Consult Clin Psychol. 2008;76(2):243–258. doi:. doi:10.1037/0022-006X.76.2.243 [CrossRef]
- Brewerton TD. Eating disorders, victimization, and comorbidity: principles of treatment. In: Brewerton TD, ed. Clinical Handbook of Eating Disorders: An Integrated Approach. New York, NY: Marcel Dekker; 2004:509–545.
- Resick PA, Monson CM, Chard KM. Cognitive processing therapy: veteran/military version. http://www.alrest.org/pdf/CPT_Manual_-_Modified_for_PRRP%282%29.pdf. Accessed September 13, 2018.