Eating disorders often arise from a need to control one’s self or environment, and this behavior can be triggered by a traumatic experience. In particular, childhood trauma is very highly correlated with a manifestation of eating disorders later on in life (teens typically). Ultimately the biggest predictors of psychopathology in regard to eating are:

Emotional abuse, particularly from parents
Physical abuse
Neglect — this differs from direct abuse in that a patient suffering from neglect might not have their needs met, but would not be directly assaulted

In addition, studies have found that patients who suffer from PTSD from specific trauma are significantly more likely to suffer from an eating disorder in the future. This can be extrapolated to any singular event that causes clinically significant anxiety or depression as well. Simply put, there is direct evidence that traumatic experiences dramatically increase the chances of developing an eating disorder later in life, and coupled with dissociative psychopathology, is one of the main reactions to such trauma.

Patients who suffered childhood trauma also often see a rise in OCD and anxiety that is measurably linked to eating disorders. While not all eating disorder or OCD patients have experienced direct trauma, many who have had trauma will develop an eating disorder and comorbid psychological distress, primarily:

Major depression
General anxiety disorder
Panic disorders
Agoraphobia
PTSD

We will look at some reasons why the development of an eating disorder is common following trauma, the occurrence of trauma in anorexia nervosa and bulimia nervosa, social climate and how it impacts eating psychopathology and how treatment progresses once diagnosis occurs.

Causal Link Between Eating Disorders And Trauma

Trauma in life is often an indicator of future psychological problems; chief among these are anxiety, PTSD, depression, self-harm and eating disorders. Moreover, studies indicate that these disorders occur concurrently and the lines between them blur in trauma victims, and especially in ED patients. For some people, the psychological impact of trauma is so great that it causes depersonalization or dissociation, which leads to a greater risk of self-injurious behavior. This has been theorized to lead to restrictive eating habits that, though harmful, bring a level of control to the patient.

External factors such as social media and peer groups and how they perceive or accept the trauma of the patient can impact their development of emotional distress and associated psychopathologies. Essentially, if a patient is not provided an understanding peer group or if the trauma is viewed as a non-issue by other friends and family, the resulting incongruity causes distress that can lead to disordered eating.

One suggested reason for eating disorders among abused youth is that eating is seen as a nurturing act. The very concept of feeding your children is so ingrained into parents and every culture in the world that, when coupled with abuse causes children to not assimilate the concepts correctly. Traumatized children may see eating as an escape, as it may be the only positive emotion they can consider when thinking of their abuser. They may also mistrust the rituals and characteristics of eating with other people.

Trauma patients who suffered a loss — say a car accident that took the life of someone close — may develop an eating disorder to regain some sense of control. When someone loses something important, violently and without warning, it can profoundly shape how they interact with their world. Restrictive eating is a way to get a firmer grasp on the randomness of life.

Finally, neglectful households can trigger trauma-induced eating disorders for a variety of reasons. Simply living far below necessity is enough to make a child not trust food, where it’s going to come from next and who is providing it to them. Moreover, a patient who has frequently gone undernourished and is taken from that neglectful environment might then develop a cycle of binging. This binge eating disorder may be coupled with restriction the next day or purging, or excessive exercise. Some studies indicate a patient-reported sense of self-worth tied to body image can result from trauma, particularly if the trauma is due to abandonment or physical abuse, and this can lead of course to restrictive eating.

While there is no definitive causal link, as stated above, the incidence of eating disorders among PTSD patients is remarkably higher than average. While it could seem like it’s not unreasonable, the incidence of anxiety and depression among PTSD trauma patients is not significantly higher, at least not on par with an eating disorder, though all three can occur simultaneously.

Peer And Social Impact On Eating Disorders

With any mental health difficulty, having an understanding support group is essential to health and recovery. Patients who had a reliable network of friends and family in aftercare were substantially more likely to not relapse.

For trauma patients, the impact of not having a compassionate peer safety net is a statistically significant indicator of further distress and difficulty. Patients who reported their abuser but were met with skepticism were significantly more likely to develop comorbid disorders or increase self-harming behavior. A patient who exhibits both PTSD and disordered eating requires a robust social system in place to help aid in recovery.

Another factor in recovery is the role social media plays. It is increasingly difficult to escape abusers with a growing digital footprint and the increased complexity of remaining anonymous online. A patient in recovery who is forced to observe or interact — even digitally — with their abuser or see reminders of their trauma is less likely to be successful in the long term.

As a support person, it’s likely impossible for you to monitor all of their interactions with other people, and moreover, you wouldn’t want to. The goal is to help your loved one establish good, safe social protocols that keep them away from triggering media or people. This is particularly important with adolescents and teens because trauma impacts frontal-lobe development, leading to a greater incidence of impulsivity and reckless behavior, which can increase the likelihood of disordered eating.

Trauma And Anorexia Nervosa

Anorexia nervosa is one of the most common eating disorders in the industrialized world, but it’s still relatively rare in terms of the broader scope of mental health issues. The incidence among the general population is around 1%, markedly lower than anxiety or depression. Regardless, it continues to be the most dangerous mental health disorder, with a fatality rate of around 10%.

It is precisely because of this danger that so much research is poured into determining a cause and a better path to recovery. Cognitive-behavioral therapy in an outpatient, residential setting remains one of the most effective methods for treating and resolving eating disorders, including anorexia nervosa.

Trauma plays a direct role in the development of anorexia, and in some surprising ways. Physical abuse and neglect, especially when those traumas are directly responsible for the development of PTSD or anxiety, are high predictors for the development of an eating disorder. Several studies indicate that birth trauma and low birth weight are directly correlated with eating disorders later in life as well, usually during adolescence.

Ultimately, it requires diligence on your part as a loved one to observe and talk to your family and friends to determine if they need help. The biggest predictor of recovery is having a support system that cares enough to intervene in the first place and be there after treatment.

Bulimia Nervosa And Trauma

Bulimia nervosa has a lifetime prevalence around .4%, making it somewhat rarer than anorexia or binge eating disorder, but it’s still a dangerous disorder by itself. While it’s less firmly rooted in trauma than binge eating disorder or anorexia, there is still a strong link between trauma-induced PTSD and bulimia.

Bulimia nervosa patients often do not exhibit the same restrictive behavior or physical symptoms that an anorexia nervosa patient might. Their physical presentations are less obvious, and so they require more observation and inference, particularly in suspected trauma cases. Traditionally, struggles with both bulimia and anorexia nervosa were thought to have better outcomes if parents and peers were excluded from treatment but advances in research and sub-clinical treatment have proven that to be incorrect.

Particularly in trauma and abuse situations where a new, stronger social network is present and the abuse or neglectful element has been removed, there is a strong association with familial involvement and recovery. As with anorexia nervosa , it’s critical to be open to listening, to engage with therapy and to avoid judgment at all costs.

Treating Eating Disorders When Trauma Is A Factor

Cognitive-behavioral therapy in a sub-clinical, comfortable setting is still the best treatment for eating disorders. Coupled with a strong family support system and reliable aftercare program, recovery rates are quite high.

Methods For Treating Trauma-Associated Eating Disorders

The first step is to determine if there might be an eating disorder and what we’ve established is that a non-judgmental approach of openness is the most important thing. If you suspect that your loved one is suffering from an eating disorder, taking them aside into a comfortable setting, alone and asking them some of these questions is a good way to gauge if there’s a problem:

“Is there anything going on right now that you’d like to talk about?”
“Is there anything I can do to help you? Has anything changed recently you need help with?”
“Do you feel like there are things in your life that are overwhelming you?”

This is not an exhaustive list, of course, the idea is to be open and willing to listen to them about whatever is causing distress. If you establish there is a condition, then getting them into a treatment center is the next step.

The intake at the facility they are working with will determine the best course of action to treat the ED. In most cases, the first step is to remove trauma. This is something that has likely already occurred by the time they’re in treatment. In the majority of trauma-induced mental health cases, if the family is getting the patient help, they have already resolved or removed the traumatic element (removal from an abusive home, for instance).

Once the traumatic element and triggering related factors are removed, then group therapy is often a key component of treatment. Clinical treatment or hospitalization is often seen as a last resort when treating disordered eating. A familial, comfortable, home-like setting is critical because it is when a patient is relaxed that they can truly open up and resolve the conflict that causes mental health crises.

After outpatient treatment is over, the doctors at the clinic will establish an aftercare routine. This is usually a group effort between the support system, a general practitioner, nutritionist or dietitian who is trained in working with eating disorder patients, and the treatment clinic themselves. Regular therapy visits are also integral to recovery, along with scheduled visits back to the treatment facility to follow-up.

When the traumatic incidence is removed, and consistent, loving steps are taken to distance the patient from that trauma, concurrent pathologies like anxiety and PTSD can be addressed. Once that has happened, then the eating disorder itself can be resolved. The confounding variables need to be fixed first because the eating disorder often transcends just emotional and psychological difficulty into very present physical harm and danger. It takes a team of loving individuals and trained professionals to truly work out an eating disorder once and for all and to prevent relapse.

Melissa Spann, PhD, LMHC, CEDS-S

Melissa Orshan Spann, PhD, LMHC, RTY 200, is Chief Clinical Officer at Monte Nido & Affiliates, overseeing the clinical operations and programming for over 50 programs across the U.S. Dr. Spann is a Certified Eating Disorder Specialist and clinical supervisor as well as an accomplished presenter and passionate clinician who has spent her career working in the eating disorder field in higher levels of care. She is a member of the Academy for Eating Disorders and the International Association of Eating Disorder Professionals where she serves on the national certification committee, supervision faculty, and is on the board of her local chapter. She received her doctoral degree from Drexel University, master’s degree from the University of Miami, and bachelor’s degree from the University of Florida.

The Link Between Trauma And Eating Disorders