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On August 6th, Monte Nido Senior Director of Research and Clinical Outcomes Giulia Suro, Ph.D., CEDS presented “Sexual Trauma & Eating Disorders: Exploring the Link.”
Research consistently reflects a strong connection between sexual trauma and the development of eating disorders. Individuals with eating disorders report significantly higher rates of trauma, particularly sexual trauma, than the general population. Childhood sexual trauma is especially impactful with one longitudinal study demonstrating that females who experienced sexual trauma before age 16 faced a fivefold increase in the risk of developing an eating disorder.
Sexual trauma is now recognized as a unique and independent predictor of eating disorder pathology, even when controlling for other forms of trauma, with associations observed across diverse populations, including individuals experiencing food insecurity. Those with a sexual trauma history are more likely to develop binge eating disorder, and the co-occurrence of post-traumatic stress disorder (PTSD) and an eating disorder often intensifies symptoms of the eating disorder, anxiety, depression, and related concerns.
Early-onset eating disorders, particularly in childhood, are associated with higher trauma exposure, provisional PTSD, and increased illness severity, underscoring the need for trauma-informed care in treatment and recovery.
The Trauma-Eating Disorder Cycle
The trauma–eating disorder cycle reflects the interplay between emotional dysregulation, maladaptive coping strategies, and the enduring effects of trauma. Loss of control, a hallmark of a traumatic event, often leads to chronic anxiety and hypervigilance. In an effort to regain control, some may turn to behaviors such as restricting food intake, engaging in rigid rituals, or attempting to alter body size. Shame is central to this cycle - implicated in the onset, maintenance, and severity of all eating disorder diagnoses. Higher levels of shame are associated with more severe behaviors, increased self-criticism, and overvaluation of body shape and weight. Shame can both precipitate and result from disordered eating, for example, triggering a binge episode and then intensifying afterward, reinforcing the cycle.
Experiential Avoidance is Common in Trauma and Eating Disorders
Experiential avoidance, the attempt to escape or reduce unwanted internal experiences, is common in both PTSD and eating disorders. Disordered eating behaviors can serve as a form of emotional avoidance, offering temporary relief or detachment from distressing emotions but ultimately perpetuating avoidance patterns and worsening symptoms. Emotional numbing is an important function to recognize, as individuals may use restriction, binge eating, or other eating disorder behaviors as a “break” from the psychological aftermath of trauma.
Within Acceptance and Commitment Therapy (ACT), experiential avoidance is understood as a core process that sustains distress, making it critical for treatment to help individuals identify, tolerate, and accept painful internal experiences rather than attempt to suppress them.
Dissociation and Body Image Distortion
Dissociation, a common response to sexual trauma, can significantly impact body perception and awareness. By creating a sense of disconnection from the body, dissociation can impair the ability to accurately assess size, shape, or appearance, sometimes resulting in persistent body image distortion.
This disconnection may also reduce awareness of internal bodily cues such as hunger and fullness, creating conditions that contribute to the onset and maintenance of eating disorder behaviors. When sexual trauma occurs in childhood or adolescence, it can further disrupt the development of a stable and cohesive sense of self, including a grounded and accurate body image.
Insula Cortex Disruption Associated with Trauma and Eating Disorders
Both PTSD and eating disorders are associated with disrupted function of the insula cortex, a brain region critical for integrating interoceptive awareness, emotional processing, and self-perception. Altered insula activity can interfere with accurately detecting and interpreting internal bodily signals such as hunger, fullness, and emotional states. This disruption may manifest as emotional and physical numbness, dissociation, and misperception of body size and shape.
Neuroimaging studies in both PTSD and eating disorders have demonstrated abnormal insula activation patterns, correlating with symptoms such as body image distortion, alexithymia (reduced emotional awareness), and interoceptive deficits, highlighting the shared neurobiological pathways of trauma and disordered eating.
The Case for Concurrent Treatment of Trauma and Eating Disorders
For many, eating disorder symptoms are both a consequence of and a coping mechanism for PTSD. PTSD symptoms often perpetuate disordered eating, and reductions in PTSD symptoms are associated with corresponding decreases in eating disorder severity. Helping clients understand the connection between their trauma history and eating disorder behaviors, particularly the role of avoidance, is essential.
Because eating disorder behaviors that reduce PTSD distress have been highly reinforced, treatment must replace these behaviors with adaptive coping strategies while reinforcing the understanding that the trauma is in the past and that current triggers, such as thoughts and memories, cannot physically harm them. Concurrent treatment is critical for breaking the cycle linking trauma and disordered eating.
Cognitive Processing Therapy (CPT) and the Brain’s Response to Trauma
Cognitive Processing Therapy (CPT) is an evidence-based, front-line treatment for PTSD. Its structured, 12-session protocol is efficient, flexible, and transdiagnostic - targeting multiple symptoms at once. CPT’s reliance on cognitive behavioral principles and Socratic questioning makes it adaptable across providers and levels of care, making it well-suited for integration into eating disorder treatment settings.
From a neurobiological perspective, trauma activates the amygdala to detect threat, the hypothalamus to trigger fight, flight, or freeze responses, and the hippocampus to retrieve autobiographical memories, all before the prefrontal cortex, responsible for reasoning and problem-solving, has fully engaged. In PTSD, the amygdala-driven system can dominate, resulting in heightened emotional reactivity. CPT shifts this pattern by activating the prefrontal cortex earlier, encouraging individuals to examine and reframe trauma-related beliefs before emotional and physiological responses escalate. This process helps recalibrate the brain’s trauma response system, reducing reliance on maladaptive coping strategies such as eating disorder behaviors.
CPT for Sexual Trauma and Eating Disorders at Monte Nido
Research from Monte Nido has shown that integrated, multi-modal treatment using CPT principles can be successfully delivered in higher levels of care, resulting in significant symptom reductions maintained at 6-month follow-up for most measures except for depression (PHQ-9). It is noted that while patients with PTSD experience worse symptoms at all time points, all groups show significant improvement, but recurrence of depressive symptoms still poses a challenge and may signal ED relapse, necessitating aggressive intervention and longer periods of follow-up.
These findings emphasize the importance of individualized case formulations, helping clients understand how trauma and ED symptoms are interconnected, and focusing on addressing avoidance behaviors common to both PTSD and eating disorders. Treatment approaches should be tailored and interwoven by the same providers to ensure the most effective care.
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Sources:
Brewerton, T.D., Gavidia, I., Suro, G. et al. Eating disorder patients with and without PTSD treated in residential care: discharge and 6-month follow-up results. J Eat Disord 11, 48 (2023). https://doi.org/10.1186/s40337-023-00773-4
Gomez F, Kilpela LS, Middlemass KM, Becker CB. Sexual trauma uniquely associated with eating disorders: A replication study. Psychol Trauma. 2021 Feb;13(2):202-205. doi: 10.1037/tra0000586. Epub 2020 Sep 17. PMID: 32940521; PMCID: PMC9024223.
Convertino AD, Morland LA, Blashill AJ. Trauma exposure and eating disorders: Results from a United States nationally representative sample. Int J Eat Disord. 2022 Aug;55(8):1079-1089. doi: 10.1002/eat.23757. Epub 2022 Jun 19. PMID: 35719053; PMCID: PMC9545485.
