On September 17^th, Monte Nido Walden Psychiatrist John Chardavoyne, MD presented “Discovering the Unknown: Chronic Dissociative Processes in People with Eating Disorders.”

Eating disorders rarely occur in isolation. For many clients, especially those with chronic and severe trauma histories, dissociation plays a critical role in both the development and maintenance of symptoms. Because dissociation is strongly associated with worse treatment outcomes, understanding and addressing it is essential in eating disorder care.

What Is Dissociation?

The American Psychiatric Association defines dissociation as:

“Disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior.”

Two main categories of dissociation symptoms are often described:

• Positive symptoms - unwanted intrusions, such as identity fragmentation or depersonalization.

• Negative symptoms - gaps in memory or loss of access to normal mental functions, such as amnesia.

Chronic Dissociative Processes

Chronic dissociation refers to ongoing disruptions that shape how a person thinks, feels, and functions. Common processes include:

• Amnesia - memory gaps for daily events or trauma.

• Depersonalization - feeling detached from oneself or the body.

• Derealization – perceiving the world or loved ones as unreal.

• Identity confusion - uncertainty about identity or sense of self.

• Identity alteration - shifting into distinct states, sometimes with different behaviors or memories.

• Somatic dissociation - physical symptoms linked to dissociation, such as unexplained pain.

Structural Dissociation

One way to conceptualize dissociation is that there are divisions in aspects of the personality into:

• Apparently Normal Parts (ANPs) - manage daily life while avoiding traumatic memories.

• Emotional Parts (EPs) - remain fixated in trauma-related action systems, such as fight, flight, or freeze.

Levels of division can vary:

• Primary - one ANP, one EP (e.g., PTSD).

• Secondary - one ANP, multiple EPs (e.g., complex PTSD, trauma-related borderline personality disorder).

• Tertiary - multiple ANPs and EPs (e.g., Dissociative Identity Disorder).

Why Understanding Dissociation Matters for Eating Disorder Treatment

Dissociation and eating disorders are closely linked:

• Trauma is highly prevalent among clients with eating disorders.

• Dissociation is tied to worse treatment outcomes, including higher dropout rates.

• Dissociation can contribute directly to disordered behaviors—such as binge eating functioning as an “escape” from overwhelming negative affect.

Research shows:

• Individuals with bulimia nervosa report more trauma-related memory gaps than peers without eating disorders.

• Dissociation often follows increases in negative affect before and during binge episodes, numbing distress but reinforcing the cycle of symptoms.

How to Screen for Dissociation in Eating Disorder Clients

Several validated tools can help identify dissociation in eating disorder clients:

• Dissociative Experiences Scale (DES-II)

• Cambridge Depersonalization Scale

• Somatic Dissociation Questionnaire (SDQ-20)

• Multidimensional Inventory of Dissociation

How to diagnose a Dissociative Disorder

• SCID-D (Structured Clinical Interview for Dissociative Disorders)

Even if a formal diagnosis is not confirmed, noting dissociation as a potential factor can shape treatment planning and improve outcomes.

Treatment Approaches for Dissociation and Eating Disorders

Phase-Based Model

A structured, phase-based approach has shown the best results for complex dissociative processes:

Phase One: Safety & Stabilization

1. Build skills in self-care, grounding, and emotional regulation.

2. Reduce shame and establish a sense of safety.

3. Educate clients about dissociation and its role in symptoms.

Phase Two: Trauma Processing

1. Gradually process traumatic memories while maintaining stability.

2. Use grounding and containment to manage emotional flooding.

3. Support healthier narratives about past experiences.

Phase Three: Integration & Reconnection

1. Foster a cohesive sense of self.

2. Strengthen relationships with others and daily life functioning.

Evidence of Dissociation and Eating Disorder Treatment Effectiveness

• TOP DD studies: Treating dissociation directly leads to reduced hospitalizations, fewer PTSD symptoms, and improved functioning.

• Monte Nido case series: Residential clients with both eating disorders and dissociative identity disorder showed medium to large improvements in eating disorder, PTSD, depression, and quality-of-life outcomes when trauma and dissociation were integrated into care.

Addressing Dissociation Alongside Eating Disorders is Vital for Outcomes

• Dissociation is common in eating disorders, particularly when trauma is present.

• Unaddressed dissociation worsens treatment outcomes.

• Screening tools and simple questions can identify clients who need extra support.

• A trauma-informed, phase-based approach improves both eating disorder and dissociation outcomes.

Dissociation may feel like a hidden or unfamiliar process, but it is a critical factor in eating disorder care. By recognizing the signs, screening thoughtfully, and using evidence-based strategies, clinicians can help clients move toward integration and recovery.

Eating disorder treatment must extend beyond nutritional stabilization - it must address the impact of trauma and dissociation. With compassionate, trauma-focused care, clients can achieve not just symptom relief but also greater connection, stability, and hope for the future.

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