In this Ask the Experts continuing education session, When Treatment Gets Tough: Exploring Trauma in Complex Eating Disorder Cases, Monte Nido Senior Director of Research and Clinical Outcomes Giulia Suro, Ph.D., CEDS explored the high overlap between trauma and eating disorders, how posttraumatic symptoms can maintain disordered eating behaviors, and how evidence-based trauma treatments can be integrated into eating disorder care.

Eating disorders rarely exist in isolation. Many individuals entering treatment have histories of trauma, dissociation, shame, and chronic emotional dysregulation. When trauma is not recognized or addressed, eating disorder symptoms may persist despite otherwise appropriate treatment. Understanding the relationship between trauma and eating disorders can help clinicians make more effective treatment decisions and reduce the risk of stalled progress.

Trauma is common in eating disorder treatment

Individuals in higher levels of care frequently present with both eating disorders and trauma-related symptoms.

Trauma and eating disorder research reviewed in the session showed:

• Approximately 45 percent of adults with eating disorders in residential treatment meet criteria for PTSD at admission
  
  
• Individuals with PTSD in higher levels of care tend to show:
  
  
  
  • More severe eating disorder symptoms
    
    
  • More anxiety and depressive symptoms
    
    
  • Greater overall clinical complexity
    at all measured time point
    
    
• Adults entering eating disorder treatment report an average of three lifetime traumatic events 
• Individuals with elevated PTSD symptoms report an average of four traumatic events
  
  

These findings suggest that trauma is not an exception in eating disorder treatment. It is often part of the clinical picture.

How trauma symptoms can maintain eating disorder behaviors

After a traumatic event, it is common to experience:

• Intrusive memories, nightmares, or sensory flashbacks
  
  
• Negative beliefs about self, others, or the world
  
  
• Persistent guilt, shame, or fear
  
  
• Irritability, sleep disturbance, or hyperarousal
  
  
• Avoidance of reminders of the trauma
  
  

For many individuals, distressing internal experiences create a strong desire to escape or avoid uncomfortable thoughts, emotions, or bodily sensations.

Eating disorder behaviors can become part of this avoidance cycle.

A functional model presented in the session showed how:

• Trauma reminders trigger distress
  
  
• Eating disorder behaviors provide short-term relief
  
  
• Avoidance prevents emotional processing
  
  
• PTSD symptoms remain active
  
  
• Eating disorder behaviors continue
  
  

Examples of eating disorder behaviors that may function as avoidance include:

• Restriction
  
  
• Binge eating
  
  
• Purging
  
  
• Compulsive exercise
  
  
• Dissociation
  
  
• Emotional suppression
  
  
• Social withdrawal
  
  

When these behaviors reduce distress temporarily, they can reinforce both the eating disorder and the trauma response.

Evidence-based trauma treatments should not be delayed

Several treatments have strong evidence for PTSD, including:

• Cognitive Processing Therapy (CPT)
  
  
• Prolonged Exposure (PE)
  
  
• Eye Movement Desensitization and Reprocessing (EMDR)
  
  

These approaches to PTSD treatment are:

• Structured
  
  
• Time-limited
  
  
• Well-researched
  
  
• Designed to reduce PTSD symptoms directly
  
  

Evidence shows that treating PTSD can also improve co-occurring conditions, including:

• Depression
  
  
• Anxiety disorders
  
  
• Substance use
  
  
• Self-injury
  
  
• Personality disorders
  
  
• Dissociation
  
  

Because of this, delaying trauma treatment until all eating disorder symptoms resolve may not always be the most effective approach.

Should you treat the trauma or eating disorder first?

Treatment planning should be guided by function, safety, and readiness rather than rigid rules.

Factors to consider when planning trauma and eating disorder treatment include:

• Is there imminent medical or psychiatric risk?
  
  
• Are eating disorder behaviors directly linked to trauma avoidance?
  
  
• Can the client engage in trauma-focused work?
  
  
• Is adequate nutrition present to support cognitive processing?
  
  

In some cases, trauma treatment may need to wait briefly for stabilization. In many cases, integrated or concurrent treatment is appropriate.

Concurrent trauma and eating disorder treatment may be helpful when:

• Eating disorder behaviors function as trauma avoidance
  
  
• PTSD symptoms worsen eating disorder behaviors
  
  
• Progress stalls when only one condition is addressed
  
  

Therapist caution in trauma treatment can become avoidance

Clinicians often hesitate to begin trauma work, especially in complex cases.

Common therapist concerns about treating trauma include:

• The client is not ready
  
  
• Trauma work will destabilize the client
  
  
• The alliance is not strong enough
  
  
• Comorbidities must be treated first
  
  
• The client is too complex for manualized treatment
  
  

These beliefs can lead to underuse of evidence-based trauma interventions.

Examples of therapist avoidance of trauma treatment may include:

• Deferring trauma assessment
  
  
• Staying in psychoeducation indefinitely
  
  
• Over-focusing on eating disorder metrics
  
  
• Avoiding trauma discussion when distress increases
  
  
• Labeling clients as not ready without clear criteria
  
  

Increasing awareness of clinician avoidance can help prevent unnecessary treatment delays.

How to integrate trauma-informed eating disorder treatment

Trauma-informed care does not mean changing eating disorder treatment completely. It means delivering standard interventions in ways that support safety and agency.

Key principles of trauma-informed care include:

• Assess trauma history and its function in the eating disorder
  
  
• Provide predictable routines and clear structure
  
  
• Explain treatment steps and rationale
  
  
• Emphasize collaboration
  
  
• Consider identity, culture, and context
  
  
• Connect eating disorder behaviors to trauma responses
  
  

Trauma-informed environments may include:

• Transparent medical and meal procedures
  
  
• Non-shaming language
  
  
• Consistent expectations
  
  
• Trauma-sensitive de-escalation practices
  
  

Trauma-related dissociation, shame, and body image

Trauma-related dissociation can interfere with eating disorder treatment.

Dissociation may appear as:

• Feeling unreal or detached
  
  
• Memory gaps
  
  
• Losing awareness of time
  
  
• Emotional numbness
  
  
• Narrow focus on food, weight, or exercise
  
  

Body image distress may also reflect trauma-related beliefs rather than weight concerns alone.

Examples of trauma-related body image beliefs include:

• Feeling unsafe in the body
  
  
• Shame or disgust toward the body
  
  
• Desire to disappear or become invisible
  
  
• Avoidance of mirrors or physical sensations
  
  

Eating disorder behaviors may serve to:

• Reduce visibility
  
  
• Increase control
  
  
• Avoid memories
  
  
• Numb emotions
  
  

Understanding the function of symptoms helps guide treatment.

The role of shame in eating disorders

Shame is a central experience in both trauma and eating disorders.

Shame can:

• Contribute to the development of eating disorders
  
  
• Maintain symptoms over time
  
  
• Increase self-criticism
  
  
• Intensify body image distress
  
  
• Trigger binge eating or restriction
  
  

Eating disorder behaviors may temporarily reduce shame but often increase it later, creating a cycle that reinforces the disorder.

Compassion-focused approaches may help interrupt this cycle.

Supporting eating disorder clinicians working with trauma

Treating trauma and eating disorders can be emotionally demanding.

Clinicians may experience:

• Vicarious trauma
  
  
• Compassion fatigue
  
  
• Emotional numbing
  
  
• Irritability
  
  
• Burnout
  
  

Protective factors for clinicians include:

• Supervision
  
  
• Peer consultation
  
  
• Trauma-informed workplace culture
  
  
• Training in trauma treatment
  
  
• Attention to clinician self-care
  
  

Supporting providers is essential to sustaining effective trauma-informed eating disorder care.

Moving forward with integrated trauma and eating disorder treatment

Trauma and eating disorders often interact in ways that make treatment more complex but also more meaningful.

Key takeaways from the session include:

• Trauma is common in eating disorder populations
  
  
• Avoidance maintains both PTSD and eating disorder symptoms
  
  
• Evidence-based trauma treatments are effective
  
  
• Integrated treatment may improve outcomes
  
  
• Clinician avoidance can delay progress
  
  
• Trauma-informed care supports safety and engagement
  
  
• Addressing shame, dissociation, and body image is often necessary
  
  
• Supporting clinicians is part of effective treatment systems
  
  

Understanding these connections allows clinicians to respond more confidently when treatment becomes difficult. When trauma and eating disorders are addressed together, recovery may become more possible for individuals whose symptoms have felt resistant to change.

Explore more Monte Nido Continuing Education programs.

Resources: 

This American Life Podcast Episode: Ten Sessions 

CPTforPTSD.com 

Fact Sheet for Clinicians  

13 Hour CEU CPT Training  

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