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What Is the Connection Between Trauma and Eating Disorders?

In honor of National Mental Health Awareness Month, we’re going to take a look at one of the most common co-occurring presentations that come with major eating disorders: trauma and PTSD. Not only can trauma trigger the negative emotions that bring on disordered eating behaviors, but those behaviors can also trigger further trauma in a dangerous cycle. To put it simply, eating disorders and trauma go hand-in-hand. Eating disorders like ARFID, anorexia nervosa, bulimia nervosa, and binge eating disorder don’t exist in a vacuum; when understood as a response to stress caused by trauma, they are easier to diagnose and treat. Here, we’ll explore some common eating disorders and how they connect to past trauma.

What Is ARFID?

Avoidant/Restrictive Food Intake Disorder (ARFID), which used to be called “selective eating disorder,” is an eating disorder in which individuals restrict their eating to certain types of food, avoiding certain ingredients and food groups completely. ARFID goes well beyond a simple preference for one type of food, and importantly, it is not caused by restrictions due to cultural or religious reasons. People with ARFID might experience negative health effects due to imbalances in nutrition. ARFID was listed in the DSM-V in 2013, but it’s something of an outlier compared to other eating disorders listed there. unlike better-known disorders requiring eating disorder recovery programs like anorexia nervosa and bulimia nervosa, ARFID is not characterized by a negative body image or obsession with weight.

Symptoms of ARFID

Although people with ARFID do not generally intend to lose weight or control the number of calories taken in, experts at eating disorder treatment centers have noted that extreme weight loss can take place. On the other hand, depending on the type and amounts of the selected foods being eaten, there may not be any major weight changes, and the person may be at a “normal” or medically-deemed “high” weight. The most common symptom of ARFID that may require eating disorder recovery treatment is malnutrition resulting from a refusal to eat a variety of proteins and vitamins. Other symptoms and corresponding health risks can include:

  • Only eating foods of a certain texture
  • Nutritional deficiencies (especially iron and certain vitamins)
  • Distress and discomfort when sharing meals
  • Anxiety in the presence of the foods being avoided
  • Dependence on nutritional supplements
  • Anemia
  • Bloating, constipation, and other digestive problems
  • Osteoporosis and other bone density issues
  • Low blood sugar
  • Kidney and liver issues

What Causes ARFID?

While ARFID which requires help from an eating disorder treatment center is similar in many of its symptoms to other eating disorders, especially anorexia nervosa, it does not normally share the preoccupation with body image and caloric intake restriction observed in those disorders.  However, it does share a few root causes which are found in more common eating disorders. As with most mental health disorders, genetics play a factor in the development of ARFID. Co-occurring mental health disorders such as anxiety and obsessive-compulsive disorder have been linked with ARFID as many of the anxious behaviors observed in OCD treatment are similar to the restrictive behaviors seen in ARFID.

As with many mental health and behavioral disorders, a common triggering event is past trauma. Traumatic events such as abuse, a car accident or even losing a job, or going through a divorce can have very strong effects on the psyche, especially in children. Not coincidentally, ARFID’s first incidence is most commonly observed before the onset of adulthood.

What Is Bulimia Nervosa?

Bulimia nervosa is the product of a person’s inability to self-evaluate correctly. Self-evaluation among people with bulimia nervosa or anorexia nervosa focuses solely on the superficial appearance of the body–size, shape, and weight. The physical and psychological experience of depriving the self of food through extreme dieting ultimately contributes to binge-eating episodes. After eating an enormous amount of food, the individual becomes panic-stricken with fear of gaining weight combined with deep shame and guilt over losing control during a binge-eating episode.

People with bulimia nervosa obsess overachieving what they think is an “ideal” body shape and weight. Perfectionism of this magnitude leads to a negative and distorted self-evaluation process that responds to a failure to meet unattainable high standards. Mood intolerance (an inability to cope with adverse states of mind and emotion) promote participation in bulimia nervosa behaviors as well as sustained depression and generalized anxiety.

What Are the Symptoms of Bulimia Nervosa?

Bulimia nervosa side effects involve health problems that may require extensive medical treatment or hospitalization. These symptoms and the behavioral changes may include:

  • Frequent dieting
  • Body image distortions and negative self-image
  • Hiding their body behind baggy or loose-fitting clothes
  • Discomfort at meals
  • Constant use of mints, gum, etc to hide the smell of vomit
  • Tooth decay due to repeated vomiting. Over time, stomach acid erodes tooth enamel and may cause tooth loss and gum disease
  • Visible swelling of salivary glands
  • Chronic sore throat
  • Hoarse voice and esophageal damage
  • Dehydration
  • Anemia
  • Electrolyte imbalance (lack of potassium, chloride, and sodium in the body could cause heart arrhythmias and/or heart failure)

What Causes Bulimia Nervosa?

Bulimia nervosa is often triggered by past trauma as well as body image concerns and genetics. Every eating disorder is caused by a combination of factors, and these need to be well-understood by the treatment team when the recovery plan s being designed. People whose parents or close family experienced bulimia nervosa are more likely to develop the disorder, indicating a biological aspect of its development.

What Is Binge Eating Disorder?

Binge eating disorders can be slightly misunderstood by the general public; many people assume all eating disorders are about avoiding food intake via extreme dieting or purges, as seen in anorexia nervosa and bulimia nervosa, respectively. This is quite unfortunate, since binge eating disorder is the most common eating disorder in the United States, affecting about 2.8 million people.  Binge eating disorder is characterized by repeated binge eating episodes, which are compulsive in nature and occur regularly over a month or more. People with this disorder often also experience body dysmorphic disorder, which causes distorted self-perception and negative body image.

What Causes Binge Eating Disorder?

Although mental health professionals haven’t isolated a single cause of binge eating disorder, it’s clear that a combination of biological factors and social pressures are present in most cases.  Since it’s become more well-known a few positives have come to light; first, identifying the causes allows binge eating disorder treatment centers to devise strategies for treatment based on this knowledge, since understand the root causes is essential to eating disorder treatment. Second, it helps to dispel the idea that people with binge eating disorder have some kind of moral failing or lack of willpower rather than experiencing a mental health disorder.

What Are the Symptoms of Binge Eating Disorder?

Understanding the signs and symptoms of this ailment can help you identify it in yourself or a loved one, and begin seeking out professional help.

  • Eating large amounts of food in a very short period
  • Eating beyond the point of satiety during these episodes
  • Hiding or hoarding food in secret
  • Feelings of guilt or shame after eating, especially after a binge eating episode
  • Hiding or strategically throwing away food wrappers
  • Visiting several different groceries (to hide the amount of food being purchased)
  • Avoiding regular meals or eating very little at them
  • Avoiding eating in groups at home or restaurants
  • Frequent dieting
  • Expressing that they are not satisfied with their weight or appearance

Because unlike bulimia nervosa there is no purging behavior associated with the disorder, people with binge eating disorder are often in bigger bodies than most people associate with eating disorders. These factors can result in serious health complications, including heart disease, diabetes, liver disease, and others.

What Is Anorexia Nervosa?

Anorexia nervosa is a serious eating disorder characterized by an attempt to control one’s body weight and shape by restricting the number of calories consumed each day. People with anorexia nervosa have an obsession with food and may also spend much of their time focusing on dieting and exercise. Eating disorders such as anorexia nervosa can often be associated with malnutrition. This can result from a long-term restriction of calories and vital nutrients.

What Are the Symptoms of Anorexia Nervosa?

If left untreated, malnutrition can cause serious complications in every major organ system in the body. Over time, these complications can result in chronic fatigue, muscle damage, dental health issues, abnormal heart rhythms, gastrointestinal problems, and more. Anorexia in adolescence can present with a variety of different signs and symptoms, depending on the severity of the condition.

Some of the most common symptoms of anorexia nervosa include:

  • A low body mass index based on an individual’s age, height, and stature
  • Amenorrhea (loss of the menstruation cycle, yellowing skin, brittle hair, and nails)
  • Obsession with dieting and exercise
  • Always feeling cold
  • Lanugo (a condition where soft, fine hairs begin to grow all over the body and face)
  • Preoccupation with food, and cooking, without actually eating very much themselves
  • Excessive exercise even in events of illness, in bad weather, instead of socializing, etc.
  • Food rituals such as eating foods in certain orders, cutting all foods into tiny pieces, refusing to eat around others
  • Anxiety, depression, and insomnia

What Are the Causes of Anorexia Nervosa?

As with the other disorders mentioned here, and indeed with virtually every kind of mental health disorder, the causes of anorexia nervosa vary from case to case but usually combine a variety of factors. Commonly, body image distortions, a sense of perfectionism, trauma, and certain genetic factors are present in these cases. Similar to treatment plans for other eating disorders, the individual’s underlying causes must be examined to make a complete plan.

How Trauma and PTSD Influence the Development of Eating Disorders

Post-Traumatic Stress Disorder (PTSD) was once only considered to affect combat veterans and people involved in violent experiences, but it has become crystal clear to clinicians and the psychiatric community that various kinds of stress can have a tremendous effect on people of all stripes, especially in childhood. Trauma and the resulting PTSD often result in new behaviors which are often disordered – it has been linked clinically to the development of drug and alcohol abuse issues, panic attacks, repetitive behavior patterns like those seen in cases of OCD, and clinical depression. While in most cases these disorders have some genetic and environmental causes, traumatic events and the resultant PTSD can act as triggers, setting off the onset of disordered eating behaviors, which act as a coping mechanism for the negative emotions brought on by PTSD.

According to a 2007 study, as much as 20 percent of respondents who had bulimia nervosa also experienced acute PTSD, usually based on childhood experiences. There were similar percentages present in people with binge eating disorder and anorexia nervosa. Because of the frequency of these concurrently presenting disorders, trauma and PTSD have become a major part of diagnostic criteria for eating disorders.

Treatment for Trauma and Eating Disorders

Quality eating disorder treatment centers are focusing more and more on combining a medical/psychiatric approach to promoting full recovery. While recently medication has become less popular among treatment professionals, there has been a shift towards mindfulness training and talk therapy designed to address the underlying causes. When applied to treatment for eating disorders, this can mean nutritional programming to help balance vitamin and protein deficiencies which may have developed, added to family therapy and techniques such as CBT (Cognitive Behavioral Therapy) which can promote emotional regulation and retraining of the thought patterns. With a multidisciplinary methodology for treating any eating disorder, the underlying causes (especially trauma) can be addressed simultaneously with the physical and any psychiatric symptoms resulting in the disorder. This gives hope for individuals with an eating disorder to take the steps necessary to heal – mind, body, and spirit.

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.