To promote better treatment adherence and superior health outcomes, clinicians may not deal with ED as an isolated condition. Instead, perform a thorough inquiry into lifetime traumatic events and follow an integrated approach to care delivery. Brewerton’s Principles and Review (2018) indicates that a significant body of research evidence suggests interactions between ED and adverse events at different levels. The following article discusses an integrated care model and trauma-informed practice (TIP) to successfully resolve ED.
Geography: United States; Focus Area: Trauma-informed care
Adverse events are dependent on multiple environmental variables. Although behavioral, mental health, and substance use disorders have been routinely attributed to trauma during care delivery, Brewerton maintains that eating disorders (EDs) must also be accounted for superior treatment outcomes. According to the American Psychiatric Association (APA), eating disorders may refer to one or more conditions among anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and specified and unspecified feeding and eating disorders.
Recent evidence suggests a correlation between eating disorders and adverse experiences, and that EDs are concomitant with other trauma-related disorders. The review indicates that EDs are the result of cumulative trauma. Strong links between trauma, PTSD, and EDs justify the need to understand “predisposition, precipitation, and perpetuation” of EDs. In this context, it is possible to define trauma-informed care (TIC), trauma-informed practice (TIP), and trauma-informed approach (TIA).
Findings from the National Comorbidity Survey Replication (NCSR) on multiple trauma types, across a sample of men and women, with and without EDs indicated that 98%-100% of individuals in both groups had concomitant trauma and EDs. The occurrence of BED was less common when compared to AN and BN. Another study indicated higher lifetime rates (National Women’s Study - NWS) and higher lifetime prevalence (NCSR) of PTSD in individuals with EDs.
Common PTSD, cPTSD, and ED Markers
Furthermore, PTSD and EDs have common risk factors such as being a woman, having a family psychiatry history, previous adverse events, previous trauma, temperament, personality traits, and a lack of social support. Individuals with EDs were also observed to have heightened sensitivity to disgust, reactivity to stress, and perception of threat, and on the other hand, decreased tolerance to distress, increasing the likelihood of emotional reactivity and avoidance. Other symptoms observed in ED were anxiety sensitivity, exaggerated inhibition, fear of cognitive dyscontrol, sensitivity to criticism, weak central coherence, adaptivity to change, misinterpretation of social cues (perceiving hostile intent in human faces, misinterpreting fear as anger), vulnerability and reactivity to trauma, and impaired processing.
EDs may also exist with cPTSD. Complex PTSD (cPTSD) results from repeated traumas leading to a lack of control, escape, and sense of disempowerment, disorganized attachment, pervasive insecurity, personality changes, complex, tenacious, diffuse symptoms, and vulnerability to repeated harm.
Trauma Informed Care (TIC) and Trauma-Informed Approach (TIA)
A trauma-informed care approach (TIC) is comprehensive, at the individual, organizational, and systemic levels. TIC draws upon biological, neurological, social, and psychological foundations, and estimates the burden on individuals, families, and communities. The healing approach is derived from the resources, capacity, and strength of the survivor toward recovery.
A trauma-informed organization understands the pervasive impact of trauma, assesses pathways to recovery, recognizes signs and symptoms of trauma in patients, families, and staff, integrates trauma policies, practices, and procedures, and resists re-traumatization. Organizations involved in EDs may imbibe TIA principles endorsed by Substance Abuse and Mental Health Services Administration (SAMHSA) i.e. trustworthiness and transparency, safety, collaboration and mutuality, peer support, empowerment, voice, and choice, and historical, cultural, and gender issues.
Promotion: Trauma-Informed Approaches to Eating Disorders Paperback – Import, 30 August 2018 by Andrew Seubert (Editor), Pam Virdi (Editor)
Integrated Treatment Approaches
Experts recommend integrated treatment approaches for individuals with coexisting PTSD and ED. Recent studies suggest the need for trauma-focused care for ED. Researchers found that ED clinicians were not sufficiently familiar with trauma-focused PTSD therapies such as cognitive processing therapy (CPT), eye movement desensitization and reprocessing (EMDR), trauma-focused cognitive behavioral therapy (CBT), and prolonged exposure (PE). A small minority of community clinicians providing care for ED were familiar with CPT and EMDR. Non-ED clinicians had negative reactions (hopelessness, frustration, worry) to patients with ED. Limited training in ED among clinicians may make it challenging to manage life-threatening conditions. Further, evidence-based therapies are available for PTSD and ED separately although some studies have indicated the positive effects of integrated approaches, such as improved CPT scores in EDs in women with PTSD. Furthermore, there is very little research evidence for treating ED in individuals with cPTSD. One study indicates the efficacy of PE, TF-CBT, and CPT in ED individuals with cPTSD.
Overall safest approaches recommended by experts include anxiety and stress management, interpersonal and social skills training, cognitive restructuring, trauma education, and emotional regulation, the latter three and narration of trauma memory being the most effective. Experts recommend that an integrated treatment plan must entail an accurate assessment and diagnosis with planning for individuals with PTSD and ED. A standard treatment plan may have a psychiatric and psychological evaluation. Care providers need to understand the functional link between ED and PTSD and adapt according to symptoms. To understand the interactions between coexisting conditions, clinicians may utilize assessment instruments, understand factors that may interfere with the processing of trauma and differences in beliefs, memory, attention, control, avoidance, and revictimization. Integrating care for ED and PTSD involves addressing both conditions by the same clinician. Clinicians may follow specific guidelines to start treatment for PTSD individuals with ED by establishing a timeline of significant trauma events, educating the individual and family members, establishing functional links, followed by addressing the element of highest risk, danger, or impairment. When the individual can process emotional and cognitive information, and ED symptoms improve, leading to a certain level of distress tolerance, the individual is likely to show a willingness to begin healing trauma.
Therefore, trauma-informed care, that is based on a trauma-informed approach, is supported by research evidence as a change that moves beyond one treatment at a time. TIC integrates an understanding of lifetime events and resulting conditions, and implements standard and relevant integrated assessment and care models, for improved adherence to treatment and better care quality and outcomes.
Promotion: Internal Family Systems Therapy for Addictions: Trauma-informed, Compassion-based Interventions for Substance Use, Eating, Gambling and More Paperback – Import, 1 March 2023 by Cece Sykes (Author), Ph.D. Sweezy, Martha (Author), Ph.D. Schwartz, Richard C. (Author)
Keywords
cPTSD, PTSD, complex PTSD, post-traumatic stress disorder, integrated care model, trauma-informed care, eating disorders, integrated treatment approaches, trauma informed approaches
References
Brewerton, T. D. (2018). An Overview of Trauma-Informed Care and Practice for Eating Disorders. Journal of Aggression, Maltreatment & Trauma, 28(4), 1–18. https://doi.org/10.1080/10926771.2018.1532940
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