PTSD- And How it Relates to Eating Disorders
By Judy Scheel, Ph.D.
Exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury or threat to one’s physical integrity is included in the DSMIV-R description of the diagnosis for Post-Traumatic Stress Disorder (PTSD.) For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threat or actual violence or injury. (DSM pg. 424) Physical and/or sexual abuse, incest and rape are all included in the events hailing the diagnosis of PTSD.
Studies have demonstrated statistically significant links between patients who suffered abuse and the later development of an eating disorder. (See Brewerton, T. “The Links Between PTSD and Eating Disorders.” 2008. Psychiatric Times.) Brewerton cites several studies, one which states that, “74% of 293 women attending residential treatment indicated that they had experienced a significant trauma, and 52% reported symptoms consistent with a diagnosis of current PTSD based on their responses on a PTSD symptom scale.”
(It is important to note that it cannot be assumed that individuals who have eating disorders have had a history of prior sexual and or physical abuse. Contrarily, an individual who has been sexually or physically abused is an increased risk for the development of an eating disorder.)
The diagnostic features associated with PTSD are of particular importance in the understanding of the etiology of eating disorders. The DSM IV states, “The Traumatic event can be re-experienced in various ways. Commonly the person has recurrent and intrusive recollections of the event…In rare instances, the person experiences dissociative states that last from a few seconds to several hours… during which components of the event are relived and the person behaves as though experiencing the event at the moment. Intense psychological distress or physiological reactivity often occurs when the person is exposed to triggering the events that resemble or symbolize an aspect of the traumatic event”… (DSM IV pg. 424)
One of the primary purposes of eating disorder symptomatology is to avoid and cope with painful, disquieting or uncomfortable feelings or affect. The eating disorder serves both to distance oneself from these feelings or states as well as to relieve them. From an abuse perspective, the eating disorder is a clever, albeit, destructive means to accomplish both distance and numbing as well as a means to relive the painful past events through a recreation of it through the eating disorder symptomatology. In effect, the individual with the eating disorder assumes roles of both the victim and abuser. S/he is typically at the mercy of the eating disorder symptomatology, which can be quite sadistic (i.e. laxative abuse, using a blunt instrument down the throat in order to vomit, starvation, binge eating until exhausted and physically in pain) as well as simultaneously assuming the role of the abuser who is in effect doing the harm, perpetrating the assault, to her own body. This paradigm fits with the relationship between the individual who is physically and/or sexually abused and the abuser, only this time, the sufferer is able to assume “control” by taking on both roles. The individual therefore is able to maintain recurrent and intrusive abusive events through the use of the eating disorder while simultaneously enabling herself to dissociate, distract and sooth the pain through the obsession with food – either avoiding eating, vomiting it away, or stuffing it down.
Triggering events of the traumatic event can initiate extreme present day psychological distress for the sufferer of PTSD. In this vein, feelings of shame, humiliation and guilt, whether perceived or actual events, can initiate a symptomatic response by the eating disorder sufferer. However, with eating disorders, these “feelings” are typically projected onto the body. For example, a woman presently suffering with bulimia and a history of incest attends a party and perceives that a man across the room is looking at her. Assuming that the man is gazing appropriately and is seeking to make eye contact, the sufferer converts his attention into fearing that the man is actually looking at her critically because she believes she is fat and undesirable. The woman leaves the party feeling ashamed of her body and disgusted. She binges on carbohydrates and high fat food when she returns home and spends several hours vomiting. Upon analysis, the woman reports the shame, disgust and guilt she felt as a child when her father initiated his abuse by looking longingly at her. Her feelings of love for her father became distorted as she sought his affection and was disgusted, horrified and terrified in the same breath. These feelings later became projected on to her body as an adult. The shame, disgust and guilt she feels now is experienced as believing she is fat, disgusting because of her eating disorder behavior. She feels guilty over eating too much and shameful about her eating disorder, a “secret,” not unlike the secret of the incest.
Memories of the abuse remains repressed for some eating disorder sufferers. The eating disorder symptomatology further ensures the psychic coma; the eating disorder consumes an enormous amount of time, psychological energy and focus. Literally, there is not time to think about anything else.
What is important to keep in mind is that assumptions cannot be made about the development of an eating disorder; the casual factors are unique to the individual sufferer. Clearly, for all eating disorder sufferers there is a unique constellation of causes, of one kind or another, which has lead to the development of their specific symptomatology. The impact of relationships and parenting in the development of self-concept and self-esteem, family dynamics, biological depression and anxiety, cultural and societal pressures about weight and body image particularly for women, physical and/or sexual abuse, are all contributors in the development of eating disorders. All are significant. Which one(s) apply is unique to the individual. Post Traumatic Stress Disorder is indeed a condition, which affects some individuals who have been victims of abuse, the manifestations of which may find expression through an eating disorder.
Judy Scheel, Ph.D., LCSW