Post‐traumatic stress disorder as a moderator of transdiagnostic, residential eating disorder treatment outcome trajectory

A network analysis of eating disorder, PTSD, major depression, state-trait anxiety, and quality of life measures in eating disorder patients treated in residential care

BACKGROUND

The network approach in the eating disorder (ED) field has confirmed important links between EDs and posttraumatic stress disorder (PTSD) symptoms. However, studies including comorbid symptoms are scarce, which limits our understanding of potentially important connections. We hypothesised that anxiety, depression and poor quality of life (QOL) would provide a more complete picture of central, maintaining factors.

METHODS

Network analysis using R was performed in 2178 adult ED patients (91% female) admitted to residential treatment. Assessments included the ED Examination Questionnaire (EDEQ), the Eating Disorders Inventory (EDI-2), the PTSD Checklist for DSM-5 (PTSD clusters (PCL-5)), the Patient Health Questionnaire (PHQ-9), the Spielberger State-Trait Anxiety Scale (STAI), and the ED QOL Scale (EDQOL), which measure symptoms of EDs, PTSD, major depression, state-trait anxiety, and QOL, respectively.

RESULTS

EDI-2 ineffectiveness showed the highest centrality (expected influence) followed by EDI-2 interoceptive awareness, STAI state anxiety, EDEQ shape concern, EDQOL psychological subscale, and PTSD cluster D (hyperarousal) symptoms. Eating Disorder Quality of Life psychological and physical-cognitive subscales and PHQ-9 major depressive, STAI state anxiety and PCL-5 PTSD cluster E (negative alterations in mood and cognition) symptoms showed the highest bridge expected influence, suggesting their interactive role in maintaining ED-PTSD comorbidity.

CONCLUSIONS

This is the first network analysis of the interaction between ED and PTSD symptoms to include the comorbid measures of depression, anxiety, and QOL in a large clinical sample of ED patients. Our results indicate that several symptom clusters are likely to maintain ED-PTSD comorbidity and may be important targets of integrated treatment.

A Systematic Review of the Effect of PTSD and Trauma on Treatment Outcomes for Eating Disorders

There is growing evidence of prior experiences of trauma and trauma-related symptoms among people with eating disorders; however, there is little understanding as to how post-traumatic stress disorder (PTSD) and exposure to traumatic events affect treatment outcomes. Without this knowledge, eating disorder clinicians are unable to tailor treatment to ensure good outcomes for the large percentage of this population that is affected by PTSD and trauma. This systematic review aimed to identify how PTSD and trauma exposure influence outcomes in eating disorder treatment. Systematic searches of PsycINFO, MEDLINE, PubMed, and Scopus databases identified 16 articles that met the inclusion criteria. The results indicated a negative effect on rates of eating disorder treatment completion and eating disorder psychopathology posttreatment. These findings were evident across studies that investigated the impact of a history of traumatic events as well as studies that investigated the impact of the presence of trauma-related symptoms seen in PTSD. Several methodological limitations were identified in the literature. These include: heterogeneous and unstandardized measures of PTSD and trauma, high attrition rates with follow-up, and insufficient data to enable comparisons by treatment setting, diagnostic presentation, and type of trauma exposure. The findings of this review have implications for future research and clinical care, including the importance of considering PTSD and trauma in assessment, treatment planning, and provision of both trauma-informed care and trauma-focused treatments for individuals with eating disorders.

Associations between major depressive and bipolar disorders and eating disorder, PTSD, and comorbid symptom severity in eating disorder patients

OBJECTIVE

Major depressive disorder (MDD) and bipolar disorder (BD) are commonly comorbid with eating disorders (EDs). However, there is limited data about the clinical features of such patients, especially their association with traumatic histories and PTSD, which occur commonly in patients admitted to residential treatment.

METHODS

Adults (≥18 years, 91% female, n = 2155) admitted to residential ED treatment were evaluated upon admission for DSM-5 defined MDD and BD. Patients were divided into three groups based on an admission diagnosis of no mood disorder (NMD), MDD, and BD (types I and II) and compared on a number of demographic variables, clinical features and assessments.

RESULTS

Mood disorders occurred in 76.4% of participants. There were statistically significant differences across groups in most measures with the BD group showing higher rates and doses of traumatic events; higher current PTSD; higher BMIs; higher severity of ED, depression and state-trait anxiety symptoms; worse quality of life; and higher rates of substance use disorders. Similarly, the MDD group had higher rates than the NMD group on most measures.

CONCLUSIONS

These findings have important implications for prevention, treatment and long-term follow-up and highlight the need for early trauma-focused treatment of ED patients with comorbid mood disorders and PTSD.

Psychogenic Nonepileptic Seizures Associated with an Eating Disorder and PTSD Are Responsive to Cognitive Processing Therapy

Objective

Eating disorders (EDs) are often associated with prior histories of trauma, subsequent PTSD and related psychiatric comorbidities. There is a paucity of information about their relationship to somatic symptom disorders, specifically psychogenic nonepileptic seizures (PNES), a type of functional neurological symptom disorder or conversion disorder.

Methods

We report a case of a 39-year-old bisexual female with bulimia nervosa (BN), PTSD, recurrent major depressive disorder (MDD), cannabis use disorder, and PNES who responded to integrated trauma-focused treatment during residential ED treatment using cognitive processing therapy (CPT). Symptoms of ED, PTSD, major depression, and state-trait anxiety were measured using validated assessment instruments.

Results

During the course of CPT treatment, the patient's total scores on the PTSD Symptom Checklist for DSM-5 (PCL-5) went from 59 to 26, which is below the diagnostic threshold for PTSD. In addition, she demonstrated improvements in the Eating Disorder Examination Questionnaire (EDE-Q) Global Severity score, the Eating Disorder Inventory (EDI-2) total score, the Patient Health Questionnaire (PHQ-9) total score, the Spielberger State and Trait Anxiety Inventory scores, and the Eating Disorder Quality of Life (EDQOL) total score. Furthermore, her PNES also abated, and she remained seizure free for ∼1 year following discharge with the exception of one short seizure, per report of the patient.

Conclusion

The use of CPT as part of an integrated trauma-informed treatment approach during residential ED treatment was successful in a woman with PNES, BN, PTSD, MDD, and cannabis use disorder.

Posttraumatic stress disorder, traumatic events, and longitudinal eating disorder treatment outcomes: A systematic review

OBJECTIVE

Many individuals diagnosed with an eating disorder (ED) have been exposed to traumatic events, and some of these individuals are diagnosed with posttraumatic stress disorder (PTSD). Although theorized by researchers and clinicians, it is unclear whether traumatic event exposure or PTSD interferes with outcomes from ED treatment. The objective of the current study was to systematically review the literature on traumatic events and/or PTSD as either predictors or moderators of psychological treatment outcomes in EDs.

METHOD

A PRISMA search was conducted to identify studies that assessed the longitudinal association between traumatic events or PTSD and ED outcomes. Eighteen articles met the inclusion criteria for review.

RESULTS

Results indicated that traumatic event exposure was associated with greater ED treatment dropout, but individuals with a traumatic event history benefited from treatment similarly to their unexposed peers. Findings also indicated that traumatic events may be associated with greater symptom relapse posttreatment.

DISCUSSION

Given the limited number of studies examining PTSD, results are considered very tentative; however, similar to studies comparing trauma-exposed and nontrauma-exposed participants, individuals with PTSD may have similar treatment gains compared to individuals without PTSD, but individuals with PTSD may experience greater symptom relapse posttreatment. Future researchers are encouraged to examine whether trauma-informed care or integrated treatment for EDs and PTSD mitigates dropout from treatment and improves symptom remission outcomes. Furthermore, researchers are encouraged to examine how the developmental timing of traumatic events, self-perceived impact of trauma, and cumulative trauma exposure may be associated with differential ED treatment outcomes.

PUBLIC SIGNIFICANCE

Eating disorders (EDs), trauma, and posttraumatic stress disorder (PTSD) often co-occur. Individuals with traumatic event exposure and/or PTSD demonstrate greater ED symptoms; it is unclear whether these individuals benefit similarly in ED treatment to their peers. The current study found that individuals with traumatic event exposure are more likely to drop out of treatment but benefit from treatment with similar symptom remission. Traumatic history was associated with greater relapse posttreatment.

The integrated treatment of eating disorders, posttraumatic stress disorder, and psychiatric comorbidity: a commentary on the evolution of principles and guidelines

Psychiatric comorbidity is the norm in the assessment and treatment of eating disorders (EDs), and traumatic events and lifetime PTSD are often major drivers of these challenging complexities. Given that trauma, PTSD, and psychiatric comorbidity significantly influence ED outcomes, it is imperative that these problems be appropriately addressed in ED practice guidelines. The presence of associated psychiatric comorbidity is noted in some but not all sets of existing guidelines, but they mostly do little to address the problem other than referring to independent guidelines for other disorders. This disconnect perpetuates a "silo effect," in which each set of guidelines do not address the complexity of the other comorbidities. Although there are several published practice guidelines for the treatment of EDs, and likewise, there are several published practice guidelines for the treatment of PTSD, none of them specifically address ED + PTSD. The result is a lack of integration between ED and PTSD treatment providers, which often leads to fragmented, incomplete, uncoordinated and ineffective care of severely ill patients with ED + PTSD. This situation can inadvertently promote chronicity and multimorbidity and may be particularly relevant for patients treated in higher levels of care, where prevalence rates of concurrent PTSD reach as high as 50% with many more having subthreshold PTSD. Although there has been some progress in the recognition and treatment of ED + PTSD, recommendations for treating this common comorbidity remain undeveloped, particularly when there are other co-occurring psychiatric disorders, such as mood, anxiety, dissociative, substance use, impulse control, obsessive-compulsive, attention-deficit hyperactivity, and personality disorders, all of which may also be trauma-related. In this commentary, guidelines for assessing and treating patients with ED + PTSD and related comorbidity are critically reviewed. An integrated set of principles used in treatment planning of PTSD and trauma-related disorders is recommended in the context of intensive ED therapy. These principles and strategies are borrowed from several relevant evidence-based approaches. Evidence suggests that continuing with traditional single-disorder focused, sequential treatment models that do not prioritize integrated, trauma-focused treatment approaches are short-sighted and often inadvertently perpetuate this dangerous multimorbidity. Future ED practice guidelines would do well to address concurrent illness in more depth.

Eating disorder patients with and without PTSD treated in residential care: discharge and 6-month follow-up results

INTRODUCTION

We studied whether provisional posttraumatic stress disorder (PTSD) moderated discharge (DC) and 6-month follow-up (FU) outcomes of multi-modal, integrated eating disorder (ED) residential treatment (RT) based upon principles of cognitive processing therapy (CPT).

METHODS

ED patients [N = 609; 96% female; mean age (± SD) = 26.0 ± 8.8 years; 22% LGBTQ +] with and without PTSD completed validated assessments at admission (ADM), DC and 6-month FU to measure severity of ED, PTSD, major depressive disorder (MDD), state-trait anxiety (STA) symptoms, and eating disorder quality of life (EDQOL). We tested whether PTSD moderated the course of symptom change using mixed models analyses and if ED diagnosis, ADM BMI, age of ED onset and LGBTQ + orientation were significant covariates of change. Number of days between ADM and FU was used as a weighting measure.

RESULTS

Despite sustained improvements with RT in the total group, the PTSD group had significantly higher scores on all measures at all time points (p ≤ .001). Patients with (n = 261) and without PTSD (n = 348) showed similar symptom improvements from ADM to DC and outcomes remained statistically improved at 6-month FU compared to ADM. The only significant worsening observed between DC and FU was with MDD symptoms, yet all measures remained significantly lower than ADM at FU (p ≤ .001). There were no significant PTSD by time interactions for any of the measures. Age of ED onset was a significant covariate in the EDI-2, PHQ-9, STAI-T, and EDQOL models such that an earlier age of ED onset was associated with a worse outcome. ADM BMI was also a significant covariate in the EDE-Q, EDI-2, and EDQOL models, such that higher ADM BMI was associated with a worse ED and quality of life outcome.

CONCLUSIONS

Integrated treatment approaches that address PTSD comorbidity can be successfully delivered in RT and are associated with sustained improvements at FU. Improving strategies to prevent post-DC recurrence of MDD symptoms is an important and challenging area of future work.

Integrating evidence-based PTSD treatment into intensive eating disorders treatment: a preliminary investigation

PURPOSE

Given data suggesting common co-occurrence and worse outcomes for individuals with eating disorders (EDs) and post-traumatic stress disorder (PTSD), it is critical to identify integrated treatment approaches for this group of patients. Past work has explored the feasibility and initial efficacy of intervention approaches that draw on evidence-based treatments for both EDs and PTSD; however, this work remains limited in scope. In the current study, we explored the feasibility and naturalistic outcomes of PTSD treatment delivered within the context of intensive ED treatment.

METHOD

Participants were 57 adult men and women with DSM-5 EDs and comorbid PTSD who completed a course of either Prolonged Exposure (PE; n = 22) or Cognitive Processing Therapy (CPT; n = 35) (Msessions = 10.40; SD = 5.13) and weekly validated measurements of clinical symptoms while enrolled in ED programming.

RESULTS

Multi-level models for PTSD symptoms indicated a significant linear effect of time, such that participants demonstrated significant decreases over time in PTSD symptoms, regardless of treatment modality.

CONCLUSION

Our preliminary investigation provides support for the feasibility and efficacy of an integrated approach to treating EDs and PTSD. It is critical for future work to undertake randomized tests of this integrated approach using large, heterogeneous samples.

LEVEL OF EVIDENCE

Level IV, multiple time series with intervention.

Mechanisms by which adverse childhood experiences, other traumas and PTSD influence the health and well-being of individuals with eating disorders throughout the life span

BACKGROUND

Multiple published sources from around the world have confirmed an association between an array of adverse childhood experiences (ACEs) and other traumatic events with eating disorders (EDs) and related adverse outcomes, including higher morbidity and mortality.

METHODS

In keeping with this Special Issue's goals, this narrative review focuses on the ACEs pyramid and its purported mechanisms through which child maltreatment and other forms of violence toward human beings influence the health and well-being of individuals who develop EDs throughout the life span. Relevant literature on posttraumatic stress disorder (PTSD) is highlighted when applicable.

RESULTS

At every level of the pyramid, it is shown that EDs interact with each of these proclaimed escalating mechanisms in a bidirectional manner that contributes to the predisposition, precipitation and perpetuation of EDs and related medical and psychiatric comorbidities, which then predispose to early death. The levels and their interactions that are discussed include the contribution of generational embodiment (genetics) and historical trauma (epigenetics), social conditions and local context, the ACEs and other traumas themselves, the resultant disrupted neurodevelopment, subsequent social, emotional and cognitive impairment, the adoption of health risk behaviors, and the development of disease, disability and social problems, all resulting in premature mortality by means of fatal complications and/or suicide.

CONCLUSIONS

The implications of these cascading, evolving, and intertwined perspectives have important implications for the assessment and treatment of EDs using trauma-informed care and trauma-focused integrated treatment approaches. This overview offers multiple opportunities at every level for the palliation and prevention of EDs and other associated trauma-related conditions, including PTSD.

Treatment Outcome for Adults in a Residential Program for Binge Eating Spectrum Disorders: Protocol for a Prospective Pragmatic Single-Arm Trial

Background

Most studies reporting treatment outcomes for eating disorders at higher levels of care focus on anorexia nervosa and bulimia nervosa. No studies have been published with a singular focus on examining treatment outcomes for adults receiving residential programming specifically designed for the treatment of binge eating spectrum disorders (BESD), including binge eating disorder and bulimia nervosa.

Objective

The purpose of this paper is to outline the protocol of a prospective study examining treatment outcomes at discharge and 3-month, 6-month, and 12-month postdischarge follow-up, for a sample of consecutive admissions to a residential program specifically for patients with BESD.

Methods

One hundred consecutive admissions to a binge eating treatment program were enrolled in the prospective single-arm trial between January 2019 and February 2020. Data were collected at admission, discharge, and 3, 6, and 12 months postdischarge, with admission, discharge, and 12-month follow-up as the major timepoints of interest. Results across the major timepoints will be analyzed with mixed effects general linear models.

Results

The primary aim is to assess the impact of the program on eating disordered behaviors at discharge and 12-month follow-up, which are hypothesized to improve as a result of treatment. Secondary hypotheses include improvements on comorbid symptoms, including trauma, depression, and obsessive-compulsive symptoms, as well as improvements on medical indicators of health, including cholesterol and triglycerides, at discharge and 12-month follow-up.

Conclusions

This study may aid in the development of treatment guidelines for patients with BESD at higher levels of care and lend support to having specialty treatment programs for patients with BESD.

International Registered Report Identifier (IRRID)

DERR1-10.2196/32270

Eating disorder onset during childhood is associated with higher trauma dose, provisional PTSD, and severity of illness in residential treatment

OBJECTIVE

Age of eating disorder (ED) onset has been of significant interest to both researchers and clinicians. The identification of factors associated with early or child onset has important prevention and treatment implications. The presence of prior trauma, resultant posttraumatic stress disorder (PTSD), ED severity, and comorbid psychopathology are of particular relevance to age of ED onset, but data are limited.

METHODS

Adults (≥18 years, 93% female, total n = 1283) admitted to residential ED treatment self-reported age of ED onset. Patients were divided into child onset (ages 5-10 years), adolescent onset (11-17 years), and adult onset (≥18 years) groups and compared on a number of clinical features and assessment measures.

RESULTS

The child onset group had significantly higher rates and doses of traumatic life events; higher current PTSD prevalence; higher BMIs, higher severity of ED, depression and state-trait anxiety symptoms; worse quality of life; and more prior inpatient and residential admissions for ED treatment, in comparison to both the adolescent and adult onset groups. Similarly, the adolescent onset group had significantly higher rates than the adult onset group.

CONCLUSIONS

These results have important implications for prevention, treatment and long-term follow-up and highlight the need for early trauma-focussed treatment of ED patients.

The Role of Emotion Regulation in Eating Disorders: A Network Meta-Analysis Approach

Background

Previous theoretical models and reviews have documented a strong connection between emotion dysregulation eating disorder (ED) psychopathology among the general and clinical populations. The aim of this review was to build on this previous work by conducting a network meta-analysis to explore associations between adaptive and maladaptive emotion regulation strategies and ED psychopathology trans-diagnostically across the ED spectrum to identify areas of emotion dysregulation that have the strongest association with symptomatology.

Methodology

A total of 104 studies were included in the meta-analysis and correlation coefficient representing the associations between specific emotion regulation strategies and ED symptomatology were extracted. We ran a Bayesian random effects network meta-analysis and the initial network was well-connected with each emotion regulation strategy being linked to at least one other strategy. We also conducted a network meta-regression to explore whether between-study differences in body mass index (BMI), age, and whether the sample consisted of solely female participants explained any possible network inconsistency.

Results

The network meta-analysis revealed that ruminations and non-acceptance of emotions were most closely associated with ED psychopathology. There was no significant network inconsistency but two comparisons approached significance and thus meta-regressions were conducted. The meta-regressions revealed a significant effect of BMI such that the associations between different emotion regulation strategies and ED symptomatology were weaker among those with low BMI.

Discussion

The present findings build on previous work and highlight the role of rumination and difficulties with accepting emotions as key emotion regulation difficulties in EDs. Additionally, the finding that the associations were weaker among ED patients with low BMI may point toward a complex relationship between ED behaviors and emotion regulation. Taken together, our findings call for interventions that target emotion regulation, specifically rumination and difficulties accepting emotions, in the treatment of EDs.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021249996, PROSPERO, identifier: CRD42021249996.

Results of the first randomized controlled trial of integrated cognitive-behavioral therapy for eating disorders and posttraumatic stress disorder

BACKGROUND

Eating disorders (EDs) and posttraumatic stress disorder (PTSD) frequently co-occur and can share a functional relationship. The primary aim of this initial randomized controlled trial was to determine whether integrated cognitive-behavioral therapy (CBT) for co-occurring ED-PTSD was superior to standard CBT for ED in improving PTSD symptoms. Intervention safety and desirability, as well as the relative efficacy of the treatments in improving anxiety, depression, and ED symptomatology, were also examined.

METHODS

Following a course of intensive ED treatment, individuals with ED-PTSD were recruited to participate and randomized to integrated CBT for ED-PTSD or standard CBT for ED. The sample consisted of 42 individuals with a range of ED diagnoses. Outcomes were assessed at end-of-treatment, 3-, and 6-month follow-up using interview and self-report measures.

RESULTS

Mixed models revealed significant interactions of time and therapy condition on clinician-rated and self-reported PTSD symptom severity favoring Integrated CBT for ED-PTSD. Both treatments were associated with statistically significant improvements in PTSD, anxiety, and depression. Improvements were maintained at 3- and 6-month follow-up. There was good safety with both interventions, and satisfaction with both treatments was high. However, there was a stronger preference for integrated treatment.

CONCLUSIONS

Integrating CBTs for PTSD and ED following intensive ED treatment is safe, desirable, and efficacious for improving PTSD symptoms. Future studies with larger sample sizes are needed to determine whether Integrated CBT for ED-PTSD provides benefits over standard CBT for ED with respect to ED outcomes.

The impact of comorbid posttraumatic stress disorder on eating disorder treatment outcomes: Investigating the unified treatment model

PURPOSE

Many women with eating disorders (EDs) have comorbid posttraumatic stress disorder (PTSD). However, there have been few studies on how comorbid PTSD may impact ED treatment outcomes.

METHOD

Participants were 2,809 patients from residential ED treatment facilities who were treated using the Unified Treatment Model (UTM). We investigated whether PTSD diagnosis at admission was associated with changes in Eating Disorder Examination-Questionnaire (EDE-Q) scores, binge eating, self-induced vomiting, and restriction, across three time points, as well as clinically significant improvement and treatment drop-out.

RESULTS

Using latent growth models, with time modeled as a second-order polynomial, we found that EDE-Q scores and behavioral symptoms decreased from admission to discharge, but increased from discharge to 6-month follow-up. PTSD diagnosis was associated with higher baseline EDE-Q scores and restriction, and lower binge-eating frequency. PTSD diagnosis was not associated with symptom change over time, treatment dropout, or clinically significant change.

DISCUSSION

Although PTSD diagnoses were associated with higher ED symptom levels at admission, PTSD was not associated with worse treatment outcomes, suggesting the UTM is a promising treatment for patients with and without PTSD. Future studies should investigate the impact of ED treatment on PTSD symptoms in order to determine the need for integrated treatments for these comorbid conditions.