Initial Findings From Project Recover: Overcoming Co-Occurring Eating Disorders and Posttraumatic Stress Disorder Through Integrated Treatment

Alliance processes in eating disorders with childhood maltreatment sequelae: Preliminary implications

BACKGROUND

Effective eating disorder (ED) treatments are drastically needed for patients with experiences of sustained and prolonged emotional, physical and sexual childhood maltreatment (CM) that often results in post-traumatic sequelae such as severe, complex posttraumatic stress disorder (cPTSD). EDs with comorbid cPTSD (cPTSD-ED) have protracted treatment courses and poorer prognoses.

AIM

To summarise the knowledge base on cPTSD-ED with specific emphasis on disturbances in self-organisation (DSO) in relation to therapeutic alliance (TA) processes.

METHOD

Expert opinions based on current relevant literature are critically examined.

RESULTS

Preliminary insights on change and alliance processes suggest that neglecting to address emotional-relational processes in the conceptualisation and treatment of cPTSD-ED impedes treatment progress.

CONCLUSION

We hypothesise that the DSO construct inherent in cPTSD-ED calls for a focus on TA processes in addition to traditional ED treatment elements such as nutritional rehabilitation and behaviour change, and regardless of ED treatment provided. More process research on a larger scale is urgently called for.

Posttraumatic stress disorder (PTSD) and complex PTSD in eating disorder treatment-seekers: Prevalence and associations with symptom severity

Although childhood trauma and posttraumatic stress disorder (PTSD) have been well-researched in eating disorder epidemiology, prevalence rates are unavailable for complex PTSD (CPTSD). Under recently introduced ICD-11 criteria, individuals with CPTSD have both PTSD symptoms and additional disturbances in self-organization (DSO). Using ICD-11 criteria, this study aimed to determine the prevalence of PTSD and DSO symptoms, diagnostic rates of PTSD and CPTSD, and childhood trauma exposure in eating disorder treatment-seekers. Participants (N = 217) were individuals attending residential, partial hospitalization, and outpatient services who completed measures of eating disorder- and trauma-related symptoms and childhood adverse experiences. One third of participants reported PTSD symptoms, and over half reported DSO symptoms, with probable ICD-11 diagnostic rates of 3.8% for PTSD and 28.4% for CPTSD. CPTSD was significantly more prevalent than PTSD and more common in higher levels of care. Both PTSD and DSO symptom severity were positively correlated with eating disorder symptoms and impairment, rs = .285-.642. DSO symptom severity was a significant and unique explanatory factor of eating disorder severity and impairment. The findings highlight the prevalence of CPTSD in eating disorder populations and the association between DSO symptoms and eating psychopathology independent of PTSD symptoms. Implications are discussed for adjunct treatment approaches for individuals with comorbid eating disorders and PTSD or CPTSD.

Treatment of patients with anorexia nervosa and comorbid post-traumatic stress disorder; where do we stand? A systematic scoping review

Objective

Comorbid post-traumatic stress disorder in patients with anorexia nervosa may negatively affect the course of anorexia nervosa treatment, which is already challenging. There are currently no guidelines or recommendations on concurrent treatment approaches for both anorexia nervosa and post-traumatic stress disorder. This systematic scoping review aims to explore the feasibility, acceptability and effectiveness of psychological trauma-focused treatment concurrently offered to underweight patients receiving anorexia nervosa treatment.

Method

A multi-step literature search, according to an a priori protocol was performed. Databases PubMed, Embase, APA PsycINFO, Web of Science, Scopus and Cochrane Central were searched up to September 19th 2022, and the search was rerun June 19th 2023. For quality assessment, Risk of Bias in Non-randomised Studies-of Interventions tool was used.

Results

The extensive search yielded 1769 reports, out of which only three observational pilot studies, both English and German, published between 2004 and 2022, could be included. The included studies reported on a total of 13 female participants between 16 and 58 years old, with anorexia nervosa or otherwise specified feeding or eating disorder, baseline BMI ranging between 14.6 and 16.5, who received concurrent anorexia and post-traumatic stress disorder treatment. In all participants, the emotional and cognitive functioning was sufficient to process the offered trauma-focused interventions, despite their significantly low body weight.

Discussion

The findings of this review identify a dearth of treatment research on knowledge of concurrent trauma-focused treatments for patients with anorexia nervosa. Refraining patients with anorexia nervosa from trauma-focused treatment may not be warranted.

Associations between posttraumatic stress disorder and eating disorder symptoms among women veterans

Recent research suggests high rates of posttraumatic stress disorder (PTSD) and eating disorder (ED) comorbidity in women veterans. This study aims to expand the literature by examining associations between PTSD and ED diagnoses and symptoms in this population. We assessed probable PTSD diagnosis and symptom clusters (intrusion, avoidance, arousal and reactivity, and negative alterations in cognition and mood [NACM]), as well as probable Binge Eating Disorder (BED) diagnosis and ED subscales (dietary restraint, shape/weight overvaluation, and body dissatisfaction) in a sample of women veterans (N = 371). We investigated significance at the standard p < .05, and the Bonferroni-corrected p < .005 cut-off to adjust for experiment-wise error. Overall, we found that probable PTSD was associated with provisional BED (p < .001) using logistic regression at both cut-offs. Probable PTSD was associated with all ED subscales (all p's < 0.003) using linear regression models also at both cut-offs. Provisional BED was associated with NACM at p < .05 (p = .046), though it did not meet significance at our conservative cut-off. NACM was also associated with shape/weight overvaluation (p = .02) and a global ED score (p = .01) at p < .05, but not at our conservative cut-off; arousal was associated with shape/weight overvaluation (p = .04) and the global ED score (p = .02) at p < .05, but not at our conservative cut-off. Our findings may further guide how ED-related topics can be integrated in PTSD treatment for women veterans with comorbid PTSD and ED.

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.

PTSD symptoms as a potential mediator of associations between military sexual assault and disordered eating

Despite increasing rates of sexual assault in the military and high rates of disordered eating and post-traumatic stress disorder (PTSD) among veterans, little is known about how these constructs are related. This study examined whether PTSD symptoms mediate the relation between military sexual assault and disordered eating among female veterans. United States female veterans (N = 98) completed self-report measures assessing military sexual assault, PTSD, and disordered eating. Results indicated that military sexual assault was associated with higher PTSD symptoms and disordered eating. PTSD symptoms did not mediate the relation between military sexual assault and overall levels of disordered eating. However, PTSD symptoms fully mediated the relation between military sexual assault and the Bulimia and Food Preoccupation subscale of the Eating Attitudes Test-26. Findings suggest that military sexual assault may contribute to the development of bulimia nervosa symptoms indirectly through PTSD symptoms. Thus, the findings do not support a global relationship between trauma and all facets of disordered eating, but demonstrate a relationship between PTSD and bulimia nervosa symptoms, with purging potentially functioning as an emotion regulation strategy. Future longitudinal studies are needed to establish temporal precedence of these associations.

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.

Perspectives of underweight people with eating disorders on receiving Imagery Rescripting trauma treatment: a qualitative study of their experiences

BACKGROUND

The prognosis for underweight individuals with an eating disorder (ED) and posttraumatic stress disorder (PTSD) is worse than for their peers without these comorbid symptoms. This qualitative study explores the experiences of trauma-focused Imagery Rescripting (ImRs) therapy of underweight inpatients being treated for an ED.

OBJECTIVE

To test the feasibility and to improve ImRs by understanding the experiences and perspectives of people with an ED and PTSD who, when underweight, received ImRs as an adjunct to their inpatient ED treatment.

METHOD

To explore how underweight people with an ED experience and perceive ImRs, we used a qualitative study design involving semi-structured interviews with 12 participants. After analysis, the data were summarized and classified within a thematic framework that focused on experiences and improving the ImRs method.

RESULTS

The thematic analysis resulted in the following 6 main themes; (1) Expectations of ImRs; (2) Ability to participate in ImRs; (3) Effect of ImRs; (4) Experience of ImRs technique; (5) Conditions under which ImRs is given; (6) In depth-analysis. The results show that despite the fear of disappointment the participants appreciate addressing the PTSD and ED symptoms simultaneously. Further, results showed that it had been possible for them to attend ImRs but that the effects of ImRs were not uniformly perceived. Also, participants indicated that a caring context is important and that ImRs should not be scheduled immediately before a meal. Finally, the treatment generated hope.

CONCLUSIONS

The findings of this study demonstrated the feasibility of the integration of ImRs trauma treatment for individuals who are being treated in an ED inpatient treatment setting, and are in contrast to standard practice where the focus of inpatient treatment has been ED-symptom improvement without comprehensively addressing past traumatic experiences during an underweight phase. Trial registration International Clinical Trials Registry Platform (ICTRP) (NTR6094). Date of registration 09/23/2016. https://trialsearch.who.int/Trial2.aspx?TrialID=NTR6094.

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.

Traumatic stress, body shame, and internalized weight stigma as mediators of change in disordered eating: a single-arm pilot study of the Body Trust® framework

To enhance access to evidence-based treatment it is increasingly important to evaluate scalable virtual programs that support the needs of those struggling with disordered eating. This study described a scientifically grounded, trauma-informed framework known as Body Trust,® and aimed to pilot test the preliminary effectiveness and mechanisms of change in a Body Trust® program to improve disordered eating. Using quality outcomes data, we examined 70 mostly white (87%) female-identifying (97%) individuals enrolled in a 6-module online program based in the Body Trust® framework (M_age = 45.5 ±10.9; M_BMI = 33.7 ±8.0). Putative mediators included traumatic stress, internalized weight stigma, and body shame. Outcomes were objective and subjective binge episodes, overvaluation of weight and shape, and eating concerns. Generalized estimating equations were applied to determine pre-to-post changes. We applied Montoya's MEMORE macro, the joint-significance test, and calculated 95% Monte Carlo confidence intervals to assess mediation. Significant pre-to-post improvements with medium to large effect sizes were detected for all outcomes and mediators (ps<.008). All hypothesized mechanisms supported mediation. Using the Body Trust® framework shows early promise for alleviating disordered eating symptoms through targeting traumatic stress, body shame, and internalized weight stigma. Given the program's use of mindfulness techniques, future research should test target mechanisms like interoception.

Psychological characteristics and childhood adversity of adolescents with atypical anorexia nervosa versus anorexia nervosa

The assessment and diagnosis of atypical anorexia nervosa (AAN) is an ongoing challenge for clinicians. This study aims to examine psychological morbidity and exposure to childhood adversity in adolescents with AAN compared to adolescents with anorexia nervosa, restricting type (AN-R). This registry-based study compared 42 adolescents with AAN to 79 adolescents with AN-R on a variety of psychosocial measures at the time of presentation to a specialized eating disorder program. In contrast to AN-R, adolescents with AAN had more severe drive for thinness (p =.011), body dissatisfaction (p =.038), and lower quality of life (p =.047), but had better global functioning (p =.032). Adolescents who had high Adverse Childhood Experiences (ACE) Questionnaire scores (ACE score ≥ 4) had over 5 times higher odds of having AAN than those who did not have high ACE scores (p =.008). There was no significant difference between groups on measures of low self-esteem and non-accidental self-injury. Adolescents with AAN presented with similar or more severe psychosocial distress compared to their peers with AN-R across a majority of the measures. The findings highlight the need to address trauma, body-related difficulties, and quality of life in the assessment and treatment of adolescents with AAN.

Experiences when implementing enhanced cognitive behavioral therapy as a standard treatment for anorexia nervosa in outpatients at a public specialized eating-disorder treatment unit

BACKGROUND

Enhanced cognitive behavioral therapy (CBT-E) is a promising treatment option for outpatients with anorexia nervosa (AN). We aimed to determine the effectiveness of CBT-E as a standard treatment for adult outpatients with AN from the specialized eating-disorder unit of a public hospital with responsibilities to their catchment area.

METHODS

This study had an open, longitudinal design. Thirty three (of planned 100) outpatients aged > 16 years suffering from AN were included to receive 40 sessions of CBT-E. Eating-disorder psychopathology and body mass index (BMI) were assessed before and after treatment, while comorbid psychiatric symptoms and trauma experiences were evaluated at the baseline, and therapeutic alliance was assessed after 4 weeks of treatment.

RESULTS

A high proportion (69%) of patients dropped out of the treatment. Patient recovery was considered when they reached BMI > 18.5 and Eating Disorder Examination Questionnaire (EDE-Q) score < 2.5, and 27% of all patients recovered.

CONCLUSIONS

Patients who completed the treatment had mostly satisfactory outcomes. Considering the high dropout rate, it is necessary to improve the strategies for engaging patients in therapy. Several aspects of CBT-E as a standard treatment are discussed regarding the high dropout rate. Trial registration ClinicalTrials.gov. Identifier: NCT02745067. Registered: April 20, 2016. https://clinicaltrials.gov/ct2/showNCT02745067.

Posttraumatic stress disorder symptoms moderate the relation between childhood sexual abuse and disordered eating in a community sample

OBJECTIVE

Previous work has found clear associations between childhood sexual abuse (CSA) and disordered eating in adulthood. However, further research is needed to clarify factors that may influence this relationship. The current study advanced existing research by examining the moderating influence of posttraumatic stress disorder (PTSD) symptom severity in the association between CSA and disordered eating.

METHOD

Data were collected from 463 individuals with a history of sexual assault or other unwanted sexual experience(s) (M_age  = 34.71, 54.9% women, 77.5% white) who were recruited from MTurk.

RESULTS

Results indicated significant positive relations among CSA, PTSD symptom severity, and disordered eating. CSA was found to be associated with disordered eating at high, but not low, levels of PTSD symptom severity.

DISCUSSION

This study highlights the importance of assessing disordered eating and PTSD symptoms in individuals who report a history of CSA. Clinicians aiming to reduce their patients' symptoms of disordered eating may benefit from considering the potential role of PTSD symptom severity as a barrier to achieving treatment gains.

Provisional posttraumatic stress disorder is associated with greater severity of eating disorder and comorbid symptoms in adolescents treated in residential care

OBJECTIVE

Past traumatic events, subsequent posttraumatic stress disorder (PTSD) and related psychiatric comorbidities are commonly associated with eating disorders (EDs) in adults but remain understudied in adolescents.

METHODS

Adolescent participants (mean [SD] age = 15.1 ± 1.5 years, 96.5% female) with EDs entering residential treatment (n = 647) at six sites in the United States completed validated self-report assessments of ED, PTSD, major depression, anxiety disorders and quality of life. Provisional DSM-5 PTSD diagnoses (PTSD+) were made via the Childhood Trauma Questionnaire, admission interviews and the PTSD Symptom Checklist for DSM-5.

RESULTS

PTSD+ occurred in 35.4% of participants, and those with ED-PTSD+ had significantly higher scores on all assessments (p ≤ 0.001), including measures of ED psychopathology, major depression, anxiety disorders and quality of life, as well as significantly higher rates of all forms of childhood trauma. Those with PTSD+ also exhibited a significantly higher percent median body mass index for age and sex and a lower propensity toward anorexia nervosa, restricting type.

CONCLUSIONS

Results confirm that adolescent patients in residential treatment with ED-PTSD+ are more symptomatic and have worse quality of life than their ED counterparts without PTSD. Integrated treatment approaches that effectively address ED-PTSD+ are greatly needed in ED programs that treat adolescents.

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.

Integrating cognitive processing therapy for posttraumatic stress disorder with cognitive behavioral therapy for eating disorders in PROJECT RECOVER

Posttraumatic stress disorder (PTSD) frequently co-occurs with eating disorders (ED) and is likely to be a powerful ED maintaining factor for a significant subgroup of individuals. The goal of PROJECT RECOVER is to develop and evaluate concurrent integrated treatment approaches for ED-PTSD to enable these individuals to recover from both their ED and PTSD. To date, we have trialed two approaches to concurrent/integrated treatment in PROJECT RECOVER: (1) concurrent delivery of Cognitive Processing Therapy (CPT) for PTSD to individuals receiving intensive ED treatment, and (2) delivery of a manualized individual cognitive-behavioral therapy (CBT) addressing both ED and PTSD (Integrated CBT for ED-PTSD) following a period of initial ED treatment. Interventions from both CBT for ED, and CPT for PTSD can be utilized and adapted to address the functional relationship between ED and PTSD, and promote full recovery from both disorders. Examples include integrating PTSD symptoms into the cognitive-behavioral individualized formulation of ED maintenance; integrating the ED into psychoeducation about PTSD maintenance; and identifying maladaptive beliefs that connect the ED to the trauma and/or PTSD. Emerging evidence suggests that CPT can be successfully integrated with CBT for ED.

Genetic and environmental influences on posttraumatic stress disorder symptoms and disinhibited eating behaviors

Posttraumatic stress disorder (PTSD) and eating disorders (ED) frequently co-occur, but the mechanisms underlying this association remain unclear. EDs are characterized by features of maladaptive eating behaviors including disinhibited eating and cognitive dietary restraint. Identifying the genetic overlap between PTSD symptoms and maladaptive eating behaviors may elucidate biological mechanisms and potential treatment targets. A community sample of 400 same-sex twins (102 monozygotic and 98 dizygotic pairs) completed the PTSD Checklist-Civilian (PCL-C) for PTSD symptoms and the Three-Factor Eating Questionnaire-Reduced (TFEQ-R18) for eating behaviors (uncontrolled eating, emotional eating, and cognitive dietary restraint). We used biometric modeling to examine the genetic and environmental relationships between PCL-C and TFEQ-R18 total and subscales scores. Heritability was estimated at 48% for PTSD symptoms and 45% for eating behavior overall. Bivariate models revealed a significant genetic correlation between PTSD symptoms and eating behavior overall (r_g =.34; CI:.07,.58) and Uncontrolled Eating (r_g =.53; CI:.24,.84), and a significant environmental correlation between PTSD symptoms and Emotional Eating (r_e =.30; CI:.12,.45). These findings suggest the influence of common etiology. Future research and clinical efforts should focus on developing integrated treatments.

Posttraumatic stress disorder and eating disorders: maintaining mechanisms and treatment targets

Many individuals with lifetime histories of eating disorders (EDs) report exposure to interpersonal trauma and posttraumatic stress disorder (PTSD). However, this relationship is not well-understood, and there are no established, evidence-based therapies for the concurrent treatment of EDs and PTSD. This review focuses on studies of the mechanisms associating trauma exposure and/or PTSD with EDs. Possible mechanisms of the trauma-ED association identified from the literature include self-criticism, low self-worth, guilt, shame, depression, anxiety, emotion dysregulation, anger, and impulsivity/compulsivity. ED behaviors may be used as coping strategies to manage PTSD symptoms and negative affect. Avoidance of hyperarousal symptoms by engaging in binge eating, purging, and/or restriction may serve to maintain both the ED as well as the PTSD. Given the evidence of the bidirectional relationship between EDs and PTSD, we describe an integrated cognitive behavioral theory that may account for the persistence of comorbid PTSD and EDs. The integrated model is based on the theoretical models that underpin existing evidence-based treatments for PTSD and ED and incorporates many of the potential mechanisms highlighted to date. The primary aim of the model is to identify potential treatment targets as well as elucidate future directions for research.

Treatment outcomes of psychotherapy for binge-eating disorder in a randomized controlled trial: Examining the roles of childhood abuse and post-traumatic stress disorder

OBJECTIVE

To examine childhood abuse and post-traumatic stress disorder (PTSD) as predictors and moderators of binge-eating disorder (BED) treatment outcomes in a randomized controlled trial comparing Integrative Cognitive-Affective Therapy with cognitive-behavioural therapy administered using guided self-help.

METHOD

In 112 adults with BED, childhood abuse was defined as any moderate/severe abuse as assessed by the Childhood Trauma Questionnaire, lifetime PTSD was assessed via the Structured Clinical Interview for DSM-IV, and outcomes were assessed via the Eating Disorder Examination (EDE). Covariate-adjusted regression models predicting binge-eating frequency and EDE global scores at end of treatment and 6-month follow-up were conducted.

RESULTS

Lifetime PTSD predicted greater binge-eating frequency at end of treatment (B = 1.32, p = 0.009) and childhood abuse predicted greater binge-eating frequency at follow-up (B = 1.00, p = 0.001). Lifetime PTSD moderated the association between childhood abuse and binge-eating frequency at follow-up (B = 2.98, p = 0.009), such that childhood abuse predicted greater binge-eating frequency among participants with a history of PTSD (B = 3.30, p = 0.001) but not among those without a PTSD history (B = 0.31, p = 0.42). No associations with EDE global scores or interactions with treatment group were observed.

CONCLUSIONS

Results suggest that a traumatic event history may hinder treatment success and that PTSD may be more influential than the trauma exposure itself.

The association of traumatic events and posttraumatic stress disorder with greater eating disorder and comorbid symptom severity in residential eating disorder treatment centers

OBJECTIVE

Traumatic events, posttraumatic stress disorder (PTSD) and related symptoms are commonly associated with eating disorders (ED). Several clinical features indicative of a more severe and complex course have been associated with traumatized ED patients, especially those with PTSD, who may be more likely admitted to residential treatment (RT). Research in this population is sparse but of increasing interest.

METHOD

Adult participants (96.7% female) with EDs entering RT (n = 642) at seven sites in the U.S. completed validated self-report assessments of ED, PTSD, major depression, state-trait anxiety, and quality of life. Presumptive diagnoses of DSM-5 PTSD (PTSD+) were made via the Life Events Checklist-5 and the PTSD Symptom Checklist for DSM-5.

RESULTS

PTSD+ occurred in 49.3% of patients. PTSD+ patients had significantly higher scores on all assessment measures (p ≤ .001), including measures of ED psychopathology, depression, state-trait anxiety, and quality of life. Those with PTSD+ had significantly higher numbers of lifetime traumatic event types, higher rates of almost all lifetime traumatic events, and a greater propensity toward binge-type EDs.

DISCUSSION

Results confirm that ED-PTSD+ patients in RT are more symptomatic and have worse quality of life than ED patients without PTSD+. Integrated treatment approaches that effectively address ED-PTSD+ are greatly needed.

Impact of trauma in childhood and adulthood on eating-disorder symptoms

Exposure to a traumatic event is concurrently and prospectively associated with disordered-eating behaviors such as binge eating, restricting, and purging. Specifically, purging has been found to be elevated in individuals with trauma histories, suggesting that purging may be a method for coping with trauma-related distress. However, there has been limited research investigating whether the time at which trauma occurs during development is differentially associated with disordered-eating behaviors and internalizing psychopathology. The purpose of this study was to examine the effect of trauma that occurred in childhood, adulthood, or childhood and adulthood on eating disorder (ED) and internalizing psychopathology. Participants were community-recruited adults with a current DSM-5 ED (N = 225) and were subsequently grouped into categories based on the time at which trauma occurred. Groups included: no trauma exposure ED controls (n = 54), child trauma group (n = 53), adult trauma group (n = 53), and child+adult trauma group (n = 65). We compared groups on their level of disordered-eating symptoms. Participants were administered the Structured Clinical Interview for DSM-IV, the Eating Pathology Symptoms Inventory (EPSI), and the Inventory of Depression and Anxiety Symptoms-II (IDAS-II). Univariate analyses revealed significantly higher levels of purging symptomatology in the child+adult trauma group compared to the no trauma, child trauma, and adult trauma groups. The current study highlights the importance of assessing the timing of trauma among individuals with EDs. In particular, our study indicates a need for further investigation to explain why individuals with ED and trauma histories engage in greater purging.

Eating disorders and posttraumatic stress disorder

PURPOSE OF REVIEW

Childhood maltreatment is associated with all types of eating disorders. We provide a systematic review of the recent literature on comorbid posttraumatic stress disorder (PTSD) in patients with eating disorders, and focus on prevalence, relationship with symptom severity, operating mechanisms and treatment.

RECENT FINDINGS

The prevalence of comorbid PTSD in patients with eating disorders ranges from 9 to 24%, with research suggesting that comorbid PTSD is associated with more severe eating disorder symptoms. Maladaptive emotional regulation strategies may mediate the relationship between PTSD and eating disorders. Two pilot studies provide preliminary evidence that concurrent cognitive behavior therapy (CBT) for PTSD and eating disorders may be beneficial and that repetitive transcranial magnetic stimulation (rTMS) could be helpful in the treatment of PTSD in some eating disorder patients.

SUMMARY

PTSD is a common comorbidity in patients with eating disorders and impacts the severity of their eating disorder symptoms. However, there is little research into concurrent treatments for PTSD and eating disorders. Difficulties in emotional regulation may be a common mechanism in both disorders.

Trauma-informed care and practice for eating disorders: personal and professional perspectives of lived experiences

BACKGROUND

Learning about the life stories of patients who have experienced a severe eating disorder (ED), but also traumas that led to PTSD, dissociative disorders, and other comorbidities, has great value to clinicians in their efforts to deliver trauma-informed care (TIC). Many investigators have been researching and writing about these issues for years, and strong scientific evidence has emerged, indicating that trauma is a significant risk factor for the development of EDs, particularly in its bulimic forms.

PURPOSE

Peer-reviewed literature contains scarce input from people with "lived experiences". Hearing and "sitting with" such individuals are extremely useful in clinical practice and research. Further, encouraging patients to put words to their pain has recognized therapeutic effects. These lived experiences are often demonstrative of key elements of what professionals need to know about evaluating and treating patients with EDs and co-occurring trauma-related disorders.

METHOD/RESULTS

The principal author invited two courageous recovered ED advocates and writers (June Alexander and Jenni Schaefer), who have gone public about their ED-PTSD experiences, to recount their life stories and treatment experiences (both positive and negative). Dr. Brewerton then offers his professional perspectives on the course of their treatment experiences put in the context of ongoing relevant clinical research.

CONCLUSION

Their and other patients' experiences have great power to guide professionals toward trauma-informed care, more integrated practice, and theoretically improved outcomes.

LEVEL OF EVIDENCE

Level V.

An Overview of Conceptualizations of Eating Disorder Recovery, Recent Findings, and Future Directions

PURPOSE OF REVIEW

This review delineates issues in the conceptualization and operationalization of eating disorder recovery, highlights recent findings about recovery (since 2016), and proposes future directions.

RECENT FINDINGS

A longstanding problem in the field is that there are almost as many different definitions of recovery in eating disorders as there are studies on the topic. Yet, there has been a general shift to accepting that psychological/cognitive symptoms are important to recovery in addition to physical and behavioral indices. Further, several operationalizations of recovery have been proposed over the past two decades, and some efforts to validate operationalizations exist. However, this work has had limited impact and uptake, such that the field is suffering from "broken record syndrome," where calls are made for universal definitions time and time again. It is critical that proposed operationalizations be compared empirically to help arrive at a consensus definition and that institutional/organizational support help facilitate this. Themes in recent recovery research include identifying predictors, examining biological/neuropsychological factors, and considering severe and enduring anorexia nervosa. From qualitative research, those who have experienced eating disorders highlight recovery as a journey, as well as factors such as hope, self-acceptance, and benefiting from support from others as integral to the process of recovery. The field urgently needs to implement a universal definition of recovery that is backed by evidence, that can parsimoniously be implemented in clinical practice, and that will lead to greater harmonization of scientific findings.

Sensation seeking, binge-type eating disorders, victimization, and PTSD in the National Women's Study

OBJECTIVE

Higher degrees of sensation seeking (SS) are reported in community and clinical samples of individuals with eating disorders with binge-type features (BTEDs), but no reports exist in representative probability samples of adult women. Additionally, SS has been linked to victimization and PTSD, also associated with BTEDs, yet interrelationships between these variables are unexplored.

METHODS

A national, probability sample of 3006 adult women (≥18 y/o) completed structured telephone interviews including assessments for victimization, PTSD, bulimia nervosa (BN) and binge eating disorder (BED). The survey included the 6 items of the Disinhibition-Intentions for the Future (DIF) subscale of Zuckerman's Sensation Seeking Scale-VI, which asks how likely participants would be to engage in given activities. Total SS score (TSSS-DIFS) was the sum of the 6 items' scores. Differences among the 3 groups (BN, BED, non-BN/BED) were compared using ANOVA covaried by age and post-hoc t-tests. Multiple regression tested the effects of age, number of victimization experiences (NVE), lifetime PTSD, and BTEDs on TSSS-DIFS.

RESULTS

There were significant differences in TSSS-DIFS across BTED diagnoses (p ≤ .001). Participants with BN (p ≤ .002) and those with BED (p ≤ .01) had significantly higher scores than those without BTEDs. These findings persisted in both groups after correcting for NVE and lifetime PTSD. TSSS-DIFS was significantly higher in participants with BTED with PTSD versus those without (p ≤ .025).

DISCUSSION

SS traits related to disinhibition occur more commonly in U.S. adult women with BN and BED, even after controlling for NVE and PTSD, which were also associated with higher TSSS-DIFS.

Update on Psychological Trauma, Other Severe Adverse Experiences and Eating Disorders: State of the Research and Future Research Directions

PURPOSE OF REVIEW

This paper provides an updated review of the literature on the relationship between psychological trauma exposure, other severe adverse experiences, and eating disorders.

RECENT FINDINGS

Trauma exposure and other severe adverse experiences (e.g., emotional abuse) in both childhood and adulthood are associated with eating disorders. The relationship between traumatic and other adverse experiences and eating disorders appears to be mediated by emotional and behavioral dysregulation, as well as by cognitive factors such as self-criticism. Biological vulnerabilities may also be relevant to this relationship. Overall, the literature is limited by predominantly cross-sectional designs. There is clear evidence of a correlational relationship between trauma exposure and other severe adverse events, and eating disorders. Both risk and maintenance factor hypotheses have been put forth; however, prospective research testing these hypotheses remains limited. Future research should use prospective designs and focus on trauma-related symptoms (rather than trauma exposure) in order to advance research on risk and maintaining factors for eating disorders and inform treatment directions.