Bulimia and Post-traumatic Stress Disorder (PTSD) frequently occur together, primarily when a stressful or traumatic event occurs. Reactions can be overwhelming, and cause distress to the point of emotional impairment, dysfunction to daily life, and physical problems [1].

The Substance Abuse and Mental Health Services Administration (SAMHSA) states that trauma varies from person to person and reactions depend on 1) How impactful the event is, 2) The experience of the trauma, and 3) The effects on the individual [1].

Individuals manage trauma in two ways. Either through avoiding or numbing the experience, or actively coping with the trauma.

Avoidant coping is when a person engages in unhealthy behaviors, such as eating disorders, self-harm, or numbing. Avoidance can also include shutting out thoughts and beliefs around the trauma. Often the sufferer’s thoughts are self-defeating.

Active coping is when a person engages in healthy coping skills and thinking to manage stress and trauma. This includes problem-solving and resiliency behaviors.

Past research has shown that those who struggle with eating disorders, especially bulimia, tend to be more sensitive to stress. In one study, it was seen that those with bulimia and anorexia had a higher rate of anxiety [1].

Further research also found that people with an eating disorder tend to perceive threats or conflict from others more acutely, exhibit higher levels of sensitivity to anxiety, and they are often concerned about negative consequences [1].

Those with bulimia also show exaggerated inhibition and anticipatory anxiety. They also tend to be more sensitive to change and struggle to see the big picture in situations or events.

PTSD

The American Psychiatric Association defines PTSD as a person experiencing the following after a traumatic event:

Symptoms of the trauma, such as flashbacks and nightmares
Hyperarousal symptoms
Avoidance of emotions or thoughts related to the trauma
Negative thoughts and moods that are associated with the trauma experience [1]

Maintaining Factors

PTSD is chronic, particularly if not treated. It can be challenging for individuals with an eating disorder and PTSD to get an adequate assessment and the proper treatment. Often untreated, PTSD can be a perpetuating factor in the continuation of the eating disorder.

In a major study that looked at the prevalence of bulimia and PTSD, researchers found that the highest rates of lifetime PTSD were 38% and 44% in bulimia nervosa groups [2].

When PTSD was included, over half of the individuals with bulimia had PTSD or significant PTSD symptoms.

Individuals who are traumatized tend to show higher levels of dissociative symptoms which may contribute to physical and medical negative consequences.

Purging tends to reduce the hyperarousal state and anxiety that typically comes with trauma. The binge eating symptoms of bulimia numb out and avoid the emotions and memories associated with the traumatic event.

Because of these reasons, it can be extremely challenging to break the cycle of bulimia. Treatment that includes therapy for both issues, especially trauma, has been shown to be highly effective [2].

Shared Features

Features of trauma and bulimia are shared. Emotional dysregulation, impulsivity, and alexithymia (difficulty in identifying and describing emotions) are prevalent in both disorders [2].

Individuals seem to over-regulate their emotional state through avoidance. Interoceptive awareness (the inability to identify the difference between feelings and sensations) are shared with both PTSD and bulimia.

Trauma-related disorders, especially sexual abuse, are coupled with a variety of disorders that affect eating, mood, anxiety, substance use, dissociative somatoform, impulse control, disruptive behavior, and personality [3].

Often the person will struggle with suicidal ideation and self-harm behaviors as well. Other shared features such as dissociation, hyperactivation, and interpersonal relationships are mutual in this population.

Dissociation

Typically when a person is engaging in binging and purging behaviors, dissociation is common. In prior research, sufferers with bulimia who report abuse have higher rates of dissociation than those individuals who do not report abuse [3].

Higher rates of a loss of control over thoughts, behaviors, and emotions are also reported by this group, which pushes the individual to engage in disordered eating as a way to cope or survive with the trauma.

Hyperactivation

Numbing out emotions is also a part of eating disorders, and emotional reactivity is controlled through the bulimic behaviors. Self-harm is also used as a way to disrupt dysphoric affect states which feel unbearable.

This cycle continues as the individual tries to control their emotional reactions to the trauma and can produce a dissociative state and purging enables the person to regulate their emotions.

Interpersonal Relationships

Individuals struggle with healthy relationships and boundaries. Self-Concept identification is a struggle and eating disorder symptoms can be the transitional object for the individual for comfort and self-soothing.

Final Thoughts

PTSD and Bulimia are a specific sub-group of this population and understanding the maintaining factors, and unique symptoms of this group are essential for treatment.

The engagement of eating disorders with PTSD are typically a way to protect the person from an attachment injury or to survive during trauma and to continue to survive after the event [3].

The eating disorder acts as a way to help with relationships, functioning, and internal cohesion.

It is essential to be mindful of evaluating for both eating disorders and trauma, especially when working with sufferers of bulimia.

Accurate assessments are needed to be able to provide effective concurrent treatment to an individual struggling with co-occurring issues. Working with this population can be challenging, but recovery is possible.

About the Author: Libby Lyons is a Licensed Clinical Social Worker and Certified Eating Disorder Specialist (CEDS). Libby has been practicing in the field of eating disorders, addictions, depression, anxiety, and other comorbid issues in various agencies. Libby has previously worked as a contractor for the United States Air Force Domestic Violence Program, Saint Louis University Student Health, and Counseling, Saint Louis Behavioral Medicine Institute Eating Disorders Program, and has been in Private Practice.

Libby currently works as a counselor at Fontbonne University and is an Adjunct Professor at Saint Louis University, and is a contributing author for Addiction Hope and Eating Disorder Hope. Libby lives in the St. Louis area with her husband and two daughters. She enjoys spending time with her family, running, and watching movies.

References:

[1] Trauma, Posttraumatic Stress Disorder and Eating Disorders. (n.d.). Retrieved December 28, 2017, from https://www.nationaleatingdisorders.org/learn/general-information/trauma
[2] T. (2013, June 28). Comorbid PTSD and Eating Disorders: Can Treating One Improve The Other? Retrieved January 10, 2018, from http://www.scienceofeds.org/2013/06/28/comorbid-ptsd-and-eating-disorders-can-treating-one-improve-the-other/
[3] Strickler, H. L. (2013, December 27). The Interaction between Post-Traumatic Stress Disorders and Eating Disorders: A Review of Relevant Literature. Retrieved January 10, 2018, from https://www.omicsonline.org/open-access/the-interaction-between-posttraumatic-stress-disorders-and-eating-disorders-a-review-of-relevant-literature-2167-1222.1000183.php?aid=23401

The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer discussion of various issues by different concerned individuals.

We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.

Published on February 17, 2018.

Published on EatingDisorderHope.com

PTSD and Bulimia: Relational Statistics & Trends