Eating Disorders are common in people with PTSD
Some parts of this post may be slightly triggering.
Why do people develop eating disorders?
There are many different reasons why people develop eating disorders, but people suffering from PTSD are at an increased risk. Some eating disorders are more closely linked to child abuse and neglect than others.
In their book on Traumatic Stress, Van der Kolk et al. (2012) state that the “lack or loss of self-regulation” (emotional regulation, also known as affect regulation) “is possibly the most far-reaching effect of psychological trauma in both children and adults”. Difficulties in relgulating emotions are a known symptom of both Complex PTSD and Borderline Personality Disorder.
How are Eating Disorder thoughts linked to trauma and abuse?
Why do people develop one eating disorder rather than another? What thoughts might be involved?
The relationship between Trauma and Eating Disorders
Lemberg and Cohn’s Eating Disorder Sourcebook states:
“Eating disorders may represent a powerful response to and means of coping with the psychological and biological effects of trauma outlined above. When viewed as a means of coping, as well as a possible symbolic representation of the trauma, eating disturbances become more comprehensible to the patient and clinician alike.” 
Brewerton (2007) summarizes significant conclusions in the link between trauma and eating disorders (EDs), as follows:
- childhood sexual abuse is a “nonspecific risk factor” for EDs
- a spectrum of trauma is linked to EDs, including a variety of forms of abuse and neglect
- trauma is more common in bulimic EDs compared to nonbulimic EDs
- the link between EDs and trauma extends to children and adolescents with EDs, and to boys and men with EDs
- multiple episodes or forms of trauma are associated with EDs
- trauma is “not necessarily associated with greater ED severity”
- trauma is associated with more co-existing diagnoses (including PTSD) in people with EDs
- subthreshold (partial) PTSD may be a risk factor for bulimia nervosa and bulimic symptoms
- the trauma and PTSD or its symptoms must be addressed in order to fully recover from the ED and co-existing diagnoses 
Weight loss in eating disorders and the psychology of trauma and abuse
Lemberg (1999) goes on to explain the following links:
- dieting – avoiding needs – to need is dangerous during trauma
- dieting may be seen as a way to “purify” a damaged self
- some sexual abuse survivors deliberately starve themselves to repulse the perpetrator and any future perpetrators
- starving can bring on dissociative-like states, allowing “a level of removal from the here-and-now”
- refusing food can give the illusion of power; those who have been repeatedly powerless (as occurs in cases of abuse), in this case regaining a sense of personal power in different areas of life is crucial in recovery
- many people with eating disorders lack a sense of meaning and purpose in life, and trauma survivors often experience internal chaos, confusion and pain.
- Westernized culture links a slender physique with control, happiness, emotional stability and calmness, and success which can lend additional importance to the pursuit of “thinness”. 
Ferentz (2012) also states that
“A person’s quest to reduce their physical size can be a desire for invisibility, and an expression of vulnerability”
“denial of food may have roots in prior neglect and lack of adequate nurturance” 
Binge eating and trauma
- comfort and nurturance which is not supplied by the self or others
- The negative thoughts or mood experienced as a core symptom of PTSD can involve “exaggerated negative beliefs or expectations about oneself”, binge eating to the point of painful fullness may represent punishment, particularly when an abuser instilled the belief “I am bad”, which later was internalized in the trauma survivor. (see also: Copy alters (introjects)). Self injury, alcohol and substance misuse can also be used as punishment.
- some find binge eating a means to escape through dissociation, experiencing a trance-like state to avoid moods such as anger
- excess weight can be seen as an “armor” to repel potential abusers and/or make the person more “powerful and formidable”
- Shame and guilt are examples of negative alterations in cognitions and mood are associated with PTSD.
- The societal stigma and stereotyping of overweight people allows excess weight to be a public symbol of the bodily shame and self-contempt gained as a result of abuse as well as a representation of the person feeling unworthy of love
Purging and trauma
Purging can include self-induced vomiting, abusing laxatives, diuretics, excessive exercise or enemas.  Purging’s psychological role includes:
- often symbolizing “a cleansing of a person’s body from abuse” or removing the internal feeling of being “dirty” 
- allows for the removal of rage or “anger pent up inside.” 
- releasing unspoken memories 
- reclaiming a sense of control over a person’s own body by removing what was forced inside 
- purging reenacts and perpetuates the sense of “badness” which many trauma survivors experience 
- purging may be a way for trauma survivors to regain control over their emotions 
A large study of adult women with anorexia nervosa found that 13.7% met DSM-IV criteria for PTSD, with those having the restricting form of anorexia nervosa significantly less likely to have PTSD than those with purging anorexia nervosa without binge eating. Of those with PTSD the majority experienced their first traumatic event before the onset of anorexia nervosa, with the most common traumatic events reported being child sexual traumas and adult sexual trauma. 
Personality Disorders and Eating Disorders
Self-induced vomiting within eating disorders is significantly associated with both borderline and narcissistic personality disorders. Avoidant Personality Disorder is the most common personality disorder present in those with eating disorders. 
- World Health Organisation, (2010). International classification of diseases. ICD-10.
- Durso, L.E.; Latner J.D, Hayashi K (2012). Perceived Discrimination Is Associated with Binge Eating in a Community Sample of Non-Overweight, Overweight, and Obese Adults. The Europenan Journal of Obesity, volume 5. (doi:10.1159/000345931)
- International Society for the Study of Trauma and Dissociation. Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, volume 12.2, page 115-187.
- Diagnostic and Statistical Manual of Mental Disorders-5.
- Ferentz, Lisa (2012). Treating Self-Destructive Behaviors in Trauma Survivors: A Clinician’s Guide. ISBN 1136843159.
- Ross, Carolyn (2009). The Binge Eating and Compulsive Overeating Workbook: An Integrated Approach to Overcoming Disordered Eating. ISBN 1572245913.
- Fairburn, C. G.,; Doll, H. A., Welch, S. L., Hay, P. J., Davies, B. A., & O’Connor, M. E. (1998). Risk factors for binge eating disorder: a community-based, case-control study.. Archives of general psychiatry, volume 55.5, issue 425.
- World Mental Health Surveys. The Prevalence and Correlates of Binge Eating Disorder in the World Health Organization. Biological Psychiatry, volume 73, issue 9, 1.
- Lemberg, Raymond (Editor) (1999) (coauthors: Cohn, Leigh (Editor)). Eating Disorders: A Reference Sourcebook. ISBN 1573561568.
- Attia, Evelyn; et al. (2013). Feeding and Eating Disorders in DSM-5. American Journal of Psychiatry, volume 170, page 1237-1239. (doi:10.1176)
- van der Kolk, Bessel A. (2012) (coauthors: McFarlane, Alexander C.; Weisaeth, Lars). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. ISBN 1462507107.
- Southard, Ashley L. (2008). Understanding Bulimia: A Qualitative Exploration of the Roles of Race, Culture, and Family. ISBN 0549661786.
- Reyes-Rodríguez, Mae Lynn; Von Holle, Ann; Ulman, T. Frances; Thornton, Laura M. et al. (2011). Post traumatic stress disorder in anorexia nervosa. Psychosom Med., volume 73, issue 6, page 491-497. (doi:10.1097/PSY.0b013e31822232bb)
- von Lojewski, A.; Fisher, A.; Abraham, S. (2013). Have Personality Disorders Been Overdiagnosed among Eating Disorder Patients?. Psychopathology, volume 46, page 421-426. (doi:10.1159/000345856)
- Brewerton, T. D. (2007). Eating disorders, trauma, and comorbidity: Focus on PTSD. Eating Disorders, 15(4), 285-304. https://www.researchgate.net/profile/Timothy_Brewerton/publication/6128514_Eating_disorders_trauma_and_comorbidity_focus_on_PTSD/links/0046352783075737c6000000.pdf
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