August 14, 2019

Treating Trauma with Comorbid Binge Eating Disorder: Stopping the Cycle of Shame, Guilt, & Symptom vs. Person Based Treatment - Dr. Julie Friedman

treating trauma with comorbid binge eating disorderWe know that traumatic events can cause people to experience debilitating symptoms for months and even years afterwards. When trauma symptoms are present in multiple arenas for that person and persist over time, people can develop and become incapacitated by posttraumatic stress disorder (PTSD).
 
We also know that the prevalence of trauma is high in patients with binge eating disorder (BED)— much higher, in fact, than in the general population.[1]
 
Take women with lifetime binge eating disorder, for example. Ninety percent of women who have met criteria for BED at least once in their lifetime report having experienced at least one traumatic stressor (i.e. sexual assault or an unwanted or uncomfortable sexual experience, physical assault, and/or the sudden unexpected death of a friend or loved one). 
 
And almost all men with lifetime binge eating disorder — 98 percent — also report having a trauma history.[2]
 
We can’t prevent trauma, but we can — and we must — treat our patients’ traumatic stress along with their eating disorders (ED). In fact, NOT doing so leaves our patients more vulnerable to relapsing, as trauma is often a maintaining factor in an individual’s eating disorder symptoms. 
 
A brief overview of Binge Eating Disorder
 
Binge Eating Disorder is a serious eating disorder that includes frequent, regular episodes of binge eating that feel out of control and are followed by distress, shame and embarrassment.
 
An extensive body of literature suggests that eating disorder behaviors are often a way that people manage distress in their life, including the high levels of discomfort and distress that follow a trauma. 
 
When we fail to treat our eating disorder patients’ traumas, these patients will continue to experience more distress in their lives. They will continue to use their eating disorder behaviors to “numb” their symptoms. By not effectively treating their traumas, we are perpetually maintaining both their trauma-related distress and their disordered eating habits. 
 
The relationship between trauma and binge eating 
 
Multiple studies show the relationship between trauma-related conditions and eating disorders. In many cases, a traumatic event comes first, and then the individual finds that their eating disorder behaviors help to manage the uncomfortable symptoms that stem from the trauma.[3]
 
One study showed that child maltreatment was associated with an increased likelihood of experiencing eating disorder symptoms, with all seven types of child maltreatment associated with developing BED in women. Sexual abuse and physical neglect in childhood are associated with developing BED in men.[4]
 
Similarly, in an attempt to study how trauma leaves one susceptible to the development of an ED, one study concluded that childhood exposure to traumatic events actually reduced gray and white matter in the brain in areas that modulate reward derived from food, taste perception, and perception of one’s body image.[5]
 
Bingeing and bingeing — and purging in particular — can help calm and regulate the hyperarousal associated with traumatic stress. Eating disorder professionals therefore are not surprised when research shows that ED patients reporting a trauma history (emotional, sexual, or physical abuse) were significantly more likely to:
 
  • Have a comorbid psychiatric disorder
  • Be suicidal
  • Experience an earlier onset of ED
  • Be more likely to binge and/or purge[6]
 
Why do people binge when they are distressed? People binge when they are distressed because it works. Dopamine, a pleasure hormone released in the brain’s reward centers, is released when patients with BED are presented with food cues. In fact, the more symptomatic a patient with BED is, the higher the amplitude of the dopamine release in response to food. In other words, the more frequently a patient is binge eating, the more rewarding they find the behavior at a neurobiological level. In addition, eating decreases the production of stress hormones, which patients who have experienced trauma tend to have an excess of — along with concurrent physiological hyperarousal. 
 
Our patients know that their eating disorder behaviors are harmful — yet they struggle to abstain from behaviors when they are serving a purpose. 
 
Our job as a treatment team is to help these individuals learn to stop avoiding trauma-related cues and content in their environment and, ultimately, effectively regulate the distress caused by trauma memories and symptoms. Essentially, effective trauma treatment teaches patients the skills to calm their body when in distress and exposes (vs. teaching avoidance) them to trauma content and memories in order to ultimately decrease the distress associated with these memories. 
 
The downside of avoiding trauma treatment
 
As a clinician who has worked in many different care settings, I was becoming increasingly frustrated with sending my patients to a higher level of care (residential or PHP) and having their symptoms be well-controlled in an environment with almost constant containment and support. However, these patients would return to their daily lives and relapse almost immediately – feeling increasingly hopeless and like a “failure” for “not benefitting from treatment.” 
 
Almost always, the return of eating disorder symptoms can be traced to a return of the trauma symptoms or a trauma trigger in their real life that elicits trauma symptoms. Thus, the patient is returning to their eating disorder behaviors as these behaviors have become an effective way to manage their mood, anxiety, and trauma symptoms. The behaviors have helped this patient survive. 
 
Because the experience of trauma leaves the brain and body in a perpetual “fight or flight” scenario, these patients are returning to “survival mode” almost immediately. 
 
However, if we can treat that patient’s trauma symptoms and their eating disorder symptoms simultaneously, we prepare them more effectively for life outside of the containment and support that a treatment setting offers.
 
 
Treating trauma and binge eating disorder concurrently
 
The impact of untreated traumatic stress can include hypervigilance, chronic anxiety, sleep problems, self-harm, suicidality, hopelessness and helplessness, and a return to bingeing and/or bingeing and purging behaviors.
 
As behavioral health care providers, we can start by screening for trauma in all of our patients with eating disorders. A number of free screenings can be found at www.ptsd.va.gov. If a patient meets criteria for PTSD and an eating disorder, that patient should be provided with both comprehensive trauma and eating disorder treatment at the same time. If necessary, refer that patient out to a higher level of care so they can see providers experienced in using evidence-based treatments for both trauma and eating disorders. 
 
 
Learn more about treating trauma and binge eating disorder
 
Some of the many interventions we use in our program to treat trauma and binge eating disorder concurrently include:
 
  • Incorporating evidence-based, research-backed therapies like prolonged exposure and written exposure therapy
  • Teaching coping and grounding skills to regulate distress and help a patient to “calm on purpose”
  • Encouraging patients to connect to their values and decrease experiential avoidance
  • Helping patients reintegrate and process traumatic memories 
 
When we treat the whole person, and all of their issues concurrently, we set them up for full vs. partial recovery — and a life worth living.
 
Join me in San Francisco!
 
Join me in person or via livestream for our  5 CME/CE San Francisco Professional Symposium: New Treatment Strategies for Complex Cases on September 20, 2019 to learn more about concurrent treatment of trauma and Binge Eating Disorder.
 
Register for the event here.
 
 
Dr. Julie Friedman is the National Senior Director of the Binge Eating Treatment and Recovery Program at Eating Recovery Center and a health psychologist whose specialties include Cognitive-Behavioral Therapy, Night Eating Syndrome, Binge Eating Disorder, Bulimia Nervosa, Substance Use Disorder and compulsive behaviors, traumatic stress and PTSD, exposure-based and Level I trauma treatments, and Exposure and Response Prevention. 
 
Dr. Friedman is also an Assistant Professor at the Northwestern University Feinberg School of Medicine in the Department of Psychiatry and Behavioral Sciences where she teaches and supervises psychology interns and postdoctoral fellows and psychiatry residents. She received her BS in Psychology from Northwestern University and her PhD in Clinical Psychology from the Illinois Institute of Technology. She completed a fellowship in sleep disorders at Rush University Medical Center and a two-year post-doctoral fellowship in behavioral medicine and eating disorders at Northwestern Memorial Hospital. 

[1]Brewerton et al., (2014) Int J Eat Disord 2014; 47:836–843.
[2]Mitchell, K. S. et. al., (2012). The International Journal of Eating Disorders45(3), 307–315; Dansky BS et al, Int J Eat Disord. (1997) ;21(3):213–228; Vierling et al, (2015) Presse Med Nov;44(11):e341-52. 
 
[3]Brewerton TD, Rance SJ, Dansky BS, O’Neil PM, & Kilpatrick, DG Int J Eating Disorders 2014 Nov 47(7)836-843.
[4]Afifi et al 2017 Int J Eating Disorders Nov 50(11) 1281-1296.
[5]Monteleone et al, 2019, The World Journal of Biological Psychiatry, 20:4, 301-309.
[6]Molendijk, M. L., Hoek, H. W., Brewerton, T. D., & Elzinga, B. M. (2017);
 
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