How does trauma effect the diagnosis of an eating disorder

An eating disorder is a serious mental health illness in its own right and is classified in the dsm-v based on an individuals maladaptive eating patterns, weight and BMI. The most common eating disorders include anorexia nervosa (AN), bulimia nervosa (BN), eating disorder not otherwise specified (EDNOS, now commonly termed other specified feeding and eating disorder OSFED) and compulsive overeating disorder (COED or binge eating disorder); however there are cross variations of each receiving current attention within the field of research.

As eating disorders are also commonly found within survivors of both complex and childhood trauma; research surrounding a possible link has begun to come forward. Although in its infancy, trauma researchers have found there to be a potential link between eating disorders as a comorbidity to trauma disorders. The possibility being that eating disorders are caused by trauma itself. Fruition of the latter would change the face of trauma and how eating disorders (and addictions) are treated.

Eating disorders have been researched in their own right and said to be caused by a complex combination of factors such as genetics, personality traits and environmental triggers; with frequent a comorbidity of anxiety depression and OCD.

In depth analysis shows that individuals who have traits of hypervigilance, perfectionism, high-achieving, obsessive, impulsive or chaotic, negative self-worth, guilt, distress and low self-esteem. While the link between trauma and eating disorders is still developing, it can be easy to see why eating disorders are common within survivors of trauma.
  As is seen in childhood developmental trauma and interpersonal trauma; survivors are often faced with many; if not all of these personality traits as a defence or coping mechanism. Professor van der Kolk has stated that if the dsm-v were to include developmental trauma as a mental health illness; it would have the potential to turn the dsm-v and icd-10 into a pamphlet; as many mental health conditions such as borderline personality disorder, ADD, ADHD, personality disorders, substance abuse and eating disorders would then be seen as symptoms of developmental trauma.

Each type of eating disorder can manifest due to prolonged maladaptive coping from trauma-related symptoms or events. Individuals use food to express emotions and distress and so coping with trauma can lead to an individual under or over eating in order to dissociate or dull emotions and fears. It is possible for an individual to fall outwith each of the described categories of diagnosis as well as experience multiple eating disorders at a time or throughout their lives.

Enduring trauma results in a loss of individual spirit. Where the survivor can rely on dissociation to remain separate from their experiences. During childhood and early development: there can be a joining of the mind with the ego where a child learns that an order to dull parental abuse or neglect they must create a perfect environment, ignore their own feelings and seek safety from ritual. This can also be the case for late-onset Complex trauma where survivors learn to behave in a certain way that it merges with their inner self. 

The ego develops to crave more and is consistently dissatisfied causing an individual to use avoidance to retreat from pain or discomfort. During developmental trauma; children often resort to over pleasing their caregivers, even at the expense of their own needs and desires. It can manifest to the point that the child becomes the parental figure; Taking care of the needs of those who should be nurturing them. This lack of nurture follows a child through to adulthood where they often enter toxic or abusive relationships. This compounding of trauma (also seen in adult complex trauma) leads to an individual using food as a tool to fulfill the constant demands of the ego.

Food is often used by individuals in order to deal with uncomfortable emotions or events through control, dissociation and distortion of self. Lack of nutrients aids a survivor by dulling their heightened emotions and further enabling them to dissociate. 

When you look at anorexia nervosa or bulimia nervosa and it's associated traits of perfectionism and OCD, it tends to link directly with the flight response. As current research shows, a prolonged reliance on one of the 4F responses can manifest into OCD, generalized anxiety disorder, substance abuse or reliance and eating disorders. 

 To further this theory, binge eating  characteristics generally fall in line with traits of the fawn and freeze response. The notion that eating disorders are caused by our symptoms of developmental and complex trauma would change the way we look at all mental illness as well as trauma itself. 

With regards to recovery from an eating disorder focus is placed directly on restoring weight, education on nutrition, addressing body image and preventing future ill health as a consequence. Currently, with regards to eating disorder recovery; there is no focus on the traumatic childhood event(s) or developmental trauma(s) that may have caused it. Again, the blanket approach taken by the NHS of CBT and nutrition education fails in many instances to address trauma even in the minimalist of ways.

It is uncommon to visit a therapist in the first instance due to childhood trauma or interpersonal relationship trauma. Psychiatrists and psychologists usually assess patients in terms of their depressive symptoms, anxiety or OCD and eating issues. As CPTSD is only recently recognised, millions of cases could have gone unnoticed in terms of addressing core root trauma involved. For instance, it is common for eating disorder patients to state that an eating disorder never leaves, it can be controlled through awareness. What if this is because an eating disorder is a symptom of unrecognised/unresolved trauma? 

Past research focused on eating disorders being caused by the Western capitalistic world or due to being passed on through Generations via genetics. If you look at generational trauma and developmental trauma as being because of this, it would change the face of therapy into a complete trauma informed approach. This would have the potential to resolve trauma and related symptoms for millions of individuals.

Furthermore inner beliefs said to be held by those with an eating disorder tend to mirror those same negative beliefs held by a trauma survivor. Inner beliefs faced by both trauma survivors and eating disorder sufferers include not feeling worthy or deserving of anything; where food represents 'energy'; yin energy is nurturing, so the removal of that may seem normal for a trauma survivor. It is known that an individual's beliefs come from parental figures that have nurtured such ways. At present, there is little research which identifies a link between childhood neglect, complex trauma and eating disorders.

An eating disorder becomes like an addiction. If you look at the description of bulimia; addiction could be substituted for each symptom. Addiction and reliance on substances (such as removal of food) is seen commonly as a reaction and coping mechanism to trauma. If a trauma survivor who uses or relies on substances (or food removal) when they are feeling low; they may also fabricate events or enter toxic relationships (self creation of negative events) in order to cause a 'spike' in their maladaptive behaviors (ie binge, purge, run, use drugs). For survivors of trauma it is also common to have difficulties in sitting with uncomfortable emotions. This has said to be due to the activation of the survival mode response. For an individual who has experienced complex trauma or developmental trauma, we know that the heightened survival mode activation produces reliance on 4F responses as it does on the maintenance of maladaptive coping. 
  Addiction and reliance has been researched and found to link and correlate with eating disorder related behaviour on some level. Having the knowledge that we do regarding trauma; it can be simple to see the potential link and future possibilities that may bring; especially if we view other mental illness in the same respect - with an open mind to the individual effects of trauma.

The main treatment goal for eating disorders is to assist in decreasing fear of food and increasing the connection to self. However: if the inner self has been compromised due to a life of abuse or repeated complex trauma, would a trauma survivor who has a comorbidity of an eating disorder be aware of this change to their self?

Furthermore, for trauma survivors, eating disorders can be easily missed. Especially if it is tangled in a web of a variety of symptoms and illness. As anorexia nervosa is not diagnosed until an individual reaches less than 85% of a healthy BMI for their range; it can have real implications for a trauma survivor in terms of recovery. An eating disorder in its entity sits at the very bottom of Maslow's Hierarchy of Needs, is recovery from trauma possible if there is an underlying reliance on removal of food or addictive behaviours?

I wonder where the future with regards to trauma may develop and the extra lives that such knowledge could help. With addition of an adequate trauma screening procedure within psychotherapy; trauma itself could be identified quicker leading to higher recovery chances and with addition of an appropriate policy in education and health; could actually reduce trauma for the generations that are currently rising.

 If we continue to view eating disorders as an issue in attachment and trauma as research shows - eating disorder patients with 'secure' attachment have improved prognosis in treatment. From crossover with theorists in trauma - support is the biggest predictor of the impact of trauma and recovery.

I hope this article serves to open as many questions as it did for me. I personally an going to continue to actively research the notion that appropriate treatment screening and knowledge in early and healthcare systems - could change trauma in how it is approached and how it is further treated in the UK.

Our research group can be found here;

Currently we are conducting research into the causes of trauma. I have included a link to the survey here :

If you would be interested in taking part, please feel free. If you would like to share this study i would also welcome you to use the link, many thanks! 


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