Slide Guidelines & Requirements

Intermountain Project ECHO Eating Disorders

Sexual Trauma, Post Traumatic Stress Disorder, and Eating Disorders

Heidi Gordon, MS, LCSW Outpatient LCSW – Private Practice Center for Transpersonal Therapy Disclosures

The speaker has no significant financial conflicts of interest to disclose. Objectives

• To define Trauma, Eating Disorders, and Post Traumatic Stress Disorder (PTSD). To understand the clinical relationship between sexual trauma and eating disorders and PTSD.

• To understand defense mechanisms of PTSD and how eating disorders play a role of unresolved sexual trauma.

• To identify the symptoms of sexual trauma and PTSD in populations that clinicians are serving and the manifestation of trauma in eating disorders.

• Treatment for populations with sexual trauma and eating disorders. Definition of Trauma

The American Psychological Association defines trauma is an emotional response to a terrible event like an accident, rape or natural disaster. ..

A traumatic event is an incident that causes physical, emotional, spiritual, or psychological harm. The person experiencing the distressing event may feel threatened, anxious, or frightened as a result. In some cases, they may not know how to respond, or may be in denial about the effect such an event has had. DSM V Definition of Trauma

• The DSM-5 definition of trauma requires “actual or threatened death, serious injury, or sexual violence” [10] (p. 271). • Stressful events not involving an immediate threat to life or physical injury such as psychosocial stressors [4] (e.g., divorce or job loss) are not considered trauma in this definition. Definition of Sexual Abuse

Sexual abuse is defined as unwanted sexual activity, with perpetrators using force, making threats or taking advantage of victims not able to give consent. Most victims and perpetrators know each other. Immediate reactions to sexual abuse include shock, fear or disbelief. Long-term symptoms include anxiety, fear or post-traumatic stress disorder. Definition of Post Traumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, or rape or who have been threatened with death, sexual violence or serious injury.

American Psychiatric Association, 2013.

This Photo by Unknown Author is licensed under CC BY-SA-NC DSM V Post Traumatic Stress Disorder

Criterion A You were exposed to one or more event(s) that involved death or threatened death, actual or threatened serious injury, or threatened sexual violation. In addition, these events were experienced in one or more of the following ways: •Directly experiencing the event

•Witnessing the event as it occurred to someone else

•You learned about an event where a close relative or friend experienced an actual or threatened violent or accidental death

•Experiencing repeated exposure to distressing details of an event, such as a police officer repeatedly hearing details about child sexual abuse1 DSM V cont. Criterion B You experience at least one of the following intrusive symptoms associated with the traumatic event: •Unexpected or expected reoccurring, involuntary, and intrusive upsetting memories of the traumatic event •Repeated upsetting dreams where the content of the dreams is related to the traumatic event •The experience of some type of dissociation (for example, flashbacks) where you feel as though the traumatic event is happening again2 •Strong and persistent distress upon exposure to cues that are either inside or outside of your body that is connected to your traumatic event •Strong bodily reactions (for example, increased heart rate) upon exposure to a reminder of the traumatic event DSM Criteria cont. Criteria C Frequent avoidance of reminders associated with the traumatic event, as demonstrated by one of the following: •Avoidance of thoughts, feelings, or physical sensations that bring up memories of the traumatic event1 •Avoidance of people, places, conversations, activities, objects, or situations that bring up memories of the traumatic event DSM V PTSD cont. Criterion D At least two of the following negative changes in thoughts and mood that occurred or worsened following the experience of the traumatic event: •Inability to remember an important aspect of the traumatic event •Persistent and elevated negative evaluations about yourself, others, or the world (for example, "I am unlovable," or "The world is an evil place") •Elevated self-blame or blame of others about the cause or consequence of a traumatic event3 •A negative emotional state (for example, shame, anger, or fear) that is pervasive •Loss of interest in activities that you used to enjoy •Feeling detached from others •Persistent inability to experience positive emotions (for example, happiness, love, joy) Complex post-traumatic stress disorder (PTSD)

People who repeatedly experience traumatic situations, such as severe neglect, abuse or violence, may be diagnosed with complex PTSD. Complex PTSD can cause similar symptoms to PTSD and may not develop until years after the event. It's often more severe if the trauma was experienced early in life, as this can affect a child's development.

This Photo by Unknown Author is licensed under CC BY-ND Complex PTSD Features

Dissociation – the trauma is split off and fragmented, the emotions, sounds, images take on a life of their own internally. Avoidance – avoiding certain people or places that remind one of the trauma or avoiding talking about the trauma or the experience. Somatization - trauma manifesting as somatic complaints – headaches, stomach aches, pain disorders, conversion disorders. Depersonalization – telling horrendous stories without any feelings. Detached as if one were an outside. Derealization - recurrent experiences of unreality of surroundings. - dreamlike, distant, distorted. Common PTSD Symptoms of victims of sexual trauma • Reexperiencing the abuse • Flashbacks of the abuse • Hypervigilance • Fear of being victimized again • Fear of only being seen as sexual in relationships • Hyperarousal • Avoidance/emotional numbing • Fear of their attacker • Guilt Prevalence of PTSD in the Eating Disorder Population One of the most important connections between having had traumatic or adverse experiences and the development of eating disorders and other related psychiatric problems is the presence of posttraumatic stress disorder (PTSD) or its symptoms. PTSD is a serious mental health condition that can develop when someone has been exposed to one or more traumatic events. Eating Disorder Research has shown the following rates for Complex PTSD and Eating Disorders •Women with bulimia nervosa: 37-40 percent •Women with BED: 21-26 percent •Women with anorexia nervosa: 16 percent •Men with bulimia nervosa: 66 percent •Men with BED: 24 percent •Rates of PTSD are generally found to be higher in cases of eating disorders with symptoms of bingeing and purging, including the anorexia-binge/purge subtype.

Verywellmind.com Two Research Studies • The National Women’s Study and the National Comorbidity Survey Replication showed that individuals with bulimia nervosa, binge eating disorder or any binge eating have significant higher rates of PTSD. • the highest rates of lifetime PTSD were 38% and 44% respectively in the BN groups. • When partial or subclinical forms of PTSD are considered, then well over half of individuals with bulimic symptoms have PTSD or significant PTSD symptoms. This Photo by Unknown Author is licensed under CC BY-SA Post Traumatic Stress Disorder and Eating Disorders

• PTSD and eating disorders share similar characteristics. They both have high rates of dissociation. Eating disorder behaviors are a way to distance oneself from disturbing thoughts, emotions, or memories associated with PTSD. It’s possible to see the psychological symbolism of these behaviors in sufferers of eating disorders • Purging is seen as a way to get rid of something unwanted (emotion, memory, or symptom) • Bingeing is seen as a way to fill a void and to repress unwanted feelings, anxieties, memories, flashbacks by eating large enormous amounts of food. • Both binging and purging provide relief for the sufferer in either managing the symptoms of PTSD or as a coping mechanism in dealing with an unresolved (and possibly subconscious) trauma. “Binging, purging, and restricting can all numb feelings of guilt, shame, and depression. In essence, an eating disorder can be an anesthetic to soothe the pain of sexual abuse. I know this from personal experience, as I was raped in my late twenties. Already stuck in an eating disorder at the time, I began to binge and purge more frequently and in more violent ways—to cope with the emerging symptoms of posttraumatic stress disorder, PTSD. Bingeing and purging helped me to lessen those high-alert—or stuck- on—feelings of PTSD.”

Quote from an eating disorder blog, anonymous Eating Disorders as Defense Mechanisms for PTSD Anorexia - starvation produces an “intoxicating” high where there is a repression/denial of feelings through lack of nutrition. Bulimia - Eating large amounts of food to disassociate from the feelings and then engaging in behaviors that compensate for weight gain – this allows one to stay in a vicious binge-purge cycle as a distraction from life. Bingeing - Produces a “trance-like” state where all other realities fade into the background. Comorbidity between Eating Disorders and PTSD

• The comorbidity between PTSD and eating disorders is well established; the relationship appears to be largely related to a form of ‘self-medicating’ behavior. • People who have been through traumatic experiences often feel a sense of powerlessness, brought on to them by their inability to prevent the traumatic incident from happening or prevent themselves from being traumatized by it. • The act of consciously starving oneself in order to change one’s body shape is a method the victim uses to reassert control over their own body. How the Body Plays a Role in Eating Disorders and Sexual Trauma • One theory is that the trauma directly affects body image or sense of self and leads a person to attempt to modify their body shape to avoid future harm, i.e., gaining weight. • In sexual trauma, a victim feels sexualized/objectified. As a coping strategy to deal with trauma, a person begins to only identify as a sexual being, using eating disorders to mold one’s body. • Victims of sexual assault will feel responsible for one’s sexual assault based on victim blaming culture. A victim will then begin to punish her/his body through eating disorder means, i.e., becoming anorexic to look asexual.

This Photo by Unknown Author is licensed under CC BY Sexual Trauma Symptoms that will show up in the MD’s office

• Intrusive Thoughts • Depression • Flashbacks • Reporting of Nightmares • Sexually acting out reports • Reports of Obsessive-compulsive behaviors • Eating disorder symptomology • Hallucinations • Reports of Hypervigilance • Reporting trouble sleeping • Reports of trouble concentrating • Reports of isolating • Relationship problems Eating Disorder symptoms associated sexual trauma in the Dietician’s office • Reports of overeating/bingeing • Reports of under eating • Self loathing of body • Obsessions with food, weight • Negative self body image/self loathing • Rigid food rules, controlling thoughts of food • Fixations with certain parts of one’s body, ie., stomach, legs. • Possible disclosure of abuse because a patient sees a dietician as “safe.”

This Photo by Unknown Author is licensed under CC BY Features of sexual trauma in psychotherapy • Disclosure of abuse • Nightmares • Flashbacks • Guarded behavior • Report of depression • Denial of trauma/fear of reporting • Fear of intimacy • Report of an eating disorder • Depression • Sadness/isolation • Self - Blame

This Photo by Unknown Author is licensed under CC BY-NC-ND Treatment

• Individuals with an eating disorder complicated by trauma and PTSD require treatment for both conditions using a trauma-informed, integrated approach. If the trauma is not addressed during the treatment of an eating disorder, then it is likely that successful recovery will be thwarted. • Important factors contributing to the success of treatment can include positive reactions by family members and close friends to disclosure about traumatic events, as well as strong support from family and friends. • Although the best approach to address PTSD in the context of an eating disorder remains elusive, work so far has focused primarily on cognitive processing therapy (CPT) integrated with traditional treatment for the eating disorder. Role of the Eating Disorder Treatment Team in working with patients with eating disorders and sexual trauma.

• Medical Doctor - The role of the MD in working with patients with both eating disorders and sexual trauma is to assess and treat for PTSD symptoms, medication evaluation for assistance with PTSD symptoms, monitoring of vitals, laboratory tests and weight tracking, management of physical symptoms around the eating disorder: GI distress, cardiovascular issues,

• Dietician – The role of the dietician is to help with meal planning and strategies for food behavior regulation as the patient works through feelings of emotional distress and trauma responses. A dietician understands that a person who is struggling with an eating disorder and has sexual trauma has nutritional needs that are different then the rest of the general population.

• Psychotherapist - The role of the psychotherapist is to help the patient stabilize and process emotional trauma responses. To help the patient make connections between their eating disorder and suppressed trauma. Psychotherapy treatments for PTSD. Some of the leading evidence-based therapies for PTSD include:

•Cognitive Processing Therapy (CPT) teaches how to reframe your maladaptive beliefs about the trauma. •Prolonged Exposure Therapy (PE) teaches how to face feelings and involves talking about the trauma. •Trauma-Focused CBT (TF-CBT) is designed for children and adolescents, and teaches how to understand, process, and cope with trauma. EMDR • Eye Movement Desensitization and Reprocessing (EMDR) helps one to process and understand trauma while making guided eye movements. • Eye Movement Desensitization and Reprocessing (EMDR) is a psychotherapy treatment that was originally designed to alleviate the distress associated with traumatic memories (Shapiro, 1989a, 1989b). • EMDR therapy facilitates the accessing and processing of traumatic memories and other adverse life experience to bring these to an adaptive resolution. • During EMDR therapy the client attends to emotionally disturbing material in brief sequential doses while simultaneously focusing on an external stimulus Traditional Long-term Psychotherapy

• Traditional long-term psychotherapy is used to advocate the development of an active, affective, therapeutic relationship to create a safe, interactive environment. • This type of therapeutic relationship provides the context necessary for accessing, reworking, and integrating the traumatic material. • It becomes the foundation for treatment; acting as a bridge to facilitate the survivor's reconnection to self and offering a corrective interpersonal experience. • Providing, sustaining, and monitoring this type of therapeutic relationship is emotionally demanding and involves unusual challenges and responsibilities for the therapist. Resources Eating Disorder Resources • www.nationaleatingdisorders.org • anad.org • Center for Change Eating Disorder Treatment 888-224-8250 or 801-224-8255 • Avalon Hills Eating Disorder Specialists - 435-938-6060 Resources for Sexual Assault • Rape Recovery Center - Salt Lake City, Utah • Rainn 1-800-656-HOPE – National hotline for Sexual Assault References

• American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013. • Brown, H. (2015) Body of Truth. First Da Capo Press Edition. • Johnston, A (2000). Eating In the Light of the Moon: How Women Can Transform Their Relationships with Food Through Myths and Metaphors and Storytelling. Gurze Books. Carlsbad, California. • Tribole E., Resch E. Intuitive Eating. 4th Edition. St. Martins Griffin, New York, NY: Copyright: 2020. • Van Der Kolk, B. (2014) The Body Keeps the Score. Penguin Random House Publishing, New York, New York. • Muhlheim, L. (2019). Eating Disorders and PTSD. How they are treated when they co-occur. Verywellmind.com • Ross, C. (2017). Eating Disorders and Trauma. What You Need to Know to Get Better. Nationaleatingdisorders.org • Weinberg, R., Gould, D. (2011) Foundations of Sport and Exercise Psychology. 5th Ed. Human Kinetics Publishing. • Wolf, N. (1991) The Beauty Myth: How Images of Beauty are Used Against Women. William Morrow and Company Publishing • Woodman, M. (1982) Addiction to Perfection. The Still Unravished Bride. Inner City Books Toronto Canada.