traumatic experience and PTSD and eating disorders commonly co-occur , which can complicate recovery due to how the two psychiatric disorders can fuel one another .

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 In the words of Dr. Bessel van der Kolk:
“After trauma, the world is experienced with a
different nervous system. The survivor’s energy now
becomes focused on suppressing inner chaos, at
the expense of spontaneous involvement in their
lives.
 Traumatic Experience (TE) and Post-traumatic
stress disorder (PTSD) and eating disorders ِ Eds
commonly co-occur, which can complicate
recovery due to how the two psychiatric disorders
can fuel one another.

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 ‫جميعا‬ ‫سنموت‬
.
‫قريبا‬ ‫نموت‬ ‫ان‬ ‫نامل‬
‫لنتتهي‬
‫المعاناه‬
‫ثانيه‬ ‫فكل‬ ‫نعيشها‬ ‫التي‬
‫غزه‬ ‫جنوب‬ ‫من‬ ‫حدود‬ ‫بال‬ ‫أطباء‬ ‫من‬ ‫طبيب‬ ‫من‬ ‫رسال‬
–
‫العاصي‬ ‫يارا‬ ‫بقلم‬
 Post-traumatic stress disorder is a severe mental health
condition caused by witnessing or being involved in a
terrifying, dangerous, or life-threatening event.
 Sometimes it’s a singular event or traumatic experience
but when many traumatic events occur over long periods
of time it is known as complex trauma.
 Complex trauma often develops from ongoing trauma,
such as physical, emotional, or sexual abuse.

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- Risk factors for PTSD and Eating Disorders.
- PTSD and Eating Disorders statistics
- Trauma , complex trauma and Eating Disorders
- Symptoms of C- PTSD .
- How does PTSD affect eating behaviors
- PTSD-ED importance
-

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 In PTSD and an eating disorder, these two
diagnoses share common roots.
Risk factors that may lead to one or both disorders:
• A single or repeated traumatic event
• Sexual abuse
• Unstable family or support structure
• Family history of mental health disorders
• Poor coping skills
• Chronic stress
• An additional mental health diagnosis (such as anxiety
or depression)
• Substance use Disorder

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 At least 52% of people with an Eds have a history of
trauma, and just like PTSD and C-PTSD,
• Men with BN have a 66% higher rate of PTSD than the
general population
• Approximately 37 to 40% of people with BN experience
co-occurring PTSD
• In Women with restrictive anorexia 10% reported PTSD symptoms
are almost equal to the general population
• In Women binge-purge AN About 25% have PTSD.
• Approximately 26% of women with BED meet criteria for
PTSD
(Riikers C., et., al., 2023)

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 There’s a powerful link between eating
disorders and trauma-related concerns such
as posttraumatic stress disorder (PTSD).
 The National Comorbidity Survey-
Replication Study found that 80% of people
who struggled with behaviors such as
restricting their food intake or bingeing and
purging, also reported exposure to trauma
 In a study of more than 100 adult female
patients who have anorexia nervosa or
bulimia nervosa, 95% of the respondents
reported experiencing at least one traumatic
event at some point in their life
( Tagay, 2014, Breland, J et.,al., . (2018)..

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 The DSM-5 definition of trauma requires “actual or
threatened death, serious injury, or sexual violence.”
 OHA Trauma Policy (2015): Trauma is the unique
individual experience of an event or enduring
conditions in which a person’s ability to integrate
his/her emotional experience is overwhelmed.
 The person experiences, either objectively or
subjectively, a threat to his psychological safety, bodily
integrity, life or the safety of a caregiver or family
member.
 Three types of trauma:
– Acute - Resulting from a single incident
– Chronic - Trauma that is repeated or prolonged
– Complex - Multiple traumatic events

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The consequence of Traumatic experience
that can lead to complex trauma are as
follows:
• Repetitive and cumulative
• Persistent and long-lasting trauma
• It is often interpersonal, involving
abandonment exploitation, and other
forms of harm
• Inability to escape from danger and harm
• It frequently occurs in early childhood or
adolescence (but doesn’t necessarily have
to)

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These events are severe and may include:
• Chronic neglect
• Domestic abuse
• Sexual, physical, and emotional abuse
• Repeated sexual assault
• Incest
• Military events
• Human trafficking
• Parentification (parent–child role reversal)
• Genocide campaigns
• Living in war zones
• Concentration camps
• Childhood trauma

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• Night mares and terrifying dreams
• Flashbacks
• Inability to remember details of the
trauma
• Loss of interest in hobbies or activities
• Avoiding places, objects, or people
related to the trauma
• Avoiding feelings or thoughts related
to the terrifying event
• Problems sleeping
• Hypervigilance (constantly aware of
threats around you)
• Intense anger
• Feelings of worthlessness, shame
and guilt
• Problems controlling emotions
• Finding it hard to feel connected
with other people
• Relationship problems, like having
trouble keeping friends and partner

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Nervous System Dysregulation
A regulated NS is crucial for health:
 To ensures the adaption to the changes in
the environment and maintain homeostasis.
 To regulate body’s response to stressors,
sleep regulation, appetite and digestion,
mood management, attention & all our
bodily systems.
- Trauma and chronic stress will affect the NS
becomes dysregulated.
-.

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Central Nervous
system dysregulation
Autonomic Nervous
system dysregulation
Psychological
Morbidites

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 Extreme emotional
trauma and can
negatively impact the
nervous system and
lower a person’s
natural resiliency,
leaving them
vulnerable to physical
and mental problems

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 1.The brain continuously
scans for threats. Both real
and perceived. These
threats are processed via
the limbic system.
 2. A detected threat
activates the amygdala,
which stimulates the
hypothalamus to release
stress hormones, including
adrenalin and cortisol and
reduce oxytocin .

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 Normally, once a stress is
removed, adrenalin and
cortisol are removed from
the system
 With chronic stress, these
hormones are not removed
increasing risk for anxiety,
depression, heart disease,
sleep disruption, weight
instability, and poor
memory/concentration

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1- Stress Cortisol
 Cortisol tends to promote cravings
for highly palatable foods.
 Cortisol promotes central adiposity,
which is associated with insulin
resistance, increased risk of type 2
diabetes, cardiovascular disease and
breast cancers.
 Cortisol lowers levels of the
hormone leptin (that promotes
satiety) while increasing the hormone
ghrelin (that increases appetite).
 In AN, Hypercortisolemia, altered
secretion of adipokines and appetite-
regulating hormones, and low bone
mineral density

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2-Gutamatergic excitotoxicity
 Alteration glutamate function
by trauma facilitate PTSD and
eating disorder onset
 Excessive excitation via
glutamate contributes to
excitotoxicity, and over-
activation of the hypothalamic-
pituitary-adrenal axis
 Glutamatergic excitation have
impact on hippocampus ,
hypothalamus, and prefrontal
cortex, all of which are integral
to the regulation of stress and
eating.
 Glutamatergic modulation may
be a key treatment for
individuals suffering from
PTSD and Eds

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1. Abnormal reward seeking behavior:
Thrill-seeking behaviors.
 People who grow up in chaos have significant NS
dysregulation and reward learning deficit in the neural
circuity
 PTSD clients with nervous system dysregulation may not
know “how” to feel unless they are engaging in intense
experiences that constantly push their physical, emotional,
or mental faculties to their limits.
 Many who find themselves stuck in a trauma response
commonly report feeling stuck in their head where thrill-
seeking can offer a momentary relief from this pattern.
Clients get a rush from the effects of workaholism,
restriction , purging where it taps into their need for a thrill.
All theses behavoioral patterns become their “go-to” thrill.

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2. Auto-immune disorders and diseases
 Adverse childhood experiences (ACEs),
which involve traumatic events that occur in
children and teens
 Increase the risk of developing PTSD and
eating disorders
 Adverse childhood experiences may
include:
• Witnessing violence
• Experiencing emotional, sexual, or physical
abuse
• Experiencing neglect
• Having a loved one die by suicide
• Living with family members who have
psychiatric conditions or substance use
disorders.

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Adverse childhood
experiences (ACEs
 The body’s stress response can
disrupt brain development . This
can lead to underdeveloped neural
connections in the parts of the
brain required for successful
learning and appropriate behavior
in school and the workplace.
 When a child’s brain experiences
chronic stress , it releases a stress
hormone that shrinks the
hippocampus, where stress is
managed and memories and
emotions are processed

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3. Hypervigilance
 Hypervigilance is a common
outcome of nervous system
dysregulation.
 With hypervigilance, a person is
constantly on edge, always
anticipate the worst, and can be
easily triggered into an angry, or
violent state.
 Many who have experienced
significant trauma in childhood
become adults who unconsciously
find themselves in relationships
that re-trigger their trauma and
perpetuate a sense of nervous
system dysregulation and
hypervigilance
 Eds is a maladaptive behavior to
escape from traumatic memories

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PTSD and eating disorders is a form of
‘self-medicating’ behavior.
 Reassert Control : PTSD clients feel a
sense of powerlessness, and inability to
prevent the traumatic incident from happening
therefore , starvation and or purging are an
attempt to change one’s body shape is a
method the victim uses to reassert control
over his body.
 Sense of relief : Engaging in starvation and
purging , the victim feels a sense of relief from
feelings of mental anguish similar from using
drugs or alcohol.
 Lurching from one behavior to another, as
addictions like gambling , substance use,
various eating disorders, and self-harm.
 Anesthetizing feelings: Bingeing and
purging anaesthetizing the traumatic
feelings return, so one binges and purges
the bulimic cycle begins.

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 Researchers suggest that trauma
contribute to the development of EDs
behaviors,
 others have ascertained that it's the
symptoms of PTSD, as opposed to
the actual trauma, that causes eating
disorder development and maintains
Eds symptoms.
 As such, specific symptoms of each
disorder interact with each other to
maintain and worsen both conditions.
 Taylor in 2023 , determined three
different pathways between eating
disorder symptoms and PTSD

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• Irritability and binge eating: Irritability is a common
symptom of PTSD that can lead to BED as a means of
regulating upsetting emotions and specifically, irritability.
• Trauma reminders and desire for thinness Trauma
reminders, as nightmares or terrifying memories, can
trigger preoccupation with thinness or an “ideal” body
type
• concentration problems and Body dissatisfaction :
Issues with concentration and memory, which are
symptoms of PTSD, are connected to body and shape
dissatisfaction
.
 Ultimately, the development and maintenance of both of
these psychiatric disorders are complex and multi-
faceted
(Taylor & Francis., 2023.)

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 PTSD-ED refers to people that meet the diagnostic criteria
for both PTSD and one or more EDs.
 PTSD-ED patients tend to have:
-Earlier onset of ED behaviors
-More severe ED symptoms
-Likely to drop out of treatment
-If they do complete treatment, they are more likely
to relapse after discharge
Even if patients do not meet the full criteria for PTSD,
previous trauma is a risk factor for developing EDs and
worsens ED symptoms and treatment outlook
 it is clear that we need to address the trauma in order to
successfully treat the ED.
(Perlman MM. et., al., 2023)

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Prof. Heba Essawy MD.,Psychiatry.
Certified eating Disorders Specialist
International Association of Eds profetionlas
Iaedp s – USA
Head of Eds clinics
Okasha Institute of Psychiatry
Medical school , Ain Shams
University Hospital , Egypt
essawi_h@yahoo.com
www.hebaessawy.com