Trauma and Eating Disorders

Many people with eating disorders experienced serious abuse and neglect while growing up. When people with eating disorders and serious trauma-based disorders, including dissociative identity disorder, post-traumatic stress disorder (PTSD, sometimes misrepresented as post stress traumatic disorder) and borderline personality disorder, come to a hospital or residential treatment center, they may have problems with anorexia, bulimia, over-eating, or a combination of all three.  They may avoid certain foods that remind them of past trauma, and they may be triggered or experience flashbacks because of smells, textures, or other qualities of food.  Mealtimes may have been traumatic in and of themselves in childhood, with fighting, anger, verbal abuse, or intoxication characterizing many meals. There may have been highly unhealthy family rules, beliefs and behaviors concerning food and body image.

People who come for eating disorder treatment rarely have only eating disorders.  Often, in the present or the past, there have been many other self-destructive and addictive behaviors.  Usually, trauma-based disorders including depression, anxiety disorders, dissociative identity disorder, post-traumatic stress disorder (PTSD, post stress traumatic disorder), borderline personality disorder and other mental health problems are also present.  Inpatient treatment may not focus on the eating disorder if more pressing problems require attention.  For instance, active suicidal ideation or a current abusive relationship may be higher priorities in the inpatient setting.

No matter how much trauma there was in childhood, or in adulthood, and no matter how many other mental health problems and addictions accompany the eating disorder, the eating disorder always serves the same basic function.  Like all addictions and self-destructive behaviors, eating disorders are avoidance strategies.  They help focus attention off of problems, conflicts, life situations and intolerable feelings, and they provide an illusion of power and control.

While Rome burns, everything seems OK because today’s food intake was under seven hundred calories.

To a considerable extent, treatment is not really driven by diagnosis.  We take the diagnosis into account, but most of the goals and tasks of therapy are not determined by diagnosis.  If a person has an alcohol problem, we will certainly recommend an AA program, and alcohol will be a topic of conversation.  If a person is clinically depressed, an antidepressant will almost always be prescribed.  But most of the work of recovery is the same, no matter the combination of addictions and trauma-based diagnoses, which may include dissociative identity disorder, post-traumatic stress disorder (PTSD, post stress traumatic disorder) and borderline personality disorder and other trauma-based disorders.

Why is this so?  The answer is quite simple.  Treatment is not about the avoidance strategy.  It is about what is being avoided.  One person may use alcohol to avoid grief and loneliness.  Another may act out sexually, while a third person gambles and a fourth is a rage-aholic.  Although these people have different diagnoses, they share the same underlying problem.  This logic applies to eating disorders as well.

Of course, if a person’s weight is so low, or her electrolytes so out of balance, that life is threatened, therapy has to wait until the medical danger has passed.  We are not equipped to handle such situations at Del Amo because they require intensive medical care and monitoring.  But if a person is medically stable, then the work of recovery can begin, or start again.

It would make no sense to never mention food in the treatment of an eating disorder.  Similarly body weight is always a topic of conversation.  The goal, however, is to move the focus off of food and body image onto the underlying problems.  These are not “psychiatric” problems as such – rather, they are common human, life problems.  I am talking about sadness, loss, grief, emptiness, lack of direction, unhappy or abusive relationships, and psychological trauma, contributing to trauma-based disorders, including dissociative identity disorder, post-traumatic stress disorder (PTSD, post stress traumatic disorder) and borderline personality disorder.  All of these are part of the human condition.   People who come for treatment have experienced much more trauma, loss and grief than the average person, but they are not in a separate category from everyone else as a result.  They have common human problems to an uncommon degree.

It is the coping strategy that is the psychiatric disorder.  In therapy, the goal is to understand the function of the unhealthy behaviors, then to build more flexible, healthy coping strategies.  This is done through a mix of educational, cognitive and experiential strategies.  The purpose of the experiential treatment is two-fold: desensitization and skill building.  In a structured, one-step-at-a-time manner, one learns to tolerate the intolerable, and learns new skills for dealing with feelings and conflict.  When these tasks have been accomplished, the need for the old, unhealthy behaviors associated with dissociative identity disorder, post-traumatic stress disorder (PTSD, post stress traumatic disorder), borderline personality disorder and other trauma-based disorders melts away.

There is one other principle that is relevant for eating disorders: “just say no to drugs.”  We classify all unhealthy, addictive avoidance strategies as “drugs.”  In order to get better, you have to make a serious commitment to recovery.  This means a serious commitment to tolerating feelings and conflicts which are intense and painful.  It is long, hard work but it can be done.

As therapists we ignore eating disorders and we also focus on them.  We do this to the same degree that we simultaneously ignore and focus on all other symptoms, coping strategies and addictions.  If you focus too much on the defense, you miss the real problem.  If you focus too much on the underlying problem, you never learn how to substitute more healthy defenses.  It is all a matter of balance.  There is no simple formula that applies to everyone because everyone is different.  But the general principles are the same, as are the basic tasks and goals.

I hope this clarifies the approach to eating disorders within when the person has also experienced severe psychological trauma, inclusive of trauma-based disorders such as dissociative identity disorder, post-traumatic stress disorder (PTSD, post stress traumatic disorder), borderline personality disorder.

Ross, C.A. (2006). Overestimates of the genetic contribution to eating disorders. Ethical Human Psychology and Psychiatry, 8, 123-131.

Ross, C.A. (2009).  Psychodynamics of eating disorder behavior in sexual abuse survivors.  American Journal of Psychotherapy, 63, 211-226.

Ross, C.A., & Halpern, N. (2009).  Trauma Model Therapy: A Treatment Approach for Trauma, Dissociation and Complex Comorbidity.  Richardson, TX: Manitou Communications.

Sexual Addictive Behavior: Is It Real?

Sexual addictive behavior, sexual compulsive behavior, sexual dependent behavior and hypersexuality are all terms referring to pathological sexual acting-out with associated denial of negative consequences and /or loss of control of such behavior.  Note it is not the type of behavior, its object, its frequency, or its social acceptability that determines whether a pattern of sexual behavior qualifies as sexual addiction; rather it is how this behavior pattern relates to and affects an individual’s life negatively.

Most “sex addicts” act-out against their own ethics and principles.  Like most addictions, it continues to escalate to where many ultimately suffer legal consequences.  Hence, some addicts do commit sexual offending behavior, but all sex offenders are not addicts.  More common negative consequences are massive losses of time, loss of career and marriage, loss of integrity with associated profound shame, and strong feelings of isolation and loneliness.  Ultimately, many become deeply depressed and suicidal, feeling there is nowhere to turn for help.

For the past ten years, as Medical Director of the Del Amo Hospital Sexual Addiction Recovery Program, I have had the privilege to work with hundreds of men and women caught in this devastating behavior.

Because the sex addict becomes increasingly attached to fantasy, relationships in the real world become less important and often ignored.  The most common sexual addictive behavior today is cybersex, with many addicts losing their jobs viewing pornography on the job or performing poorly due to the vast hours spent compulsively on home computer pornography.  Many professionals have been caught up in the intensity of the “web” which can provide unlimited anonymous, accessible, and affordable pornography of any type.

Sexual addiction was dropped from the DSM-IV apparently because it was felt that no solid research supported its existence.  In March of this year, a major symposium at Vanderbilt University sponsored by the American Foundation of Addiction Research, began the task of designing a diagnostic and interview instrument to be used over the next three years to substantiate this diagnosis for consideration in the DSM-V.  The name for the diagnosis is yet to be determined, but it will not be sexual addiction because the term itself has too much controversy.

Meanwhile, we must prepare to treat these people as they present to us.  Currently, the addiction model seems to work the best in providing guidelines and support for ongoing recovery.  There are four different 12 Step Recovery Meetings for sex addiction: SA (Sexaholics Anonymous), SAA (Sex Addicts Anonymous), SLAA (Sex and Love Addicts Anonymous) and SCA (Sexual Compulsives Anonymous). There are also two 12 Step Meetings for partners of sex addicts who are often the most devastated when they find their trusted partner has been living a secret life: S-Anon family Groups (S-ANON) and Codependents of Sex Addicts (COSA).  Individual therapy along with 12 Step meetings can be very helpful, especially in working through past abuse, especially sexual, which is very high in sex addicts. SSRIs, although not a silver bullet, can improve mood, allow more access to feelings and in some cases reduce sexual drive.  However, it is important to be cautious as excessive masturbation can increase on SSRIs because of the increased orgasmic threshold side effect.  As the therapist, you can be of immense support in not shaming or trivializing the behavior, but promoting re-connection to self and others who really care, establishing integrity and self-esteem, and cognitive restructuring.  Patients are profoundly grateful when they learn to trust again and reclaim their lives.