March 2010
Treatment Considerations when addressing Eating Disorders, Sexual Assault and PTSD
Jacqueline A. Reilly MS, LMSW
The coexistence of Post Traumatic Stress Disorder (PTSD) and eating disorders for those who have suffered sexual violence requires a complex understanding of each category separately before a plan for recovery can be considered.
Post Traumatic Stress Disorder manefests psychologically and in mental functioning, including changes in brain activity as a reaction to witnessing or experiencing life threatening or horrific events. Rape is often a causal factor in the development of PTSD. The symptoms of PTSD involve re-living the horrific event via intrusive images, thoughts, dreams and actual sensation based re-experiencing of the event frequently referred to as flashbacks. It includes numbing out of the emotional pain surrounding the memories and often complicated avoidant behaviors designed to squash feelings and memories of the incident. A PTSD sufferer may also experience heightened arousal states in which they may become super vigilant triggered by the slightest reminder of the causal event. Sleep may be severely disturbed as the increased state of arousal and adrenalin response suppresses the capacity to settle down to sleep. Depression and chronic anxiety are normal responses to a traumatic event and may become persistent where PTSD is involved.
How does an eating disorder answer that tendency to seek maladaptive coping remedies for unresolved pain? Without treatment it is understandable that the sufferer might seek relief in maladaptive coping strategies. Eating disorders are a natural fit for many of the difficult symptoms listed above. The re-experiencing of trauma is terrifying for the patient and avoidance of difficult emotions is often sought at great cost to the patient’s normal functioning. Obsessions and pre-occupations associated with the eating disorder serve as an effective tool for repressing terrifying memories. It offers a sense of order and mastery in a world fraught with underlying fear and great emotional distress. Thought patterns associated with an eating disorder are frequently comprised of mundane repetition and monitoring of ones weight. People suffering with eating disorders habitually express terror over the idea of weight gain. So, while the eating disorder is active, doing its maladaptive job, anxiety might not be experienced as fear of rape but, rather, as fear of becoming fat – a much more acceptable inner preoccupation mirrored by societal norms regarding appearance. Chronic counting of calories replaces vigilance over one’s safety and the patient gains a modicum of control and illusion of emotional safety. Restricting can help the patient feel a sense of control in a chaotic emotional landscape. They are the boss in their eating disorder punishing their own bodies by withholding food in place of the perpetrator’s punishments relived in the sufferers terrifying memories and nighttime dreams. Binging and purging serves to numb emotions and becomes a part of the chronic routine of avoidance of intrusive thoughts. It can also serve as a punishment in the form of purging and in becoming sick from over eating relevant to an internalized sense that the victim deserved what happened to them. It is common that victims of rape blame themselves. When utterly helpless, guilt and self blame can offer a thread of agency where, conversely, to admit that there was utterly no agency or power is intolerable.
It is important to understand that the restriction, bingeing, purging and rigid eating included in the descriptions of eating disorders, comprises maladaptive coping mechanisms that in some way work for the patient. Most treatment strategies for PTSD and especially for victims of sexual violence requires a time of purposeful re-exposure to the trauma in vivo, which means that the exposure is in a safe therapeutic environment. Though this exposure is generally thought to be necessary for recovery it is also highly triggering for eating disorder behaviors. It is important that weight restoration and a degree of cessation of bingeing and purging behaviors be attended to before the deeper work on the trauma begins. Psycho-education is a very important piece in this work since it fosters a sense that the PTSD symptoms are normative in light of what the patient has gone through. It is in the very first stages of identifying the symptoms of the PTSD and the eating disorder as clinically expected given the circumstances, that the patient starts to turn self loathing into compassion and understanding that opens the path for recovery.