As a relatively new and still poorly recognized concept, few people come to therapy identifying as suffering from Complex Post Traumatic Stress Disorder (C-PTSD). As a rule, a diagnosis of C-PTSD comes only after the process of self-discovery in therapy has begun. When people suffering from C-PTSD are referred to a therapist, or decide to seek help for themselves, it is usually because they are seeking help for one of its symptoms, including dissociative episodes, problems forming relationships, and alcohol or substance abuse. One of the more common issues that leads to the discovery of C-PTSD is the presence of an eating disorder, including anorexia, bulimia, and binge eating. In this article, I will explore some of the reasons why C-PTSD often manifests itself in the form of an eating disorder and what this means for successful therapy.
The impact of trauma on body-image and the victim’s relationship to food
As I have discussed in previous articles, C-PTSD is similar to the better known and more thoroughly studied diagnosis of Post Traumatic Stress Disorder, but — as the the name suggests — is more ‘complex’. This complexity refers both to its origin and its effects. C-PTSD is the result, not of a small number of dramatic events, but rather a prolonged series of abusive events, which take place as part of a asymmetric relationship, often during childhood at the hands of a parent or stepparent. People suffering from C-PTSD show many of the the same symptoms as victims of PTSD, but on top of this, they suffer from deeper, more complex symptoms including prolonged anxiety and depression, often associated with personality disorders and especially bipolar disorder. Perhaps the most characteristic signs of complex PTSD are having a negative self-image and an inability to cope with strong feelings of anger or sadness (known as ‘affect regulation’).
The correlation (or ‘comorbidity’) between PTSD and eating disorders is well established. As with alcohol and substance abuse, the relationship between PTSD and eating disorders 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 or engaging in purging in order to change one’s body shape is a method the victim uses to reassert control over his/her or own body. In addition, while engaging in these extreme forms of behavior, the victim feels a sense of relief from feelings of mental anguish not dissimilar to that which results from using drugs or alcohol. Perhaps not surprisingly, survivors of traumatic events often lurch from one form of self-medicating behavior to another, including lifestyle addictions like gambling or sex, substance use, various eating disorders, and even self-harm.
With C-PTSD, the danger of falling into eating disorders is even greater. As mentioned above, people suffering from C-PTSD typically have difficulty with ‘affect regulation’, or managing strong emotions. Life for a sufferer from C-PTSD is an emotional rollercoaster with frequent and often unpredictable triggers sending him or her into extremes of anger or sadness. The urge to self-medicate is, therefore, very strong, and often uninhibited by the sort of ‘common sense’ instinct to hold back that most people develop over the course of a more healthy and secure upbringing. Another risk factor is that, as I discussed in a previous article, people with C-PTSD almost always have difficulties forming relationships as a result of having suffered prolonged abuse at the hands of a caregiver. As a rule, people who are not in fulfilling relationships are more likely to fall victim to self-destructive behaviors, both because they lack the support and mutual assistance of a committed partner and also because the pain of loneliness itself drives them to seek self-medication. Finally, the sexual abusive nature of many C-PTSD cases is also a further risk factor for eating disorders. It is well documented that victims of rape and other forms of sexual abuse are more likely to develop eating disorders, though the exact reasons for this are not clear.
In summary, people suffering from C-PTSD are at a high risk of developing eating disorders for the same reason that people with PTSD are with added intensifying factors caused by the additional features of Complex PTSD. In a crucial respect, however, C-PTSD is very different. When a person with PTSD seeks therapy for an eating disorder or other issue, it usually becomes clear very quickly that they have PTSD. Even if someone is not familiar with the concept of PTSD, they will usually be aware that their problems either started or worsened after an identified traumatic event. Often they will have vivid memories of this event which they struggle to escape from, and even when their memory of the event is partial or obscured, they are almost always aware of the event having happened. By contrast, C-PTSD is frequently characterized by absences of memory. Indeed, one way of understanding C-PTSD is an elaborate and self-destructive strategy by the brain to force out memories that are too painful to bear. People starting therapy will often have forgotten entire chunks of their childhood and be highly resistant to the idea that their problems are related to childhood trauma. Unfortunately, it is frequently the case that people suffering from C-PTSD move from therapy for one symptom or syndrome to another before any link is suggested to his or her childhood.
Therapists who are meeting a new client with eating disorders should therefore be on the lookout for signs of C-PTSD. Since, those suffering from C-PTSD will not typically report, or even be aware of traumatic memories, more is needed than a superficial conversation about their childhood. As well being alert to traumatic memories, therapists should be alert to the absence of memories, or an unexplained reluctance on the part of the person in therapy to discuss his or her childhood. Of course, this goes against the grain of the general trend in psychotherapy in recent decades, which has been towards focusing on the ‘here and now’ and eschewing explorations of the past in favor of brief, solution-focused therapy. In many ways the discovery of C-PTSD necessitates a rethink and modification of the way we do therapy today; this is just one of them.
- Tagay, S., Schlottbohm, E., Reyes-Rodriguez, M. L., Repic, N., & Senf, W. (2014). Eating Disorders, Trauma, PTSD and Psychosocial Resources. Eating Disorders, 22(1), 33–49. http://doi.org/10.1080/10640266.2014.857517
- Backholm, K., Isomaa, R., & Birgegård, A. (2013). The prevalence and impact of trauma history in eating disorder patients. European Journal of Psychotraumatology, 4, 10.3402/ejpt.v4i0.22482. http://doi.org/10.3402/ejpt.v4i0.22482
- Mason, S. M., Flint, A. J., Roberts, A. L., Agnew-Blais, J., Koenen, K. C., & Rich-Edwards, J. W. (2014). Posttraumatic stress disorder symptoms and food addiction in women, by timing and type of trauma exposure. JAMA Psychiatry, 71(11), 1271–1278. http://doi.org/10.1001/jamapsychiatry.2014.1208
- McCauley, J. L., Killeen, T., Gros, D. F., Brady, K. T., & Back, S. E. (2012). Posttraumatic Stress Disorder and Co-Occurring Substance Use Disorders: Advances in Assessment and Treatment. Clinical Psychology : A Publication of the Division of Clinical Psychology of the American Psychological Association, 19(3), 10.1111/cpsp.12006. http://doi.org/10.1111/cpsp.12006
- Ford, J. D., & Courtois, C. A. (2014). Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation, 1, 9.
- Sar, V. (2011). Developmental trauma, complex PTSD, and the current proposal of DSM-5. European Journal of Psychotraumatology, 2, 10.3402/ejpt.v2i0.5622. http://doi.org/10.3402/ejpt.v2i0.5622