The relationship between trauma and eating disorders is complex and varies from person to person and trauma to trauma, but research clearly shows that the two have a strong connection. For many, disordered eating behaviors can develop as a way to cope with the emotions or memories following a traumatic event. And although this link isn't always immediately apparent—to patients, families, or even some healthcare providers—learning to recognize and understand it is crucial for effective treatment and lasting recovery from both.

If you or a loved one are struggling with an eating disorder and trauma, read on to get a better grasp on why these two often co-occur, what types of treatment are most effective, and steps to take to get the help and support you deserve.

What is trauma?

According to the American Psychological Association, trauma is any disturbing experience that results in significant fear, helplessness, dissociation, confusion, or other disruptive feelings intense enough to have a long-lasting negative effect on a person’s attitudes, behavior, and other aspects of functioning.

Trauma can be acute, such as the loss of a loved one or a car accident, or chronic, such as physical abuse or living in a war. Trauma is also very individualized: what is traumatic to one person may not be to another person.

What is PTSD?

You've likely heard of PTSD, which stands for posttraumatic stress disorder. Trauma is a core component of PTSD, but not everyone who experiences trauma develops PTSD. “Trauma is an event—we can call it a PTE or 'potentially traumatic event,'” says licensed clinical psychologist Zoe Ross-Nash, PsyD. PTSD, on the other hand, is a mental health condition triggered by a PTE. Trauma is discrete and contained, whereas PTSD continues indefinitely, until it is properly treated. PTSD involves:

• Intrusions: Recurrent, distressing memories, dreams, and flashbacks related to the PTE
• Avoidance: Trying to avoid any reminders of the PTE or thinking or talking about what happened
• Negative changes in mood or cognition: Having negative thoughts about oneself or the world, becoming less interested in activities once enjoyed, detaching from others, feeling emotionally numb, or experiencing memory problems related to the PTE
• Emotional arousal: Irritability, angry outbursts, reckless behaviors, trouble sleeping and concentrating, or being easily startled

“What makes someone more predisposed to develop a pathology like PTSD after a PTE depends on risk factors and resiliency factors,” Ross-Nash explains. For example, prior history of a mental health disorder, previously going through stressful events, and neuroticism increase the risk of PTSD. On the other hand, believing that you can cope with what happened and having social support appear to protect against PTSD.

Prevalence of co-occurring trauma and eating disorders

Many people living with trauma also develop eating disorders, although the exact numbers vary from study to study, and the connection is more common in certain types of eating disorders than others.

Overall, it’s estimated that about 25 percent of people diagnosed with an eating disorder also have posttraumatic stress disorder. Drilling down to specific eating disorders diagnoses, according to a review published in the Journal of Eating Disorders in 2022 that included over 200 studies, PTSD affects:

• 32 to 66 percent of people with bulimia
• 24 to 32 percent of people with binge eating disorder (BED)
• 16 to 22 percent of people with anorexia

Does trauma increase the risk of developing an eating disorder?

In short, yes: trauma can increase the risk of developing an eating disorder. It's estimated that between 18 and 80 percent of patients seeking eating disorder treatment have been exposed to trauma (which is, admittedly, a huge range—but it suggests there is a definite relationship there).

Ross-Nash explains that trauma impacts disordered eating behaviors in a lot of different ways, which we unpack below.

Why does trauma increase the risk of an eating disorder?

There’s not one simple reason that trauma increases the risk of an eating disorder. Rather, several factors appear to connect the two. Note that all of these factors are a two-way street: the eating disorder reinforces avoiding the trauma, and the PTSD reinforces the use of the eating disorder behaviors as coping mechanisms. This self-reinforcing nature makes treatment a challenge, and underscores the need to work with experts who are trained in addressing both conditions.

Emotion dysregulation: Disordered eating behaviors may be a way of managing the emotional dysregulation that can occur after a traumatic event. "Neurologically, we see that trauma can impact areas of our brain, particularly the amygdala, which impacts emotion regulation. And then we also see people with eating disorders using food as a way to regulate their emotions,” Ross-Nash explains.

Control: From a psychological perspective, eating disorder behaviors may give individuals a greater sense of control, Ross-Nash says. “Their body and what they put into their body offers a lot of agency and autonomy and power. This can feel really good after a traumatic experience, where something happened that's so outside of their control,” she explains. The controlling behaviors related to the eating disorder can feel protective and safe.

This may be especially true with sexual or body-based trauma. “A lot of times, there is this belief afterward that, 'If my body was different—if it was smaller, or less feminine or masculine or what have you—then this wouldn't have happened. So let me change my body to make sure I won't be at risk of this happening to me again,'” says Equip Therapist Carol Brown, LCSW. This belief can be even more pronounced if a person was told by their perpetrator that the traumatic event was their fault.

Dissociation: People who experience trauma often dissociate to cope, using different strategies to separate from their body, thoughts, or memories. For some, eating disorder behaviors are a way to numb, soothe, or silence difficult emotions.

On the other hand, Ross-Nash explains, some people with trauma may use disordered behaviors to achieve the opposite effect: “signs of pain from fullness, hunger, or purging, could act as a way to decrease dissociation—it brings an experience back into the body,” she says. “It's a really complex situation.”

Self-punishment: “The eating disorder can echo trauma because there is secrecy and punishment,” Ross-Nash says. “The thinking is, 'I am bad if I eat this cookie, and I deserve to be punished. If I was bad, I deserved the trauma.'”

In other cases, the disordered behavior may be someone's way of punishing themselves for the trauma, Brown adds. This may be because someone told them the trauma was their fault, or because that is how their brain pieced together what happened to them and why.

Hypothalamic-pituitary-adrenal (HPA) axis dysregulation: The HPA axis regulates the body's response to stress. Trauma and particularly PTSD cause the HPA axis to become overactive, and people with anorexia nervosa also appear to have hyperactive HPA axes.

Family dynamics: Any type of child abuse is associated with all types of eating disorders. “People who grew up in a dysfunctional family environment, who were never taught coping skills to manage trauma, are more likely to develop an eating disorder pathology,” Ross-Nash says. These skills were not disseminated from their caregivers.” In the absence of healthier coping strategies, disordered behaviors can seem like the best option for navigating the distress of trauma.

Treatment for co-occurring trauma and eating disorders

If you or a loved one are dealing with co-occurring trauma and an eating disorder, it’s important to recognize that it’s not your fault—and that while treatment may be more complex, recovery is possible. Working with a provider who offers trauma-informed care and understands eating disorders can make all the difference. “No one chooses this, and it makes sense that you've responded in this way,” says Brown. “There is a path forward for you to recover from your eating disorder and also be able to cope with the trauma so you feel safe.”

In an ideal scenario, when a patient has an eating disorder with co-occurring trauma, the therapist is able to treat both conditions at once, Brown says. However, this is a delicate dance.

To start, the eating disorder is a coping skill (though a maladaptive one) to help people who have experienced trauma feel safe. “If you take that away, what are they left with?” Brown says. Without alternative coping strategies, individuals may experience a resurgence of trauma symptoms—like flashbacks, nightmares, and intrusive memories—alongside the already challenging aspects of eating disorder recovery, such as the fear of weight gain.

At the same time, if you try to process the trauma before treating the eating disorder, you run the risk of a person turning to eating disorder behaviors—such as restricting, bingeing, and purging—to manage the difficult emotions the trauma brings up. For patients who need weight restoration or renourishment, this can be a significant setback.

It’s also important to acknowledge the physical impact: when you have an eating disorder, your physical body isn't properly nourished. Among other health impacts, this causes nervous system dysfunction. This can intensify the hyperarousal, anxiety, and dissociation a patient already feels due to their trauma, Brown explains, making trauma processing even more difficult.

Because of all of this, trauma treatment often starts with learning coping skills so the patient can manage treatment approaches (like a trauma narrative or exposure therapy) without resorting to eating disorder behaviors or experiencing a trauma response. “We want to create a window of tolerance for them to be able to manage the symptoms,” Brown says. “It's a balancing act to find what works for each person.”

Treatment for patients with eating disorders and trauma can take time, and needs to be highly individualized. Be patient with yourself or your loved one, trust the process, and if anything doesn't feel right, talk to your therapist or support team.

Types of treatment

Research shows that multiple therapeutic approaches can effectively address both eating disorders and trauma. Cognitive behavioral therapy (CBT), psychodynamic therapy, compassion-focused therapy, and integrative treatments have all shown significant improvements in both eating disorder and PTSD symptoms. Importantly, no single approach appears superior to the others.

The key, Brown says, is seeking trauma-informed care that is individualized to what a patient is experiencing. Rather than asking, “What's wrong with the patient?”, this treatment approach asks “What happened to them?” This shift recognizes that eating disorder behaviors serve a purpose and makes space to understand that function before working to develop healthier coping strategies.

Trauma-informed care is also important because certain aspects of eating disorder treatment could potentially be particularly hard for those with trauma. Consider the challenge of bathroom monitoring for someone whose trauma involved bodily violation, or nighttime room checks for someone with a history of nighttime assault. Trauma-informed providers understand these potential triggers and work with patients to make any difficult elements of treatment more manageable, and process any distressing feelings that arise because of them.

Accommodations when treating co-occurring trauma and eating disorders

When a patient has both an eating disorder and trauma, providers may need to make some accommodations to standard treatment protocols. “Clear expectations, communication, and consistency can help keep anxiety and unpredictability down,” Brown says. “This is key because that's what can re-traumatize folks.”

She recommends these key principles of trauma-informed care:

• Safety: Ensuring the patient feels physically and emotionally secure during sessions.
• Clear expectations: The therapist should go over agendas in treatment so the patient has an understanding of what treatment will look like. Regular check-ins to see how the patient is feeling also help.
• Consistency: Many providers see their patients at the same time on the same day each week. Along with clear expectations, this helps foster trustworthiness in the therapist.
• Collaboration and choice: When possible, the therapist works together with the patient or lets them make decisions. For example, if they need lab work done, the therapist asks which of two locations the patient prefers. This helps empower the patient.
• Cultural awareness: If applicable, the therapist acknowledges and helps the patient work through how someone's cultural, historical, and gender contexts shape their experience of the trauma.

Lastly, therapy should only proceed if the patient is safe. If they are medically unstable or have suicidal ideation, they need hospitalization.

Preventing dropouts and relapse

Patients with co-occurring eating disorders and PTSD are more likely to drop out of treatment and relapse after, according to research. This may be due to unresolved trauma symptoms that lead them to turn to eating disorder behaviors to cope. Or it may happen when trauma processing begins too soon, destabilizing the eating disorder recovery.

“It's important for therapists to meet the client where they're at,” Ross-Nash says. “This helps decrease the shame and helps with the guilt of the pathology.” As an example, she shares that she worked with one patient who was scared to talk about her trauma, because people didn't believe her in the past. In this instance, Ross-Nash emphasized that sharing was entirely the patient's choice. “That changes the experience,” Ross-Nash explains. “They get to have a choice, they get to decide, and they make the rules.” Over time, the patient was more honest and able to stay in treatment longer.

What to do if you or a loved one are struggling with trauma and disordered eating

If you believe you or a loved one are battling both trauma and an eating disorder, it's crucial to seek help. In an ideal world, you'd find someone who is both a certified eating disorders specialist (CEDS)—or at least has experience treating patients with eating disorders—and who also is trauma-informed. An expert trained in both areas can provide treatment that feels safe and validates your experiences, while using evidence-based approaches that address how trauma and eating behaviors often reinforce each other.

If you cannot find one expert, consider working with two therapists, one who specializes in trauma and one who specializes in eating disorders, and having them coordinate care. It’s also important to work with other specialists, like a registered dietitian and medical provider, who can address the eating disorder from a multidisciplinary perspective. At Equip, each patient works with a dedicated care team of eating disorder experts, including therapists who can provide trauma-informed care that is individualized to each patient’s needs.

Also consider building a support team, whether that's family members, friends, or peer support groups. Having other people you can talk to, especially on hard days, helps you feel less alone—and both eating disorders and trauma can be incredibly isolating.

Whatever you do, be patient and don't give up. “A lot of individuals who have experienced trauma feel they're not worthy to be taken care of, they're not worthy of support, and they're not worthy of recovery,” Ross-Nash says. “But you are worth it. Freedom is on the other side of recovery. Nobody deserves a life to be shackled by something as debilitating as an eating disorder.”