Strong Need for Eating Disorder Screening in Patients With PTSD

Pauline Anderson

April 18, 2023

Nick Powers

WASHINGTON, DC – Post-traumatic stress disorder (PTSD) is strongly linked to disordered eating, which in turn, impedes treatment for the anxiety disorder in new findings that underscore the need for better screening of eating disorder impairment (EDI).

"Eating-related and body-image concerns may be more prevalent than we think, and if not considered, these concerns can make psychotherapy treatment less effective," study author Nick Powers, a doctoral student in clinical psychology, La Salle University, Philadelphia, Pennsylvania, told Medscape Medical News.

The findings were presented here at the Anxiety and Depression Association of America (ADAA) Conference 2023.

Common Bedfellows

Although many patients with PTSD also have an eating disorder, they are not always properly assessed for eating pathology and related functional impairment.

Some therapists don't feel adequately equipped to target eating-related concerns in these patients and so may refer them to other providers. This, said Powers, can prolong symptoms and further distress patients.

Powers noted childhood physical or sexual abuse may affect eating patterns in patients with PTSD. "The evidence suggests these types of trauma exposure can be risk factors for the development of an eating disorder."

Undiagnosed eating pathology may exacerbate functional impairment from PTSD and weaken the impact of evidence-based treatment.

Such patients are challenging to treat as they may not have the requisite skills to fully engage in exposure therapy, an evidence-based approach to treat PTSD, said Powers.

To determine whether PTSD would be significantly linked to greater eating disorder impairment (EDI) compared with other anxiety-related diagnoses and whether this would impair treatment, investigators studied 748 patients with an anxiety disorder who were attending a cognitive behavioral therapy (CBT) clinic. Anxiety disorders included PTSD, obsessive-compulsive disorder (OCD), social anxiety, and panic disorder.

Participants completed the 16-item Clinical Impairment Assessment (CIA) questionnaire, which includes questions about eating habits and feelings about food, body shape, and weight over the previous 4 weeks. Participants also reported anxiety symptom severity at the beginning, during, and at the end of treatment.

Need for Better Screening

Results showed that compared to those with other anxiety disorders, patients with PTSD were three times more likely to have disordered eating (odds ratio [OR], 3.06; 95% CI, 1.47 - 6.37; P = .003).

In addition, higher baseline CIA scores predicted poorer PTSD treatment outcome (beta = –1.4; 95% CI, –1.67 to –1.10; P < .01).

"Having higher baseline CIA scores meant that patients' PTSD symptoms did not remit as strongly compared to those with lower scores," said Powers.

Patients with both PTSD and an eating disorder may have difficulty with regulating emotions and tolerating distress, said Powers.

"They may use binge eating, purging, or food restriction as strategies to regulate emotions. These behaviors may allow patients to become numb to or avoid heightened emotions that come from having PTSD and an eating disorder."

Prior research linked perfectionism tendencies to poorer response to PTSD treatment. Those with an eating disorder may share similar tendencies, said Powers.

"If someone is consistently thinking negatively about their eating or body to the point where it interrupts their functioning, they may not be as likely to fully engage with PTSD treatment," he said.

Ideally, clinicians would screen all patients with PTSD for an eating disorder, said Powers. "If screening instruments aren't feasible or available, even just inquiring about body image or history of maladaptive eating behaviors can be helpful."

He added this could open up a conversation about a traumatic event in the patient's past.

Confirmatory Research

Commenting for Medscape Medical News, Karen S. Mitchell, PhD, clinical research psychologist, National Center for PTSD, VA Boston Healthcare System, and associate professor in psychiatry, Boston University School of Medicine, Massachusetts, said she was "excited" to see this research.

"Very few studies have examined the impact of baseline eating disorder symptoms on PTSD treatment outcomes or vice versa," she said.

The study findings "add to the small but growing body of evidence suggesting that comorbid PTSD and eating disorder symptoms can impact recovery from each disorder," she said.

She noted the importance of assessing comorbidity in patients presenting for treatment and of addressing comorbidity in both eating disorders and PTSD treatment. "But we need more research on how best to do this."

Powers and Mitchell have reported no relevant financial relationships.

Anxiety and Depression Association of America (ADAA) Conference 2022. Abstract 59. Presented April 15, 2023.

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