Eating Disorders & Complex PTSD : Key Challenges and Gaps

Dr. Amanda Fialk: Welcome everyone. Before we officially get started, Shivani Dutt, who is the Manager of Mission and Initiatives at NEDA, will share some more information about the important work NEDA is doing.

Shivani Dutt – NEDA: Thank you so much, Amanda. I appreciate it, and the NEDA team really values this partnership with The Dorm. I’m super excited for this presentation and appreciate the opportunity to have Dr. Dennis share this important information and expertise with everyone attending today.

So thank you all so much for joining here today. I would love to share information about the work that NEDA does and also some resources that I think would be incredibly helpful post‑webinar. To begin, NEDA is a nonprofit organization working to fundamentally change the way eating disorders are understood and treated and to empower those affected to achieve lasting well‑being and recovery. Our programming and services are centered around providing communities with education, early intervention, and we also fund groundbreaking research to help develop effective treatments.

It’s super important for us to equip you with resources that you can use after the session, not only for yourselves as professionals, but also the communities that you serve. So, the first resource I’d love to center is NEDA’s Grace Holland Cozine Resource Center, which is the nation’s leading resource hub for eating disorders.

We have a dedicated section for professionals where you can access guidelines as well as our videos, webinars and blogs to help learn more about eating disorders as well as the issues that may impact your treatment approach.

As part of the resource center, we also have information for individuals and loved ones. This is often the first step individuals take, so one of our primary resources is our online screening tool. The screening tool is an anonymous tool that is appropriate for ages 13 and above. It helps determine if someone is at risk for an eating disorder and connects them to next‑step resources such as treatment options as well as free, low‑cost support options as well. The tool is available both in English and Spanish.

We also have a treatment directory which consists of eating‑disorder specialists across the country. You can find professionals who provide services in person and online. We have enhanced filters to help locate providers based on unique needs such as treatment of co‑occurring conditions, levels of care, insurance and so much more.

And lastly, we recognize that support is such an important part of the recovery process. So we have toolkits, which are comprehensive guides that help parents, educators and coaches to better understand eating disorders and to know how to support someone that they care about. So I encourage you to scan the QR code to be connected to our website and I will pass it back to Amanda. Thank you again so much for the collaboration and for sharing this important information with the community.

Dr. Amanda Fialk: Thank you. Thank you, Shivani. Thanks so much.

My name is Amanda Falk. I use she/her pronouns and I am a partner and Chief Clinical Officer at The Dorm, which is both an IOP and PHP treatment community specifically for young adults, with locations in both New York City and in Washington, DC.

I’m really happy to be here today during National Eating Disorder Awareness Week, honoring NEDA’s theme of ‘Every BODY Belongs.’ This annual campaign educates and provides hope to everybody impacted by eating disorders, a mission we are proud of and which resonates deeply within our treatment community at The Dorm.

Since we first opened our doors, we’ve been committed to an integrated, multi‑diagnostic treatment approach because we know that mental health does not exist in a silo. That’s why every single client who enters treatment at The Dorm meets with one of our full‑time registered dietitian and health and wellness providers for an assessment, regardless of what their presenting diagnosis is at admissions.

When we’re able to understand the full picture of how multiple diagnoses are intertwined, such as eating disorders and trauma, we can gain a better understanding of the client and offer a better chance at lasting outcomes and long‑term recovery.

That’s why we’re grateful today to welcome Dr. Kim, Clinical Advisory Board member of NEDA, who will lead this exclusive workshop on co‑occurring eating disorders and complex PTSD.

Dr. Kim is a psychiatrist, eating‑disorder specialist and is board certified in addiction medicine. She completed her psychiatry residency training and served as chief resident at the University of Chicago Hospitals and is extensively published in the areas of eating disorders, trauma, and gender differences in psychopathology. She serves as a member of NEDA’s Clinical Advisory Council and is the co-founder, Chief Medical Officer, and CEO of SunCloud Health.

So with that, I will turn our presentation over to Dr. Kim.

Dr. Kim Dennis: Thank you so much, Amanda, and welcome, everyone. Let me get my presentation up and share my screen.

All right, I think we are good.

Okay, so I’m delighted to be here today, and delighted to be talking about such an important topic, trauma co‑occurring with eating disorders, particularly during Eating Disorders Awareness Week. As a member of NEDA’s Clinical Advisory Council, I’m also… I’m zooming in today from Northbrook, Illinois. The treatment center that I run, SunCloud Health, is in the greater Chicago area, and I’ll share a little bit of our research on this topic during the talk today.

Okay, so disclosures. In addition to my role with NEDA, I’m a member of the scientific advisory board for ANAD, also a board member for Sero Mental Health, and I think it’s always important to claim my own bias as a medically trained professional, privilege as a white person in America, thin‑bodied person in America, and my lived experience which includes long‑term recovery from an eating disorder, alcohol use disorder and trauma. All of that informs and has informed both my academic training and my clinical practice.

I’m going to review the eating‑disorder basics for those of you who are not eating‑disorder professionals, prevalence and effects of trauma, the diagnostic criteria in DSM and ICD for trauma‑related disorders, and then I’m going to talk a bit about the eating‑disorder/post‑traumatic stress disorder link and comorbidity, and an integrated eating‑disorder/trauma clinical care model. We know—one of the things that we know—is that eating disorders and co‑morbid traumas, co‑morbid other disorders, always, always, always do better with integrated treatment models. Peter Levine says, ‘Trauma is perhaps the most avoided, ignored, belittled, denied, misunderstood and untreated cause of human suffering.’ And I agree with him. It’s very, very common for trauma‑related disorders to go missed, minimized or undiagnosed in clinical settings.

Before we launch in, I think it’s important to distinguish co‑occurring—this isn’t really just a talk about co‑occurring eating disorders and PTSD. Co‑occurring means two disorders occurring in the same individual at the same time. What we actually see is multimorbidity, like the meerkat: these things come in mobs.

Dr. Dennis: Eating Disorder Basics. “There are five different main types of eating disorders listed in the DSM‑5 from most common to least common: Other Specified Feeding and Eating Disorder (OSFED), Binge‑eating disorder, Bulimia nervosa, Anorexia nervosa, And Avoidant/Restrictive Food Intake Disorder (ARFID).

About 9% of the U.S. population—or 30 million Americans—will have an eating disorder at some point in their life. These are potentially fatal illnesses…which I think is underrecognized by most people. Every 52 minutes one person dies as a direct consequence of their eating disorder in the U.S.

As I said before, OSFED is the most common with almost 40% of eating‑disorder cases being diagnosed as OFSED. The majority of patients with eating disorders also have a mood or anxiety disorder, up to 65%. About 50% will also have substance use disorders, thats a very common co-occurring illness. About 50% of patients seeking higher level of care for eating disorders will also have trauma or stressor‑related disorders.

Global eating‑disorder prevalence has actually increased from about 3.5% to about 7.8% in the last 20 years. We know thatLGBTQ patients experience greater incidence of eating disorders than heterosexual and cisgender counterparts. BIPOC patients are also more likely to engage in disordered eating behaviors and much less likely to actually have access to care. People with higher body weight have over double the risk of disordered eating and again are about only about half as likely to either be diagnosed with an eating disorder or receive eating disorder care. We know that less than 6% of people with an eating disorder are medically underweight.

And there’s a substantial body of evidence that supports the link between eating disorders and trauma. We know that trauma is more closely associated with binge‑type eating disorders, that trauma typically predates the development of the eating disorder. We also know that not everybody that experiences trauma will develop PTSD—so PTSD develops in a subset of people that have experienced trauma. We’ll talk a little bit more on what the risk factors are. In DSM there’s a specific subset of PTSD called the dissociative subset. We’re going to spend a little bit of time on what D-PTSD is. ICD‑11, the international classification of diseases also specifies a subset of PTSD called complex trauma or C-PTSD.

When we think about trauma, we understand that it results from an event or a series of events that are experienced by an individual as physically or emotionally harmful or threatening and it has lasting adverse effects on the individual’s functioning—physical, social, emotional or spiritual well-being. So it can impact people along the whole bio, social, spiritual continuum.

Traumatic events can range from discrete traumas—identifiable as often associated with explicit memories—examples would include rape, physical abuse, childhood sexual abuse, catastrophic injury, unexpected death of a relative or friend, medical trauma, witnessing traumas like domestic or other violence, racialized aggressions, gender‑based violence, war— chronic traumas are those traumas that result from recurring situations, it’s often times more difficult to pinpoint, identify—and treatment examples of this would be non‑empathetic inconsistent responses from primary caregivers, persistent criticism or verbal abuse, childhood neglect—often times childhood sexual abuse is chronic trauma especially when its perpetrated by the hand of a family member—being bullied or teased, vicarious trauma in first responders and healthcare workers, neighborhood violence, food insecurity, systemic racism would also be included in chronic traumas that tend to be more associated with more complex trauma symptoms like complex PTSD and dissociative‑subtype PTSD.

An individual’s experience of the events determines if it’s traumatic or not. It’s highly individualized and subjective. It has a lot to do with how the individual assigns meaning to the event and about themselves as a result of the event.

And it also matters how the individual is disrupted physically, psychologically, spiritually, socially. Many people deny or minimize their traumatic experiences and aren’t quite able to link their trauma with problems that they may be having in their life as an adult today. Oftentimes, clinicians will collude with this minimization and avoidance of trauma in clinical work, this isn’t always a conscious, or really ever, a conscious decision on part of the clinician, but oftentimes this is just sort of a subconscious or unconscious collusion with minimizing or denying or avoiding the impact of trauma, whatever is deemed primary for the visit.

Traumatic experience is wrought with confusion, shame, humiliation, betrayal, silencing. And the experience is also impacted by an individual’s cultural beliefs, the availability of social supports, and the developmental stage of the individual. And the effects of trauma really are impacted by a person’s gender, developmental stage, social supports and other resilience factors that are available to them at the time of the event. We know that the effects are multidimensional. When one of the effects is dissociation or dissociative amnesia, forgetting or loss of memory around the event, clinical history taking might not sufficiently assess for PTSD Adverse effects from the trauma can be immediate or delayed and commonly again the individual does not recognize the connection between traumatic event especially if its a delayed onset effect and the long term effects of the trauma.

Some of the common cognitions that we hear from patients who have experienced trauma include: ‘It’s my fault.’ ‘I don’t belong.’ ‘I’m unlovable.’ One that we hear a lot in the eating disorder field is ‘My body is disgusting’ or ‘I feel fat.’ ‘I can’t trust anyone.’ ‘No one can help me.’ ‘I’m broken.’ ‘I’m a burden.’ ‘Nothing will ever change.’

Many of these cognitions interfere with connection and trust in the therapeutic relationship. And can serve to perpetuate eating disorder and eating disorder cognitions. What we see in therapy is these cognitions playing out and that can look like missed appointments, dropout of treatment, what clinicians commonly refer to as attention seeking or splitting behaviors, chronic suicidal thoughts, high need for control. And we know that high need for control is integral to eating‑disorder pathology—it plays out with food, it plays out with body, it plays out with dieting, it plays out with starvation.

We know that one of the common effects of trauma, especially early developmental trauma is somatic preoccupation or preoccupation with physical symptoms and more comfort talking about physical symptoms than talking about emotional states and emotional symptoms.

Dissociation is a very common manifestation of early developmental traumas and dissociation because its the absence of being present is oftentimes harder for clinicians to attend to and recognize versus some of the other trauma related symptoms like nightmares, flashbacks, hypervigilance, which are symptoms that are parent symptoms that clinicians will often talk about and recognize. Patients with high trauma doses tend to have difficulty building trust in the therapeutic relationship and can have a hard time with secure attachment with a therapy team.

Here’s an example from a patient I’ve treated for almost 10 years now and she’s a person with an eating disorder and complex PTSD. And one of the things that she revealed to me recently was when I asked, ‘Can we talk about why you always think I’m mad at you?’ She said to my surprise, ‘Well, every time you email me, you put a period after my name so for example—“Hi, Sally.”—period instead of a comma with the body of my email. And I’m sure that means you’re mad at me, because otherwise you would put a comma.’

And in talking through that, I let her know that you know fast typing on a mobile device you can double click the space button and you get a period and it’s a lot quicker than putting a comma as a busy doctor. And that’s an example of something seemingly innocuous that, if you don’t have a trauma lens on, we would miss, right? So it’s important to be able to with a trauma‑informed lens ask questions like, Let’s talk about exactly why, ‘what’s your evidence that I’m mad at you?’ and start to disentangle some of these old cognitions about beliefs about how a caregiver is going to respond to a patient rooted in early developmental traumas.

Trauma is highly, highly prevalent. 60% of men and 50% of women experience at least one trauma in their lives. Women are much more likely to experience sexual trauma and childhood sexual abuse—about one in three women will experience a sexual assault in their lifetime which is a huge number. Men are more likely to experience accidents, physical assault, combat, disaster, or to witness death or injury.

And we talk about adverse childhood experiences (ACEs): the National Survey on Child Health which was conducted between 2017 to 2017 in the U.S. asked parents/caregivers about eight ACEs. And this is what the results were, as you can see from the graph, about a third of children, and it was a huge number of children, tens of thousands of children, a third of these children had experienced 2 or more ACEs. One of the things we know from research is that people with four or more ACEs are much more likely to have poor health outcomes as adults—that data also holds true for adolescence and children.

What you see in this graph, as a child reports an increasing number of ACEs, they are much more likely in the purple bar, with more than 4 ACEs to experience poor physical health, difficulty making friends, behavioral conduct problems, anxiety and depression. If you look at depression for example, 1.3% of kids that have zero ACEs had depression. When you look at kids with more than 4 or more ACEs almost 20% of those kids had depression.

ACEs also impact beyond psychiatric health or psychological health are physical health:so people with four or more ACEs have 40% more risk of pulmonary disease, a 240% greater risk of STDs, twice as likely to have cancer, heart disease, clinical obesity; seven times more likely to have alcohol use disorder; and 12 times more likely to have suicide attempts which is really really important to attend to as a clinician to keeping people alive and mitigating risk.

Specifically with regards to eating‑disorder risk and ACEs adolescents with four or more ACEs are about six times more likely to be in the high eating‑disorder risk group than kids who report no ACEs. And there’s an increased ED risk from emotional neglect, physical maltreatment, emotional maltreatment, and sexual maltreatment, with the highest odds ratio of eating disorder—almost 11—from sexual maltreatment.

Childhood sexual abuse (CSA) is probably one of the most well‑studied risk factors within trauma for eating disorders. And the prevalence of childhood sexual abuse in a national sample of about 34,000 adults, was 10%; ~24% of those were men, and 75% of those were women. Those with CSA were more likely to be Black or Native American, and more likely to have public insurance. Other forms of childhood abuse were also more prevalent among individuals with childhood sexual abuse. So again, re-victimization and mult-victimization is connected with childhood sexual abuse. And we know that also that persons with childhood sexual abuse had higher rates of having a parent with substance use disorder, witnessing domestic violence, and having an absent parent prior to age 18. Re-victimization is very common in those who have histories of childhood sexual abuse two to three times more likely to report rape as adults. Also more likely to have physical violence in marriage. Also more likely to have unwanted sexual advances from authority figures, and dissociation is thought to be a mediating factor of re-victimization.

So what are some of the risk factors for somebody who has experienced traumatic events to develop PTSD or post traumatic stress disorder? Gender, a much higher risk for females than males Pre-existing mental health problems.The type of event matters, so interpersonal traumas, particularly sexual traumas and rape have highest rates. Combat also has a very high rate of development into ptsd. The dose of trauma, how frequently somebody’s experienced it, the extent to which the event involves injury, dissociation during the event, additional life stressors, including low income BIPOC, LGBTQ populations have higher risk for PTSD after trauma, quality of available social support, and importantly parental PTSD because of genetics and also epigenetics or changes that happen in our genes as a result of trauma and then those changes are then passed on to offspring.

Prevalence of PTSD is about 6 to 8% in the general population. For people who are exposed to trauma, about 5.6% will develop PTSD. The highest rates occur in survivors again of rape, military combat, captivity, and genocide. US Latinx, American Indians and African Americans have higher rates of PTSD. Women are twice as likely to receive a PTSD diagnosis, and then elevated rates also occur for emergency responders, refugees and individuals with substance use disorders.

PTSD defines DSM-5 defines PTSD as a diagnosis that has to include the criteria laid out on this slide. So Criterion A is that the person directly or indirectly is exposed to an actual or threatened death, serious injury or violence, sexual violence. There are many people who say who criticize this criterion because it’s very limiting. And we see in our clinical practice people who may not meet this strict definition of a criterion S trauma who have all of the other PTSD symptoms and those symptoms demand treatment. So the other symptoms would include the intrusion symptoms re-experiencing dissociation, avoidance of trauma related thoughts, feelings or situations, changes in cognition and mood hyper arousal symptoms and that these clusters of symptoms last for at least a month produced significant impairment and are not related to other causes.

In 2020, the dissociative subtype of PTSD was added to DSM-5 and the person meets full PTSD criteria but also experiences high levels of depersonalization, which is a sense of floating, numbness, being out of one’s body, and derealization, feeling as if nothing is real, being very disconnected from surroundings, surrounding environment, surrounding people, and the dissociative symptoms are not related to substance use or other medical condition. The ICD11 added complex PTSD in 2022, so relatively recently DPTSD and CPTSD were added to our diagnostic manuals. And CPSD is defined by exposure to a stressor, typically those chronic traumas, prolonged in nature, from which escape is difficult or impossible. So childhood abuse, torture, the presence of all of the core symptoms of ptsd, plus disturbances in self organization or dso. And this would include emotion dysregulation, emotion dysregulation, negative self concept and relationship difficulties.This overlaps a lot with some of the diagnostic criteria for borderline personality disorder.

And oftentimes people with complex PTSD may be misdiagnosed as having bpd.

What do we know specifically about eating disorder and ptsd? We know that PTSD is very common in patients with eating disorders. Up to 50% of adults admitted to residential treatment for eating disorders, we’ll have PTSD versus 6 to 8% in the general population. So greatly increased risk of PTSD.

An abundance of data have confirmed the links between traumatic events and eating disorders, particularly for those with binge type eating disorders. It’s common for patients with eating disorders and PTSD to have earlier eating disorder onset, more complex course of illness, greater rates of dropout in treatment, and less favorable outcomes.

This risk of poor outcome is mitigated when we actually treat people who have the combination with integrated treatment models. Treating both illnesses at the same time with the same team, rather than treating the eating disorder first and waiting for eating disorder stabilization before you address the trauma. Because much like we see in the substance use world, many people aren’t going to make it to 90 days sober or 6 months sober or a year sober before we can work on their trauma, because the trauma is a causal and maintaining factor for the eating disorder. So if we don’t treat it.

Working on the eating disorder is going to be a lot harder. We know that childhood sexual abuse is a nonspecific risk factor for eating disorders. We know that even in restrictive eating disorders, Trauma is more prevalent than in the general population, and within anorexia, it’s more likely to co occur with binge purge type anorexia nervosa than restricting type anorexia nervosa. The ED trauma link extends to all developmental ages and includes all genders.

Most studies show that comorbid PTSD is associated with, again, increased eating disorder severity. And there’s a reason that these things come in a pack. Like the meerkat, they come together.

They’re a group, and that’s reflected in our brain biology. So this is a schematic of the impact of early life stress on our brain. And specifically are reward pathway as delineated as shown here, the ventral tegmental area, which goes to the nucleus accumbens, which is our reward center. But also goes to our prefrontal cortex, which is an area of our brain which we use to make decisions whether I’m going to eat or not eat. We also use it to inhibit actions. So I want to eat more, but I’m not going to. That area of the brain is disrupted biologically with high doses of early life stressors. They’re also connections with the cortical striatal pathway and this top down pathway is highly involved in habit formation. And if any of you have worked with patients who have eating disorders, the compulsive behaviors that go with eating, whether it’s compulsive dieting, compulsive starvation, compulsive overeating are very, very, very hard to break. And it’s in part because these are biologically rooted.

This slide is a slide borrowed from Dr. Tim Brereton, who brought really broad in in a big way, a light on the comorbidity of PTSD and eating disorders. And what you’ll see in this slide is two national samples, about 40 to 45% of people with bulimia nervosa. Have PTSD. About 25% of people with binge eating disorder have PTSD and those with non bulimia non binge eating disorder.

Types of eating disorders have anywhere from 8 to 10%, 8 to 13% PTSD, which is higher than the general population. Still.

When we look specifically at dissociative subtype PTSD and eating disorders. About 50% of patients with PTSD were found in one study to meet criteria for DPTSD, and there are very, very few studies looking at DP test D specifically in eating disorder samples. The one that did looked at showed that higher levels. Again, what we’ve seen in the other literature, higher levels of severe prior traumas, higher levels of PTSD symptoms, dissociative disorders and eating disorder severity.

CPTSD and ED is also understudied, but it’s thought to occur in about 25 to 50% of individuals with PTSD. It’s associated with more complex trauma histories, typically multiple traumatic events occurring and starting in childhood.

When individuals have both CPTSD and eating disorder, they tend to have early onset eating disorders and high trauma doses.

Multiple traumatic events or types have been associated in non eating disorder populations with greater severity and complexity as well.

In treatment seeking patients with eating disorders. CPTSD is commonly found, and those folks tend to have higher treatment. Dropout patients with comorbid trauma symptoms also have more anxiety, depression, and functional disability.

We know that when patients have the disorders of self organisal, self organization, so emotion, lability, difficulty in relationships, they tend to have higher eating disorder severity, worse time in treatment. Which makes sense when so much of our treatment rests on the capacity to engage in a therapeutic relationship. So there are many unique challenges that come with treating eating disorders and comorbid cptsd. And really foundational to it is the amount of work and attention and care that needs to go into building a safe, trusting treatment alliance. And time.

That’s something that takes time and certainly at the higher levels of care. Most of us are very pressed for time due to various pressures from patient willingness to be in a higher level of care insurance willingness to pay for an adequate amount of time at a higher level of care. This is a study that I’ll show quickly from our patients at some cloud health this is 635 patients admitted to a higher level of care for treatment of eating disorder, substance use disorder, ptsd, and or mood disorder. Highly comorbid group patients completed a series of self report assessments at admet and we looked at patients with and without eating disorders. So 231 had eating disorders in about 400 did not.

Patients with ED had significantly higher rates of types of traumatic events 8 vs 7 PTSD 70% vs 50% D-PTSD was almost double for people with eating disorders and C-PTSD 33% in the patients with eating disorders vs 19% in patients without. All of these patients with DPTSD or C-PTSD and eating disorders had significantly higher eating disorder symptom scores, major depression scores, substance use scores, anxiety scores, and worse quality of life. We also found that there was a huge overlap between C-PTSD and D-PTSD, with 25% of our patients with ED meeting criteria for both disorders.

All of these differences had large, a medium to large effect sizes. So what, you know, what I’m describing to you is, and highlighting to you is that everything gets worse when these things go together. And if we don’t attend to the trauma, which is sort of the hub of the wheel, Of all of these many different diagnoses and symptoms, we are doing the patient a great disservice.

So I want to shift a little bit into talking about how we develop treatment systems and treatment plans to actually do. Three key practices are realizing the prevalence of trauma, recognizing how trauma affects all individuals involved with the program, including the treatment providers. Everybody who’s here at this talk today.

Responding by putting this knowledge into practice. Integrating knowledge about trauma into policies, procedures and practices. Resist colluding with avoidance. I can’t say that one loudly enough and respond to experiences of re victimization therapeutically manage reenactments. The example that I gave with the patient that shared with me about the period instead of the comma, being able to have a conversation with a caregiver about, I think you’re mad at me. And here is why, in and of itself is a healing and corrective experience.

There are four pillars that are foundational to trauma informed care. Safety, structure, consistency and nurturance. One of the most trauma-informed things that I do on a daily basis is showing up when I say I’m going to show up. And being consistent in how I’m showing up.

I want to look at two systems, sort of traditional care model that oftentimes is sort of default applied in eating disorder, higher level of care particularly, and trauma informed systems. So instead of what’s wrong with you? What’s wrong with you? Why do you think I’m mad at you? A trauma informed question would be what happened to you? What happened to you and how you’re responding to me right here, right now, actually strength based and adapt. How was this adaptive for you at some point in your life when you were experiencing adverse situations?

Traditional therapy is a professional driven process. I’m going to tell you what the prescription is, I’m going to tell you what your meal plan is, and you have to do it versus shared expertise. You know, what are you actually feeling in your body? What have you tried before that’s been helpful for you, what’s been unhelpful for you? And how can we work together to develop something that’s going to be sustainable and useful for you?

Traditional models focus on symptom reduction and trauma Informed models focus on understanding symptoms and behavior and again, not understanding them as how is this part of your pathology? Or how is this part of why you fit into this DSM category? But how is this symptom or behavior adaptive at the time in your life or the times in your life when you were being traumatized. Including right now, if you’re still experiencing trauma.

Therapy in the traditional model is seen as primary healing approach and then trauma informed models. The primary healing approach is connection, healthy relationship. And I believe there’s, you know, in that therapeutic connection and that connection to something bigger than either individual, there is a lot of spirituality. And a lot of potential for healing.

Trauma specific treatment is characterized by persuasion and trust rather than coercion. So it doesn’t include if you don’t do this. I’m going to have to refer you to another treatment provider. It includes ideas rather than force and mutuality rather than authoritarian control and trauma Specific therapy is focused directly on the effects of trauma along the biopsychosocial spiritual domains.

Trauma focused cbt, emdr. There’s some evidence as well for ifs, Internal Family Systems and psychodrama. SSRI pharmacotherapy, Sertraline and paroxetine are FDA approved for ptsd. Many others are used off label and under investigation. Would include ketamine, mdma, psilocybin and transcranial magnetic stimulation.

The most important thing I think I would like clinicians to know is don’t delay PTSD care until the eating disorder is under better control or until the patient is completely weight restored or recovered from eating disorder behaviors. Because many, many people with comorbid ptsd, cptsd, dsptsd will not be able to get there without trauma specific treatments at the outset of treatment. The only reason to delay trauma specific treatment is if there are immediate safety concerns, suicidal ideation with plan and intent and immediate safety concerns, eating disorder symptoms impacting medical stability.

And this is what integrated treatment looks like. It’s not serial treatment or one after the other. For each of these three diagnoses you see on the slide, based on primariness of one of the diagnoses, which is usually a way of saying whatever the clinician has the most experience and expertise in. It’s not parallel treatment, which tends to be siloed. Different treatment providers focusing on different disorders, which can be a fragmenting sort of trauma reenacting experience for people with C-PTSD and D-PTSD, but it’s integrated, same team, same location, same time. So I’m going to end there. You will all have access to my slide deck. So if you missed anything in here, don’t worry, the references and the slides will be shared with you. To view at your leisure.

Dr. Amanda Fialk: Thank you. Thank you so much, Dr. Kim. We have a lot of activity in both the Q and A in the chat. There’s been lots coming in throughout the presentation, so I don’t think we’ll get to everything, But I’m going to try my best to consolidate and get to as much as possible. But that was, that was really wonderful. You made it really clear in your presentation about how important it is not to treat diagnoses in a siloed manner, to really provide integrated treatment, whether it’s for an eating disorder and trauma, or eating disorder, depression, whatever it may be. We need to treat the whole person. And then it’s really important to avoid colluding with this avoidance of trauma and of addressing the trauma. Why do you think that that does happen in treatment? I guess, like, what, what are some of the reasons for. And actually on, on the therapist part, like, we know why it’s hard for our clients to talk about trauma. Right. But why do you think that from on our standpoint, there’s that there can be the tendency to collude with the avoidance.

Dr. Dennis: That’s a great question, I think. And I’ll answer it in two ways. The organizational level. Where an eating disorder treatment center or where a trauma treatment center or where addiction treatment center happens, because it’s really hard to do integrated treatment. As a program. We treat trauma, we treat eating disorders, we treat substance, we treat mood disorders. We treat a person in whatever package they come to. That’s hard to do because you need to invest a lot of time into cross training and multidisciplinary treatment team meetings. That’s a lot harder to do. On a very practical level than to say we are eating disorder primary and we’re going to focus on your eating disorder. If you have other stuff, we might slap on a specialist for that or give you a group for that. So it’s hard. And at the individual therapist level, I would say the most common reason for avoiding, at the conscious level, what a therapist will say to you is, I don’t want to hurt the patient. I don’t want to make them worse. Which is colluding with the cognitive distortion that many of our patients have that if I talk about this, I’m going to get worse.If I talk about this. I might feel worse in the moment. Because all the things that have been stored in my body and stored in my soul are going to come to the forefront, and that’s going to hurt. Like cleaning out an abscess. There’s a window of distress tolerance that a therapist has to have. Another reason, on a subconscious or unconscious level, I think, is if a therapist has traumas that haven’t fully been worked. It may be hard for the therapist to hear or be open to hearing what the patient has experienced. It’s launching into the great unknown. Right, versus okay, if we talk about your eating disorder? I’ve been treating eating disorders for 20 years, and there’s a certain set of symptoms that most people with this diagnosis will have versus that there’s a lot more knowns and I can, like, fix that. Versus like sitting with somebody and bearing witness to unimaginable human suffering. Right. Who wants to sign up for that? I mean, all of us do. That’s why we’re here. But most people don’t.

Dr. Amanda Fialk: A related question that came in is what is the best way to approach talking about trauma with a client who has an eating disorder? If they don’t openly identify as experiencing trauma but you highly suspect that they have experienced a trauma.

Dr. Dennis: Another great question, because most, like the vast majority of people I’ve treated in my career, don’t come in saying, I’m here for trauma, right? And in fact, if you say, have you experienced any trauma in your life? They oftentimes, sometimes people with the highest trauma burden will say no, because when it’s early developmental trauma, it’s just like, well, the sky is blue. So I wouldn’t necessarily tell you that the sky is blue. It’s just. What it is. You know, if the sky was green, I would tell you. Right. So we have to find ways of asking about early experiences that the patient might not know. Were adverse. So asking, what was it like growing up? Who did you spend your time with? How did your, you know, how did your parent interact with you? How did your parents interact with each other? Were there times when you felt, you know, unsafe? So, you know, doing a careful and probing probing without it feeling like an interrogation, I think is a tricky dance. But probing. Out of curiosity. Deep, genuine curiosity. I am a compulsive question. Ask her. I want. I love details. So the more details you get about actually how. How your patient’s early developmental relationships played out, that will give you more and more clues about that.

Dr. Amanda Fialk: Yeah. It’s such a good point because it is true that if you ask just sort of the, the very blunt question, have you experienced trauma more often than not? The the answer will be no and through understanding what life in the home looked like, what friendships were like, what romantic relat- like, that’s where you start. To really uncover more, especially regards to…

Dr. Dennis: If people have kids or if there’s, like, a small child in their life that’s meaningful to them. You know, nieces, nephews, oftentimes I’ll say, was there anything that you experience that you wouldn’t want, you know, your kid to experience, you know? Or if we’re talking about something and they’re like, that’s not trauma. I would say. Well, would you want that for your kid? No, never. Why not? You know. So sometimes that’s an avenue as well.

Dr. Amanda Fialk: We also had a handful of questions that came in around sort of treatment options, treatment approaches for clients who experienced food being used as punishment in childhood and, and therefore was very much part of their trauma. You know? How. How are we looking at treatment in those types of situations?

Dr. Dennis: That’s very common. Very, very commonly, we see.

Dr. Amanda Fialk: Great. I recognize that there were a ton of questions that we did not get to, and obviously there’s a need to do future collaborations and events because some of the questions were very specific towards certain age groups or population. So we’ll definitely be brainstorming for future CES. Thank you so much. Dr. Kim, for your time, for your insights, and thank everybody for joining us today and for being such an important part of this conversation and for being so active with your, with your questions.