Recent studies are confirming the long-suggested association between post-traumatic stress disorder and eating disorders. High rates of PTSD among people with eating disorders — such as nearly two-thirds of men with bulimia nervosa who also had PTSD, according to one study — are no surprise to PTSD expert Rachel Yehuda, PhD, professor of psychiatry and neuroscience at Mount Sinai Medical Center and mental health patient care center director at the James J. Peters Veterans Affairs Medical Center in New York City.

"It completely makes sense to me that there would be trauma-related symptoms in people who have eating disorders," Yehuda said. "Eating disorders are, in some sense, about trying to control your environment. People who have been exposed to uncontrollable, traumatic events — such as being the victim of interpersonal violence or having an accident that could have resulted in physical injury or death — may wish to try to control their environments by restricting their own food intake."

Yehuda said PTSD occurs after exposure to an unanticipated and uncontrollable traumatic event. In attempting to cope with the uncontrollability of what they experienced, as well as their own helplessness, some engage in behaviors demonstrating the ability to control. An eating disorder might start as a coping mechanism, eventually taking on a life of its own and becoming a harmful problem.

"Controlling what you eat or don’t eat … doesn’t really mean your world will become controllable," she said. "So, eventually, restricting food intake does not do much to help symptoms that may occur following traumatization. The result is that trauma survivors with post-traumatic symptoms and eating disorders probably will get worse, and be harder to treat."

Yehuda said trauma-related symptoms and eating disorder symptoms will work off of each other. Recent studies drawing associations between the two conditions include researchers who reported in the July 2011 issue of Psychosomatic Medicine that anorexia nervosa and PTSD co-occur, with traumatic events tending to precede eating disorders.

In April 2012, researchers published a large study in the International Journal of Eating Disorders suggesting the vast majority of women and men with anorexia nervosa, bulimia nervosa and binge eating disorder reported a history of interpersonal trauma. Among the findings were that 40% of women and 66% of men with bulimia nervosa also had PTSD, wrote lead author Karen S. Mitchell, PhD, clinical research psychologist, National Center for PTSD, VA Boston Healthcare System.

What nurses can do
For nurses, helping these patients often means being aware of the association, asking questions, listening, watching and making needed referrals.

"I think healthcare providers … are often reluctant to ask patients about traumatic exposures," Yehuda said. "The reality is that healthcare providers should inquire sensitively and directly about traumatic exposures because they are relevant to almost any clinically treated patient. If somebody gives you a clear answer that they do not want to talk about something in the past, then you leave it at that and probably assume there is something there they don’t want to talk about. Most providers who ask about traumatic [events] find that patients are very grateful to have been asked."

Asking about or assessing patients for eating disorders isn’t easy because while anorexia nervosa might be physically evident, binging or purging might not, said Barbara Reynolds Caldwell, RN, PMHNP, CNS, a behavioral health nurse who provides care in nursing homes and assisted living facilities in New Jersey.

"A lot of patients are very guarded about their pasts, and they’re not going to tell you if they have an eating disorder," Caldwell said. "It’s important to recognize, at least initially, you’re not going to get that information, in most cases, from your patients. Over time, you build a relationship with them and can gradually get the information out."

When assessing patients for possible PTSD, Caldwell said nurses should look for signs, such as depression and anxiety.

"One key factor in PTSD is a startle reflex ... or more anxiety than one would expect in an ordinary situation," Caldwell said.

Observation is a powerful tool in assessing these patients, according to Tova Navarra, RN, BA, who has worked as a psychiatric charge nurse in a New Jersey geriatric/psychiatric facility. "A severe thunder and lightning storm during mealtime, for example, may cause a PTSD patient to become overly defensive, anxious, prone to outbursts, cursing, taking cover or even [becoming] aggressive," she said.

One of the most important things nurses can do to help these patients is provide referrals to appropriate mental health professionals.

"Even when you’re in a busy ED, it’s not letting somebody walk out the door without talking to them and really trying to assess the best you can and, then, providing a referral," Caldwell said.

Assessing the big picture
Researchers contend healthcare providers shouldn’t ignore the potential for the disorders to coexist, whether assessing or treating patients. In the 2011 study in Psychosomatic Medicine, the authors suggest the association between PTSD and anorexia nervosa underscores the importance of assessing trauma history and PTSD in people with the eating disorder.

Treatment should address both conditions, Yehuda said. In a review of the relationships among eating disorders, trauma and psychiatric disorders, such as PTSD, in the July-September 2007 edition of the journal Eating Disorders, Timothy D. Brewerton, MD, wrote: "The trauma and PTSD or its symptoms must be expressly and satisfactorily addressed in order to facilitate full recovery from the eating disorder and all associated comorbidity."

It also is important not to generalize or underestimate the complexities of these disorders.

"There is a lot of overlap in these disorders," Mitchell said. "But it’s not one-size-fits-all. Not everyone with an eating disorder has PTSD or vice versa."

Lisette Hilton is a freelance writer.