Abstract
Despite high rates of comorbidity between posttraumatic stress disorder (PTSD) and disordered eating, there is little in the way of empirical research or practice guidelines to inform the treatment of these frequently co-occurring disorders. Clinicians who provide treatment for this patient population must navigate complicated decisions about whether these problems are best treated concurrently or sequentially, and which treatment approaches and modalities are most appropriate for the patient. The current clinical case describes the treatment of a female soldier who was admitted to a 25-day, trauma-focused inpatient program 3 months after she experienced military sexual trauma. Although treatment initially targeted her PTSD symptoms, she later disclosed her ongoing struggles with disordered eating, which raised complex questions about the most effective treatment approach. This case study illustrates the intricate link between PTSD and disordered eating, and highlights important clinical considerations relevant to the assessment and treatment of these commonly comorbid disorders.
Keywords
1 Theoretical and Research Basis for Treatment
Disordered eating behavior is commonly reported in the aftermath of trauma. Recent estimates of civilian women indicate that one in six patients with a diagnosis of posttraumatic stress disorder (PTSD) carry a comorbid eating disorder (ED) diagnosis (Becker, DeViva, & Zayfert, 2004). Comorbidity rates between PTSD and ED vary depending on trauma type, with sexual trauma survivors being at particularly high risk for disordered eating (Wonderlich et al., 2001), especially purging-type disorders (Brewerton, 2005, 2006; Wonderlich, Brewerton, Zeljko, & Dansky, 1997). A study on the association of trauma and EDs found that in a sample of women with an ED diagnosis, 59% had at least one trauma in their lifetime, and 13% qualified for a diagnosis of PTSD, with sexually traumatized patients showing more severe posttraumatic symptoms (Tagay, Schlegl, & Senf, 2010).
Military servicewomen may be especially vulnerable to co-occurring PTSD and ED given the high rates of PTSD among survivors of military sexual trauma (MST; 51%; Kimerling et al., 2010) and prevalence of eating-disordered behaviors (72%; McNulty, 2001) within this population. Limited support for this tenet was found in a single study of treatment-seeking women veterans whose histories of MST predicted that they were twice as likely to engage in binging and purging behaviors as those without MST (Rowe, Gradus, Pineles, Batten, & Davison, 2009). Within the Veterans Health Administration (VHA), treatment for MST is available at all major medical centers, but there are few treatment programs designed to provide specialty care for women veterans with the comorbidity of PTSD and ED. The purpose of the present study is to highlight the clinical presentation and treatment of a female soldier with co-occurring PTSD and ED, thereby extending the treatment literature related to these comorbidities and the treatment literature related to military servicewomen in general.
Treatment for PTSD and ED
Despite the frequency with which these clinical problems co-occur, there are no published guidelines on the treatment of comorbid PTSD and ED. Given that the symptoms of these disorders interact in a cyclical fashion, perpetuating and maintaining the symptoms of one another, it is widely speculated that treating one disorder, without considering the impact of the other, would likely prove ineffective (Ackard & Brewerton, 2010; Levitt, 2007). Trauma survivors with PTSD and comorbid ED often present with a complicated symptom presentation, and a clear understanding of the function served by these symptoms and how the two disorders interact to sustain each other is essential for good clinical outcomes (Brewerton, 2007). Indeed, some disordered eating behaviors may serve as (maladaptive) coping mechanisms that “help” the patient to manage trauma-related symptoms. For example, restrictive eating may be an attempt to repair, via weight loss, self-esteem that has been damaged by a traumatic event. Conversely, individuals with PTSD may attempt to self-soothe with overconsumption of food, which leads to dopamine release in brain regions that mediate pleasure and emotion, and may subsequently attempt to counteract excessive eating through purging (Brewerton, 2011). Bulimic symptoms have also been conceptualized as efforts to avoid or distract from trauma-related memories and cues, and may serve to decrease hyperarousal associated with PTSD (Brewerton, 2007).
In addition to the general lack of guidance on the treatment of comorbid PTSD and ED, there is no single recommended treatment sequence for PTSD and ED. When a patient presents with comorbid PTSD and ED, there are several sequence options, including (a) separate and sequential treatment of the two disorders, (b) treatment of one disorder while closely monitoring the other, and (c) simultaneous treatment of both disorders (Zayfert & Becker, 2007). Due to the paucity of treatment studies on patients with PTSD and ED (Brewerton, 2008), the research literature does not provide compelling support for one of these options over the other. Although there is evidence that successful treatment of PTSD can result in concurrent improvements to comorbid disorders such as depression (Resick et al., 2008), no study has examined the impact of PTSD treatment on ED severity. Clinically, however, there is some support for initiating trauma treatment as soon as the patient is stable, taking in sufficient calories, and purging no more than several times a week (Scholom, 2009). It is similarly unclear to what extent PTSD symptoms may change over the course of ED treatment. To select an appropriate treatment approach and treatment sequence, clinicians should also consider the relative severity of each disorder to determine whether one plays a more central role in contributing to the patient’s psychopathology (Zayfert & Becker, 2007). For example, if eating-disordered symptoms are sufficiently severe to warrant immediate hospitalization for nutritional rehabilitation, trauma-focused treatment would likely be a secondary goal.
With respect to treatment approach, cognitive-behavioral therapy (CBT) is considered a first-line treatment for PTSD and ED. Although EDs are characterized by behavioral symptoms, they are, like PTSD, considered a primarily cognitive disorder (Fairburn, 2008). Treatments that aim to teach patients skills to challenge and restructure cognitive distortions may target a shared vulnerability, thereby leading to reductions in symptoms of both disorders. In addition, cognitive-behavioral–based treatments targeting emotion regulation, such as dialectical behavior therapy (DBT), are believed to address symptoms common to both PTSD and ED, including impulsivity and affect dysregulation (Brewerton, 2007). Given CBT’s universal application to both disorders, ED experts recommend using CBT as the central component of treatment, adding additional interventions targeting specific skills and symptoms to this foundation (Brewerton, 2007). Residential treatment programs that incorporate trauma-focused CBT with treatments that aim to increase emotion regulation, social skills, and adaptive coping skills have shown success in treating PTSD. However, the effectiveness of such treatment approaches among patients with comorbid PTSD and ED remains underexamined.
Current Case
The current clinical case describes the treatment of Angela, a female soldier who was admitted to a 25-day, trauma-focused inpatient program approximately 3 months after she experienced MST. Standard to the admission screening process, her health status and health behaviors were assessed. Angela acknowledged that she had lost substantial weight shortly after the MST but reported that she had regained most of the weight and that she was no longer struggling with disordered eating. However, shortly after admission, Angela’s continued struggles with disordered eating were identified and became an important focus of treatment. The purpose of this case study is to illustrate the intricate link between PTSD and ED with respect to both development and treatment, and to propose possible avenues for navigating the inherent challenges associated with treating comorbid PTSD and ED.
2 Case Introduction
Angela is a 28-year-old, married, active duty soldier. She was born and raised in Africa and moved to the United States to attend college, ultimately enlisting in the U.S. Army. After completing basic training in the United States, she was transferred to Europe or her first military assignment. During this deployment, Angela was raped by a male coworker who was also a U.S. soldier. The perpetrator came to her room in the middle of the night smelling strongly of alcohol and violently, sexually assaulted her. She did not report the attack to authorities, but her assault came to the knowledge of her military superiors when she was hospitalized 2 months later due to malnourishment, anxiety, suicidality, and depressive symptoms. The admitting physician noticed that Angela was wearing several unnecessary layers of clothing and, recognizing that this behavior is common among sexual assault survivors, inquired about MST. In response, Angela disclosed that she had been raped. After 3 weeks of inpatient treatment in Europe, she was referred to an acute women’s specialty inpatient treatment program at a large Veterans Affairs (VA) Medical Center in the United States.
3 Presenting Complaints
Angela began to experience severe trauma-related symptoms immediately after the MST. She attended to her military duties, but with notable impairment in performance. Because the MST went unreported, she had continuous contact with the perpetrator and lived in fear that he would repeat the offense. Behavioral changes included showering up to 5 times a day, avoiding sitting on or sleeping in her bed (where the rape took place), and significant social isolation with psychomotor retardation (e.g., sitting in a chair in her room for hours doing nothing). She dedicated hours to cleaning her room but believed that she could still smell alcohol despite the continuous cleaning. In addition, she described significant periods of depressed mood, low energy, and disrupted sleep.
Within a week of the assault, Angela’s mother-in-law died, and she flew to Africa for the funeral. She had anticipated that she would improve being around her family, but instead, she realized that she was a “different person.” She isolated from her family, had little interest in being around others, and reported feeling detached and depressed. On returning to her base in Europe, Angela’s morbid ideations worsened. Although she denied purposeful suicide attempts, she reportedly drove her car mindlessly in hopes that someone would hit and kill her. She also described an incident in which she walked out of the Post Exchange (i.e., military retail store) with an item without paying. When she was confronted by military police, she asked if his gun was loaded, and in that moment, she felt so despairing that she fantasized and hoped that he might kill her.
In addition, Angela described substantial difficulties with eating following the traumatic experience. Ingesting even small quantities of food caused her to feel nauseous and she began spontaneously vomiting after meals. She had no history of purging behaviors, either willfully (e.g., gagging herself, using medications) or otherwise prior to the MST. The thought of eating caused her such distress that she avoided eating altogether and lost approximately 20 pounds in the month following the assault. Given the severity of her depression and significant weight loss, Angela was hospitalized for acute psychiatric care where she began a trial of antidepressants and nutritional support. Unfortunately, the perpetrator had access to the hospital where she was admitted, and, consequently, she continued to struggle with anxiety about a repeat offense.
Following inpatient care in Europe, Angela returned to her home in the United States for nearly 3 weeks as she waited on admission into a VA women’s inpatient program. She left her house only to attend weekly church services with her husband, purposefully arriving late and leaving early to avoid the crowds. She felt fearful even when at home and cleaned the house for several hours each day, reporting that she felt better after cleaning. While at home, Angela was quick to anger with her husband, and when he attempted to be physically intimate with her, she became so enraged that she destroyed their wedding photos.
At the time of admission to the VA Women’s Inpatient Specialty Environment of Recovery (WISER) program, she reported some improvement in the severity of symptoms as well as compliance with her psychiatric medications. Specifically, she denied suicidal or morbid ideations and denied continued difficulties related to eating. She also reported feeling calmer and less angry but stated that she still found it hard to relate to others.
4 History
Angela was born and raised by her biological parents in Africa. She immigrated to the United States at the age of 19 on an academic scholarship to a public university with the goal of attaining a degree in pharmacy. She completed 3.5 years of college before contracting an infection that required surgery; she subsequently lost her scholarship due to the medical leave required for this operation. Angela joined the military in her late 20s in hopes of earning military educational credit, as she had goals of returning to school to become a doctor.
Angela is married to her husband of 7 years who also emigrated from Africa, and the couple has no children. Her husband was unable to accompany her on her deployment to Europe due to work-related obligations in the United States. She had permitted her inpatient care team in Europe to disclose the nature of the assault to her husband, although she had not spoken with him about the assault and was unsure what details he might know. She described a close relationship with her husband and requested that he be regularly updated on her VA care.
Aside from the MST, Angela denied any history of traumatic events. Excluding her recent inpatient stay in Europe, she further denied a history of mental health difficulties and had no previous mental health treatment.
5 Assessment
On admission to the WISER unit, Angela completed a mental health evaluation that included a battery of clinician-administered and self-report measures designed to assess the frequency and severity of her clinical symptoms and functioning in a variety of psychosocial domains. Her PTSD symptoms were assessed with the Clinician-Administered PTSD Scale (CAPS; Blake et al., 1995) and the PTSD Checklist–Military Version (PCL-M; Weathers, Litz, Herman, Huska, & Keane, 1993). On the CAPS, Angela endorsed four of five reexperiencing symptoms (denied flashbacks), six of seven avoidance symptoms (denied difficulty remembering important aspects of the trauma), and five of five hyperarousal symptoms. Her self-report of PTSD symptoms on the PCL-M was consistent with her CAPS results, and scores on both measures (CAPS = 99; PCL-M = 61) supported a diagnosis of PTSD secondary to MST.
Angela also completed the Posttraumatic Cognitions Inventory (PTCI; Foa, Ehlers, Clark, Tolin, & Orsillo, 1999), a measure that assesses the intensity of negative, trauma-related beliefs. The PTCI has three scales: Self, Self-Blame, and World. The Self scale assessed Angela’s negative beliefs about herself and her symptoms, the Self-Blame scale assessed the degree to which Angela attributed the trauma to something that she did or did not do, and the World scale assessed her lack of trust in others and her beliefs that the world is unsafe. Angela endorsed negative beliefs in each of these domains, and she rated the following as her most intense beliefs: “I used to be a happy person, but now I am always miserable,” “I can’t deal with even the slightest upset,” and “People can’t be trusted.”
Given her report of food avoidance immediately after the trauma, we assessed Angela’s current eating behaviors. She indicated that, since returning to the states, she was eating at least one meal and snacks throughout the day and was not spontaneously purging after eating. She had also regained approximately 10 pounds since her inpatient admission in Europe. As part of the standard intake procedures, a registered dietician met with Angela to assess dietary needs and to develop a nutritional rehabilitation plan.
6 Case Conceptualization
As a standard of care in the WISER program, the clinical treatment team holds a diagnostic and treatment planning case conference shortly following admission. We conceptualized Angela’s symptoms from a cognitive-behavioral perspective. Given that Angela had a well-adjusted childhood and no previous trauma history, her developmental experiences allowed her to develop generally positive, yet appropriately balanced beliefs about herself, others, and the world. These core beliefs were disrupted by her MST, and as a result, she constructed new beliefs centered on the notions that the world is dangerous and other people cannot be trusted. These negative beliefs about safety and trust chronically elevated Angela’s levels of fear and anxiety, contributing to arousal symptoms such as sleep difficulty and hyperawareness of her surroundings. With respect to Angela’s self-view, her history of success in her educational endeavors and military career promoted her conceptualization of herself as efficacious and a capable woman. She found it extremely frustrating that she had not yet been similarly successful at “moving on” from the MST or forgiving the perpetrator, despite her great desire to do so.
She experienced daily intrusive thoughts about the sexual assault, and she reported that trauma-related cues and triggers activated upsetting thoughts about the trauma. Angela attempted to reduce distressing memories and feelings through distraction (e.g., cleaning for hours at a time) and limiting contact with triggers (e.g., rarely leaving her home, infrequent interactions with others). As a result, her reexperiencing symptoms were reinforced and perpetuated by her avoidance. That is, Angela experienced short-term relief from her reexperiencing symptoms through her avoidant behaviors, but in the long-term, these behaviors maintained Angela’s PTSD symptoms by preventing her from emotionally processing her trauma.
By her report, Angela conceptualized her difficulties as a consequence of her own actions (which she perceived caused the MST), and she could easily identify numerous self-blame related cognitions (e.g., “I should have resisted him more,” “I should not have opened the door when he knocked,” “I must have given him the impression that I wanted this”). She also believed that her trauma-related symptoms and difficulty coping with her trauma served as evidence that she was “weak.” Angela viewed her newfound mental health problems as a reflection of some deficit within herself, and her stated treatment goal, which was to “manage my anxiety and depression,” did not specifically mention the trauma or her PTSD symptoms.
Based on the patient’s history and information gathered during her intake assessment, the treatment team concurred that Angela met full criteria for PTSD, and as this was her only psychiatric diagnosis, the focal point of her treatment would be on evidence-based, behavioral interventions and medications for the treatment of PTSD and trauma-related symptoms.
The following treatment goals were set: (a) reduce or eliminate most of the active symptoms of PTSD and (b) stabilize or increase affect tolerance well enough to be released to outpatient care.
Treatment also included continued medication management. At the time of admission to the program, she was taking mirtazapine (30 mg) in the evening. This medication was continued at that dose throughout her stay to target symptoms related to depression and anxiety. As Angela was interested in weight normalization, she was aware and accepting of the potential for mirtazapine to increase appetite and to cause weight gain. Other psychotropic medications included ambien as a sleep aid.
Thus, in many ways, Angela’s case conceptualization was initially rather straightforward, and both her symptoms and the underlying beliefs driving these symptoms were typical of PTSD. Given her relatively uncomplicated clinical presentation and her many strengths (including intelligence, a strong desire to cooperate with providers, and a supportive husband), she appeared to be a strong candidate for therapeutic success.
7 Course of Treatment and Assessment of Progress
Angela received treatment as part of a 25-day inpatient program along with a cohort of seven other current or former servicewomen. Her multidisciplinary treatment team consisted of a staff psychologist, staff psychiatrist, physician assistant, social worker, 24-hr nursing staff, occupational therapist, and various medical residents and psychology trainees who functioned under the supervision of licensed providers. The WISER program includes a structured daily schedule for patients between the hours of 6 a.m. to 9 p.m. Angela attended 5 to 7 hours of varying group- and individual-treatment sessions each day.
Core trauma-focused treatment components included group cognitive processing therapy (CPT), an evidence-based treatment for PTSD, which was modified for administration in a residential setting (90 min, daily), and individual exposure-based therapy (60 min, twice weekly). CPT applies cognitive-behavioral techniques to challenge maladaptive beliefs (i.e., stuck points) that interfere with recovery, with the goal of helping patients arrive at balanced beliefs about their traumatic experiences. Although the CPT protocol does ask patients to write about one of their traumatic events, exposure is not believed to be the primary therapeutic mechanism for CPT (Resick et al., 2008).
In addition to Angela’s participation in group CPT, Angela received concurrent exposure-based treatment in an individual format. Although individual exposure therapy is not offered to all WISER patients, the treatment team selected to initiate exposure-based treatment for Angela to target her strong reactivity to trauma-related cues. The primary technique used in her individual exposure therapy was imaginal exposure, which consists of repeatedly describing the details of the patient’s most distressing traumatic event (Foa, Hembree, & Rothbaum, 2007). Patients are instructed to narrate the event using the present tense with eyes closed. Imaginal exposure exercises were conducted during treatment sessions, and Angela was instructed to listen to a recording of the imaginal exposure daily between sessions.
In addition to her trauma-focused treatment sessions, Angela also participated in DBT (60 min, twice weekly), as she needed individual consultation and case-management with providers, and regular group sessions to increase skills related to anger management, recreational activities, and relaxation.
Treatment Week 1: Angela Appears Disengaged From Treatment
In early group sessions, Angela was extremely soft-spoken. She was not actively participatory in groups and tended not to spontaneously contribute comments or feedback. Although she responded thoughtfully when asked a direct question, she typically waited several seconds before answering and spoke so softly that group members and therapists often expressed difficulty hearing her. She appeared easily distracted and on several occasions attempted to disengage from trauma-focused groups by reading a book or doodling during session. Each time this occurred, the therapist pointed out the behavior and helped Angela to identify this as avoidance. When engaged in group sessions, Angela was reactive to discussions about trauma and PTSD symptoms. During her initial CPT group session, she yelped aloud during a review of the treatment rationale, startling several group members. Initially, she stated that it was “nothing” but eventually acknowledged that she was having reexperiencing symptoms. She could smell alcohol from the rapist and thought that she smelled like alcohol.
Given Angela’s reactivity, she did not begin her exposure-based treatment sessions during her 1st week on the unit. Exposure therapy for PTSD is often emotionally intensive, and it can be beneficial for patients to have well-developed coping skills prior to initiating exposure work. Thus, Angela spent her 1st week adjusting to the treatment unit and cohort, and participating in numerous group sessions designed to increase her ability to adaptively manage intense affect, with the plan of initiating exposure treatment in Week 2. Herein, she practiced stress management techniques such as relaxation, breathing techniques, and mindfulness exercises.
Toward the end of her initial week in treatment, Angela met with the treatment team to discuss her progress in the program. She reported feeling overwhelmed, concerned that treatment might exacerbate her symptoms, and unsure of whether she wanted to continue in the program. With encouragement from her peers, family, and treatment team, Angela reluctantly agreed to remain in treatment.
Treatment Week 2: Angela Discloses Her ED
During her 2nd week on the unit, Angela tearfully disclosed that since her admission to the WISER unit, she had been regularly purging after eating and had not kept down any meals. She described feeling so distressed and nauseated after eating that she could purge without inducing vomiting with her fingers or other aides. Angela directly attributed her eating problems to one aspect of her MST, namely, that the perpetrator violently forced her to perform oral sex and swallow his semen during the assault. She indicated that in her culture, oral sex is considered “filthy” and “unclean,” and this sexual act had not therefore been a component of her consensual intimate relationships. She was bothered by the fact that she had shared her beliefs about oral sex during a discussion with fellow soldiers (including her perpetrator) prior to the assault. Since the assault, Angela perceived that all food tasted, smelled, and felt like semen, and on eating, she became convinced that the food and her mouth were contaminated with semen and that she would die if she did not expel the food from her body. She reported feeling out of control after eating and when purging, and this scared her. The purging was associated with an instant feeling of relief, closely followed by guilt and shame. She frequently brushed her teeth and showered after purging.
One unique aspect of Angela’s presentation is that she did not report a desire to lose weight and was not preoccupied with body image as is typical among patients with purging-type EDs. In contrast, Angela was bothered by her inability to eat because she wanted to gain weight, which she believed would decrease unwanted attention from men. During group treatment sessions, other patients sometimes commented on Angela’s small frame noting, for example, that she was fortunate to be “naturally thin.” These comments made her uncomfortable and further fueled her desire to gain weight. Angela also feared that others would notice her eating behaviors and infer that she had been sexually assaulted.
After Angela disclosed the ongoing nature of her eating difficulties, the WISER treatment team worked together to evaluate the need for changes to her diagnosis and treatment plan. At this time, Angela received a diagnosis of ED–not otherwise specified (NOS), on the basis that she presented with eating behaviors of clinical severity, but (a) did not endorse disturbance in her perceptions of body weight or shape (a criteria for both bulimia nervosa and anorexia nervosa), (b) did not meet weight status requirements for anorexia nervosa (body mass index [BMI] > 17.5), (c) was not engaging in binge eating, and (d) did not have an intense fear of gaining weight. Angela’s diagnosis of ED-NOS required the treatment team to reconsider our case conceptualization and treatment plan (see “Complicating Factors”). Ultimately, the treatment team determined that it was in Angela’s best interest to continue her course of trauma-focused treatment, provided that we could implement successful modifications to monitor and manage her eating behaviors so they would not act as a barrier to treatment success. Toward this end, we devised a care plan with the goal of managing Angela’s eating behavior: (a) consuming at least 50% of her meals and working with a nutritionist, (b) remaining in the day room for 30 min after the meal, (c) twice-weekly, blind weight assessment with nursing staff, (d) limiting showers to 2 a day, morning and evening only, and (e) brushing teeth limited to 2 times a day, morning and evening. We reviewed the care plan with Angela, and she was aware that a contingency of staying in the program was that she could comply with the mutually agreed-on plan. In addition, the team at this time started to focus on discharge planning that was to include further eating-disorder treatment.
It is notable that Angela’s disclosure took place during her initial session of individual exposure therapy. Angela and her individual therapist had planned for Angela to engage in an imaginal exposure exercise in this initial session, during which she would give a present-tense, detailed description of her MST. Given that avoidance of talking and thinking about the trauma is a hallmark feature of PTSD, patients who engage in exposure-based therapy often experience increases in anxiety in anticipation of their first imaginal exposure and may be tempted to avoid this exercise. As several experts have noted, patients may at times use eating behaviors or discussion of eating behaviors as a way to avoid or disengage from trauma-focused therapy (Fallon & Wonderlich, 1997). When Angela disclosed her disordered eating behaviors at the outset of this initial exposure session, her therapist chose to use the session to process the disclosure and assess her current needs, rather than conduct the imaginal exposure as planned. However, to minimize the degree to which her disclosure could function as an avoidance strategy, Angela completed her initial imaginal exposure the next day.
Treatment Week 3: Angela Begins to Experience Symptom Relief
In Week 3, Angela began to report some relief from her ED symptoms, and results of her blind weight assessments indicated a positive weight trend. She noted that crunchy food was becoming easier for her to eat, although foods like yogurt and certain soups were more difficult because they share physical properties with semen. Angela was very committed to adhering to her care plan, which centered on her eating-related behaviors, and staff observed that Angela stayed in the day room of her own accord, without needing reminders from staff. We suspect that Angela’s willingness to comply with the aspect of her treatment plan gave her the opportunity to habituate to the anxiety she felt after ingesting food, allowing her posteating distress to gradually decrease over time.
Angela’s motivation and commitment to treatment were also apparent in other aspects of her care. She was highly cooperative and compliant with her individual exposure-based work and listened to audio recordings of her exposures on a daily basis, with very few exceptions. Of her own initiative, she began rewinding and relistening to particularly distressing parts of the tape. Through these exercises, Angela was able to process her traumatic experience by opening up to the affect associated with the MST (e.g., fear, anger), which in turn decreased the intensity of these emotions. By revisiting the details of the trauma, Angela also gained new perspectives on aspects of the event that she had previously discounted. For instance, although Angela initially reported that she had done nothing to resist the perpetrator, she later recalled and acknowledged that she had in fact made numerous efforts to physically and verbally resist the attacker. These cognitive shifts in her conceptualization of the trauma represented important steps in her recovery.
As her reactivity and reexperiencing symptoms decreased, Angela was better able to engage with her treatment cohort and became more active in group sessions, asking questions and offering supportive comments to other patients. In one session, she became tearful as she empathized with another group member about the impact of sexual assault. Although she had been initially reticent to discuss her traumatic experiences in group, she became increasingly willing to share about these events as treatment progressed. She also began to voluntarily disclose details about her eating behaviors to other group members. Her willingness to open up about these issues appeared to have been prompted by another group member who shared, with the group, about her own disordered eating, which likely served to normalize Angela’s own struggles with ED symptoms. Although group disclosure of disordered eating can sometimes be inspired by the patient’s desire for social comparison and may result in competition or reinforcement of unhealthy eating behaviors (Polivy & Federoff, 1997), it appeared that Angela’s disclosures served to share and solicit consensual validation and genuine support. Through group discussions, Angela gained further insight into the underlying causes of her eating problems. For example, she shared with her cohort that she felt such guilt and self-blame related to the assault that she was punishing herself by withholding food, believing that she did not deserve it. Such use of the body as a target for guilt, shame, and self-blame through destructive eating behaviors is a common trauma-related symptom in eating-disordered patients (Levitt, 2007).
Treatment Week 4: Angela Prepares for Discharge
During her final week of treatment, Angela remained highly compliant with treatment expectations, and prepared for transfer to another program. For the first time, Angela elected to take advantage of her off-unit passes, which she had previously declined. She also reported that it was becoming less distressing to stay in the day room after meals. We suspect that Angela’s treatment gains resulted from habituation to the anxiety and associated with eating, as well as habituation to the fear associated with her trauma memory. It is likely that increased caloric retention over the course of treatment also contributed to Angela’s improvements. Insufficient nutrition can lead to symptoms of anxiety and depression (Kalm & Semba, 2005), and Angela’s increasing ability to consume nutritional meals over the course of treatment may have played a role in her symptom reduction.
Discharge
At discharge, Angela completed a standard battery of posttreatment measures administered to all WISER patients on discharge, including the PCL-M and PTCI (the CAPS was administered at pretreatment for diagnostic purposes and was not readministered at posttreatment). Angela evidenced a significant reduction in her PTSD symptoms as evidenced by a 9-point reduction on the PCL-M from pre- to posttreatment, which exceeds the cutoff for reliable change (Jacobson & Truax, 1991) recommended by the Veterans Affairs National Center for PTSD (5 points). She also reported fewer negative trauma-related beliefs, as evidenced by reductions on the PTCI total score and subscales (see Table 1). After completing the WISER program, Angela was referred to a residential, trauma-focused treatment program that also specialized in EDs. This program was equipped to provide the structure needed to fully monitor her throughout her ED treatment and continued trauma-focused therapy. The facility also had a step-down program to allow Angela increase control of her eating as she progressed through treatment.
Comparison of Pretreatment and Posttreatment Scores on Outcome Measures
Note: CAPS = Clinician-Administered Posttraumatic Stress Disorder Scale; PCL-M = Posttraumatic Stress Disorder Checklist–Military Version; PTCI = Posttraumatic Cognitions Inventory.
The CAPS was administered at pretreatment only for diagnostic purposes.
8 Complicating Factors
Angela initially presented with severe, yet fairly straightforward, symptoms of PTSD. However, her disclosure of trauma-related disordered eating in her 2nd week of treatment complicated her clinical picture. Because there is little research to inform decisions about treatment sequence (i.e., whether disorders should be treated sequentially or concurrently) for patients with comorbid PTSD and ED, the treatment team considered several aspects of Angela’s case when determining the best course of treatment and whether continued participation in the WISER program was clinically indicated. A primary concern was that the WISER unit is not well equipped to provide the type of supervision often helpful for the successful management and treatment of EDs (Wilson & Pike, 2001). However, discharging Angela halfway through the WISER program could have the unintended consequence of colluding with her avoidance of dealing with her PTSD symptoms. The treatment team also noted that discharging Angela and referring her to an EDs specialty clinic after she had opened up to staff about her eating difficulties had the potential to send a disempowering message that could negatively reinforce her tendency to deny or minimize the extent of her eating-related problems. With respect to case conceptualization, the treatment team (and, importantly, the patient) conceptualized PTSD as her primary diagnosis. Given that the onset of her disordered eating symptoms occurred immediately following her trauma and developed in tandem with her PTSD symptoms, it was clear that the etiology of her ED was not independent of her trauma history. Her desire to avoid the sensory-related reexperiencing symptoms triggered by eating appeared to be the driving force behind her restrictive and purging behaviors, and it was therefore possible that Angela’s purging behavior could decrease with resolution of her trauma symptoms.
Based on consideration of Angela’s presenting symptoms and the capabilities of the treatment unit, it was determined that Angela would continue with trauma-focused treatment targeting PTSD symptoms, provided that she would comply with nutritional rehabilitation while on the unit and be referred to further ED treatment at discharge.
9 Access and Barriers to Care
Angela was somewhat atypical in that she was an active duty soldier receiving treatment at a VA Medical Center. Although her status as a current member of the U.S. military did not limit her access to VA care in that she was able to use Tricare (i.e., health care coverage for military service members) to cover medical costs and was granted leave to participate in the WISER program, we suspect that her active duty status may have affected treatment in other ways. An ED diagnosis is a disqualification for military enlistment or commissioning, and servicemen and women who develop EDs during active duty may be medically discharged or have their duties restricted (Manos, Carlton, de la Cruz, & Kelly, 2006; Gilberd, 2004). This may have contributed to Angela’s initial reluctance to be forthright about the extent of her eating symptoms. Furthermore, Angela was unaware of the military’s plans for her postdischarge and, therefore, was unsure of when she might be required to return to work, or if she might be able to seek additional inpatient/outpatient care following WISER discharge. We believe that this uncertainty was a source of stress during her final phase of treatment and may have perpetuated her anxiety symptoms.
10 Follow-Up
Although efforts are underway to establish standardized follow-up care for WISER patients, current follow-up procedures consist of a brief check-in phone call within 2 weeks following discharge. Consistent with these procedures, a member of the nursing staff initiated telephone contact with Angela shortly after discharge. Angela reported that she had no complaints or questions regarding her hospital stay and had no suggestions regarding how the WISER team could have improved her care. Thus, little is known about whether Angela maintained her improvements, and we are regrettably unable to report on her long-term outcomes.
11 Treatment Implications of the Case
Angela’s clinical presentation and response to treatment has important implications related to the assessment and treatment of comorbid PTSD and ED. From a diagnostic perspective, Angela’s case illustrates that trauma, in her case MST, may trigger the onset of disordered eating, even in patients with no prior history of ED or weight/shape concerns. Furthermore, an ED secondary to trauma may be unique in that body image distortions may not be present.
Angela’s case also illustrates important clinical considerations when a patient discloses eating-disordered behaviors during the course of treatment for a different mental health problem. Had the treatment team been aware of the severity of Angela’s ED symptoms prior to her admission, it is likely that she would have been referred to a more structured environment specializing in the treatment of ED. However, since Angela’s ongoing eating difficulties did not come to the attention of the WISER staff until her 2nd week in the program, the treatment team members had to carefully evaluate their ability to treat her effectively given the capabilities of the staff and the program.
Ultimately, Angela responded to trauma-focused treatment, despite the presence of an ED. She participated in 4 weeks of inpatient treatment targeting her PTSD symptoms, and also adhered to a care plan that aimed to monitor and begin to manage her eating behaviors. She demonstrated improvement in her trauma-related symptoms, and her eating behaviors also changed over the course of treatment; she increased her caloric intake and reported a reduction in purging frequency. Several mechanisms may have contributed to Angela’s reductions in PTSD and ED symptoms. Imaginal exposure exercises allowed Angela to gradually habituate to her trauma-related fear and anxiety, and similarly, staying in the day room after meals helped her to learn that she was capable of managing her posteating anxiety. Two of the core components of Angela’s inpatient care (e.g., CPT, DBT) addressed the cognitive errors that are believed to underlie PTSD and ED, which may have led to improvements in both domains. In addition, Angela’s ED symptoms appeared to have developed as a way to manage and avoid trauma-related reexperiencing symptoms; as Angela’s reexperiencing symptoms lessened over the course of trauma-focused treatment, this may have in turn contributed to reductions in her purging behaviors. Finally, Angela’s determination to receive trauma-focused therapy appeared to motivate her to decrease purging, as she knew that her continued participation in the WISER program was contingent on her ability to maintain sufficient nutritional intake.
12 Recommendations to Clinicians and Students
Although we found several examples in the research literature of patients who presented with ED symptoms and only disclosed their trauma history later in treatment (Brewerton, 2007; Levitt, 2007), we found no examples of patients who initially presented with trauma-related symptoms and later disclosed an ED, as was the case with the current patient. Angela’s disclosure of her ED midway through her PTSD treatment suggests that some patients may feel more comfortable disclosing traumatic events than disordered eating behaviors in the initial phases of treatment, and indicates to clinicians that assessment of eating behaviors should be seen as an ongoing process that can occur over the course of treatment.
Given that there is presently no evidence-based integrated treatment for PTSD and ED, clinicians and students who provide treatment for this population face complicated decisions about treatment approach and treatment sequence. Our case highlights several important considerations when planning treatment with patients with PTSD and ED. These include patient safety (e.g., Is the patient sufficiently nourished to participate in treatment?), case conceptualization (e.g., What was the relative onset of PTSD and ED symptoms? Are ED behaviors functioning as trauma-related avoidance symptoms?), and provider/clinical capabilities (e.g., Is staff available to monitor eating/nourishment? Are the staff knowledgeable in ED clinical interventions?). In the present case, we determined that Angela was sufficiently medically stable to participate in treatment, conceptualized PTSD as her primary diagnosis, and devised a care plan that would feasibly allow staff to monitor her eating and weight throughout her participation in trauma-focused treatment. Angela’s participation in cognitive-behavioral–based treatment focusing on her primary diagnosis (PTSD), with concurrent management of ED symptoms, resulted in reductions in both PTSD symptoms and ED symptoms.
Footnotes
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the Office of Academic Affiliations Veterans Affairs (VA) Advanced Fellowship Program in Mental Illness Research and Treatment and the Department of Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center (MIRECC).