Manifestations of Trauma: The Relationship between PTSD and Eating Disorders—An Interview with Dr. Judy Scheel

Judy Scheel, Ph.D., L.C.S.W, CEDS has over twenty years of experience treating eating disorders and holds fast to the belief that mutual respect, empathy, and trust are the cornerstones on which to build a successful recovery. Her understanding of the many theories that explain eating disorders allows her to utilize all relevant evidence-based treatment approaches, and tailor treatment to suit the individuals needs. She is the author of When Food is Family: A Loving Approach to Heal Eating Disorders, as well as multiple articles featured on psychologytoday.com, and is the Executive Producer and Director of a documentary entitled Personas: Identities of an Eating Disorder.

To learn more about PTSD and eating disorders, please read Dr. Scheel’s original article, “PTSD and Its Relationship to Eating Disorders: Symptoms and Behaviors Represent Both the Victim and the Abuser.” Check it out!

Could you begin by telling us what inspired you to write this article? What are your motivations for exposing the symptoms and behaviors of those who suffer from both PTSD and eating disorders?

“I have treated patients with eating disorders who have suffered sexual and physical trauma (including rape, incest, beatings, and those who have served the military in active combat.)   Psychological abuse like verbal humiliation, emotional and physical neglect as well as those who have witnessed abuse of another person also constitute trauma.   Eating disorders are uncanny, clever and highly adaptive responses to the severe impact of traumatic events.

Professional and societal awareness regarding what causes eating disorders continue to evolve and become better informed by qualitative and quantitative research studies.   Most agree now that eating disorders are neither caused by genes nor are they the direct result of media influences regarding standards of beauty, weight and body size and shape expectations.

Trauma, however, can be a ‘single cause issue’ for developing an eating disorder.  Understanding how trauma and eating disorders are connected and finding solid treatment approaches are important for healing and recovery.”

Who did you hope to reach by publishing this article? Who was your target audience?

“My hope for having published the article is to reach a varied audience of those suffering with an eating disorder following trauma, family members as well as professionals who want to understand how eating disorders operate as a response to trauma.”

You have over twenty years of experience of treating eating disorders. In the course of your work, and through multiple pre-existing studies, it has been observed that patients who suffer from both PTSD and eating disorders assume both the role of the abuser and the victim to maintain distance and control. How important would you say control is in these patients lives? On average, are they more perfectionistic in terms of their personalities?

“Control is an overused word to categorize patients with eating disorders. It is easy to define someone with anorexia as needing to be in control, and it is often used punitively to criticize the sufferer.  It is difficult to see someone you love not take care of themselves or listen to what appears to be common sense practices. Searching for a simplistic understanding i.e. eating disorders are all about control, is appealing; we want to make sense of very complicated and confusing psychological issues.   In this way eating disorder symptoms are attempts to keep in check a person who feels helplessly out of control.  Exploring what feels out of control in life is generally more productive than focusing on inexorable efforts to maintain control over food, weight and body size.

The symptoms of an eater disorder serve both to convey pain as well as are attempts at mastery of the pain.  In some ways, eating disorders are adaptive.  They soothe. They provide comfort and maintain order.   They also replay the abuse through the destructive nature of the symptoms.  They are reliable, despite their repeated failure to fix or come through in any lasting way.

Assuming the role of both victim and abuser, the person with the eating disorder can maintain dominance, punishment and control over her body through the rigidity of food restriction, or elimination of calories through eating or excessive exercise.  However, the same body that she or he is attempting to control and master through the eating disorder symptoms also serve to defeat, harm, or destroy both the sufferer and family members. In this sense, one can see the roles of both victim and abuser.

Yes, on average, people with eating disorders are perfectionists. Research reveals that perfectionism, anxiety and depression rank high on the list of predisposing factors. However, it remains unclear as to what causes perfectionism.  For instance, did perfectionism emerge in response to trauma or prior childhood experiences? Do guilt and shame over needs, desires and wants force perfectionism to emerge?  Is perfectionism an inheritable trait?  My tendency is to define perfectionism as an effort to avoid vulnerability.  In this way, cause does not matter.    Trauma survivors often express that had they been better as children, not in the wrong place at the wrong time, not aroused by the person who committed the incest or repeatedly abused them, the abuse would not have occurred.  Had they been perfect then nothing bad would have happened.”

You are also the Founder and former Executive Director of CEDAR Associates, a private outpatient program which specializes in the treatment of eating disorders and other self-harming behaviors, as well as the President of Cedar Associates Foundation, Inc., a not-for-profit organization dedicated to the education, research, and prevention of eating disorders. What would you suggest as the best course of action for people who suffer from both eating disorders and PTSD who are looking to recover?

“Seek a qualified professional who has experience and sufficient training in the treatment of eating disorders and trauma related issues.  Any person who is an eating disorder specialist is a seasoned and competent provider of general mental health treatment.  Eating disorder treatment is a specialty whereby the provider is trained over a long period of time and has had adequate supervision and experience in both general mental health and eating disorder theory and treatment.”

Is there a specific form of therapy that you’ve found works best for the treatment of both PTSD and eating disorders?

“I am oriented psychoanalytically and remain a true believer that knowledge is power.  Uncovering the roots of the eating disorder in relationship to trauma is an interconnected process.  The eating disorder represents the repetition of trauma and until the psychologically work is done to unearth the use and perhaps ‘need’ for the eating disorder, healing will likely be hampered.

Utilizing Cognitive Behavioral Therapy (CBT) is necessary in managing symptoms and in shifting cognitive distortions and challenging irrational beliefs.

However, uncovering pain, shame, guilt, self-loathing, rage and fear are equally powerful.  These emotions take time to reveal and accept.  Having a therapist who is comfortable with a full range of emotional experience allows a patient to sense and experience safety and trust in the therapist.  It takes a seasoned and usually well analyzed therapist to be able to sit with a patient’s pain.”

What would you suggest as the best way to mediate symptoms in daily life for those who cannot afford therapy, but still wish to recover?

“There are some wonderful self-help books on dealing with symptoms. Gurze Books is an exclusive publisher of eating disorder books, including many that are self-help in nature.   There is good treatment available if one commits to the time.   The National Eating Disorders Association offers support and assistance for people in the form of free support groups and assistance in finding low cost treatment.  Also, many psychoanalytic institutes, usually found in major cities, provide low cost treatment for individuals with a variety of mental health conditions through their analytic training programs.”

Find free support groups and research studies through NEDA here.

Find treatment through NEDA here.

Find Gurze Books booklist here.

Why is it important to educate ourselves about the relationship between PTSD and eating disorders?

“Given that roughly one in nine girls and one in 53 boys under the age of 18 experience sexual abuse or assault, shedding further light on the issue makes sense.  (Rape, Abuse & Incest National Network (www.rainn.org) 2016.

Eating Disorders are in some ways a ‘natural,’ albeit unnatural response to address, repeat and attempt to repair the trauma, simultaneously.   Educating people with eating disorders, their families, professionals and the general public about the complexities of these conditions helps to further dismantle the myths that eating disorders are rooted in the wish to be thin or desire for the perfect body.  That is far from the truth.”

Lastly, what is the takeaway from this article for people living with PTSD and eating disorders? For people with eating disorders and other mental illnesses? For people with only eating disorders? For friends and family of victims? For people with no mental illness?

“Trauma induces a very specific set of responses; its psychological impact is severe and often lasts throughout life.

The use of an eating disorder in response to trauma is uniquely suited.  Its symptoms are repetitions of the abuse, serve to express and mitigate emotion, manage loss of control, convey guilt, self-rage and self-loathing.  Family members are terrified, yet held captive and often feel manipulated by the sufferer.   It serves as a perfect, although self-destructive solution.

Awareness and education lessen stigma and facilitate people coming forward to seek help.   Everyone benefits from learning.   Competent information and dialogue provide clarification and dispels myths.”

Thank you to Dr. Scheel for this enlightening interview! For more information about Dr. Scheel and her work, visit her website and check out her other articles at https://www.psychologytoday.com/blog/when-food-is-family.