Integrated psychotherapies help patients with eating disorders cope with trauma

A treatment approach of combining interventions from cognitive behavioural therapy (CBT) specific to either eating disorder (ED) or post-traumatic stress disorder (PTSD) is safe and effective, helping improve symptoms of PTSD in patients with both ED and PTSD (ED-PTSD), as shown in a recent study.

In a cohort of 42 patients (mean age 29.2 years, 97.6 percent female) with a range of ED diagnoses and concomitant PTSD, integrated CBT led to greater improvements in both clinician-rated and self-reported PTSD symptoms as compared with CBT-for-ED only (p=0.01 and p=0.001, respectively). [Psych Med 2022;52:587-596]

More patients in the integrated group achieved PTSD remission rates at the end of treatment (56.3 percent vs 5.6 percent) and at subsequent follow-up (month 3: 66.7 percent vs 23.1 percent; month 6: 57.1 percent vs 25.0 percent).

Of note, despite the seeming superiority of integrated CBT, CBT-for-ED only was also associated with statistically significant improvements in symptoms of PTSD, anxiety, and depression. These positive changes were maintained at the 3- and 6-month follow-up.

None of the participants in either group discontinued treatment for safety-related reasons. Both integrated CBT and CBT-for-ED only were rated highly, with 96.8 percent saying they were at least somewhat satisfied and 90.4 percent stating they were very satisfied or completely satisfied.

The participants said they would recommend the treatment they received to someone else. However, there was a strong preference for integrated treatment for both ED and PTSD (87.1 percent) over separate treatments for ED or PTSD. Finally, 93.3 percent of the participants who received integrated CBT thought that the intervention would facilitate their ED recovery.

“Given that integrated CBT for ED-PTSD led to superior PTSD outcomes and that integrated treatment was highly preferred by participants and perceived … to facilitate their ED recovery, we suggest that integrated psychotherapy for ED-PTSD should be offered whenever possible,” according to the investigators.

In the study, 19 patients received integrated CBT and 23 CBT-for-ED only. Both interventions consisted of 16 individual therapy sessions delivered over 14 weeks. Prior to the CBT intervention, all patients underwent intensive ED treatment that was focused on interrupting binge eating and purging, establishing a pattern of regular, nonrestrictive eating, and weight restoration.

Trauma-focused CBT often skipped in ED-PTSD

“ED-PTSD is of particular concern because of the potential for a functional relationship between the disorders that may increase the likelihood that the disorders maintain one another and result in high rates of relapse following standard ED treatment,” the investigators said. [Compr Psychiatry 2013;54:61-69; J Trauma Stress 2021;34:665-674; Curr Opin Psychiatry 2018;31:445-455]

Indeed, most frontline ED clinicians recognize the importance of addressing trauma-related symptoms in individuals with ED, since such symptoms pose as a major obstacle to successful ED treatment. Then again, many ED-PTSD patients are not offered specific trauma-focused CBTs due to concerns that they are not ready for trauma-focused therapy, and that it may lead to worsening of ED, trauma-related, and other mental health symptoms. [Eat Disord 2017;25:22-36]

“Results from this randomized efficacy-effectiveness study indicate that individuals with ED-PTSD can not only tolerate, but also greatly benefit from, manualized trauma-focused psychotherapy,” the investigators said.

“This new information is critical to overcoming barriers to accessing evidence-based PTSD treatments related to clinician perceptions that trauma processing will lead to an increase in ED and other mental health symptoms, including PTSD symptoms,” they added.

The investigators are hopeful that their study will spur a shift in practice, such that evidence-based psychotherapy for PTSD can be offered in ED treatment programs.