Breakthroughs in treatment: Past, present, and future of eating disorders

Presented by Dr. Wendy Oliver-Pyatt, Co-Founder, CEO, and Chief Medical Officer at Within Health

1. Trauma-informed treatment

THE GAME CHANGER: Dr. Timothy Brewerton, experienced clinician, researcher, teacher, and recognized leader in eating disorders.

While trauma-informed treatment for eating disorders is now the standard, it wasn't always the case. It wasn’t until the late 1990s that studies indicated a link between trauma and eating disorders. 

A study by Stiegel-Moore et al., published in 1999, reported that veterans with eating disorders had elevated rates of co-morbid post-traumatic stress disorder (PTSD) and other substance and mood disorders.1 This study revealed the need for further research into the link between trauma and other psychiatric comorbidities and eating disorders. 

Step forward, Dr.Timothy Brewerton. He has conducted extensive research that validates the importance of recognizing and treating trauma when addressing eating disorders. 

In one of his dozens of studies into the impact of PSTD, he found that the prevalence of bulimia nervosa was significantly higher only in participants with a history of rape with PTSD compared with those with histories of rape without PTSD and those with no history of rape. This suggests that it is the PTSD rather than the history of abuse that is associated with eating disorder development.

Thanks to the game-changing research by Dr. Brewerton, there is now a considerable body of evidence that supports the link between trauma and eating disorders. Some interesting findings include:3

  • Almost 14% of those with anorexia nervosa meet the diagnostic criteria for PTSD
  • Approximately 25% of those with binge eating disorder have co-occurring PTSD
  • Between 37 to 40% of individuals with bulimia have co-occurring PTSD
  • The prevalence of PTSD is higher in individuals that engage in purging behaviors than any other disordered eating behavior. 

Thanks to this wealth of evidence, trauma-informed care is now the norm in eating disorder treatment, to the great benefit of those struggling with disordered eating.

The connection between PTSD and Eating Disorders

Eating disorders and PTSD share similar characteristics, including:

  • Disassociation/avoidance: Both PTSD and eating disorders have high rates of dissociation.4 In PTSD, this can manifest as a lack of interest in usual activities, less expression of moods, and deliberately avoiding people, places, and situations that remind an individual of their trauma. In eating disorders, avoidance characteristics can be seen in emotional apathy, disconnection from food, or purging to distance oneself from a painful emotion, thought, or memory.
  • Arousal: Hyperarousal is a core symptom of PTSD which occurs when a person’s body suddenly kicks into high alert when thinking about their trauma.5 Hyperarousal can show as difficulties concentrating, irritability, and excess awareness. In eating disorders, hyperarousal can manifest as extreme anger around eating and an exaggerated response to satiety (faulty alarm system).
  • Reliving: Also known as retraumatization, reliving in PTSD is having sudden and unwanted traumatic memories, e.g., flashbacks, dreams, and physical reactions to situations that remind of the event.6 In eating disorders, thinking about food all the time and the overwhelming physical reactions to food could be seen as a form of reliving.

Complex post-traumatic stress disorder

Typically the result of childhood trauma, complex post-traumatic stress disorder (C-PTSD) is an anxiety condition caused by severe, repetitive abuse over a long period. The symptoms of C-PTSD usually include those of PTSD, plus additional symptoms including:7

  • Lack of emotional regulation, e.g., uncontrollable feelings of anger or ongoing melancholy.
  • Changes in consciousness, including feeling detached from emotions or your body, and detachment from the trauma
  • Negative self-perception
  • Difficulty with relationships
  • Loss of systems of meaning, e.g., losing faith in long-held beliefs

The types of long-term traumatic events that can cause C-PTSD include, but are not limited to:8

  • Child abuse, neglect, or abandonment
  • Domestic violence
  • Racism and oppression
  • Torture
  • Slavery 
  • Genocide

Epigenetics and trauma

Epigenetics is a field of study focused on structural changes in DNA that don’t involve changes in alternations to the underlying DNA sequence. Still, they can change how your body reads a DNA sequence, e.g., by turning gene expression on and off.9

As part of normal development and aging, your epigenetics change as you age. Environment and behaviors like diet and exercise can also result in epigenetic changes. Although these changes can be inherited through multiple generations, not all epigenetic changes are permanent. Some can be reversed through changes in behavior or environment.9

Regarding PTSD, epigenetics provides one way for environmental exposure to leave a mark on DNA. For example, in a study by Uddin et al., an analysis of 14,000 genes of PTSD suffered found marks in favor of epigenetic transmission. Compared to people without PTSD, 6-7 times more genes than expected were found to function unusually. The genes in question were largely involved in immune function.10

The effects of trauma on an individual's epigenome can have a ripple effect on the next generation. Examples of trauma that can be intergenerational include war, ongoing sexual abuse, and systemic trauma like racism.11 

ACEs and epigenetics

An adverse childhood experience (ACE) score measures experienced childhood trauma, such as abuse, neglect, racism, witnessing violence, or having a parent incarcerated.11

Epigenetic modifications resulting from ACEs can increase the likelihood of a myriad of health issues—such as psychiatric disorders, suicide, cardiovascular disease, and diabetes—potentially due to a weakened stress response.11

Types of stress

In terms of child development, there are three types of stress :12

  • Positive stress: A normal and essential part of healthy development, positive stress is characterized by brief increases in heart rate and mild elevation in hormone levels. Examples of situations that may trigger a positive stress response include getting an immunization shot or meeting new people.
  • Tolerable stress: During tolerable stress, the body’s alert system is turned up higher for longer due to more severe, longer-lasting difficulties, such as the loss of a loved one, a frightening injury, or a natural disaster. Also, a normal and essential part of healthy development, if the time of tolerable stress is limited and buffeted by adult relationships, the brain, and other organs can recover.
  • Toxic stress:  Strong, frequent, and long-lasting adversity - such as emotional abuse, chronic neglect, and exposure to violence - without enough adult support can result in a child experiencing toxic stress. The prolonged activation of the stress response can disrupt brain development and other organ systems and increase the risk for stress-related disorders.

Racism as trauma

Racial trauma or race-based trauma is the cumulative traumatizing impact of racism on an individual, which can include individual acts of racism combined with systemic racism, as well as historical, community, and cultural trauma.13

Racism and child development

A growing body of evidence connects toxic stress's effect on developing brains and other biological systems to racism.14 Research suggests that constant coping with daily discrimination and systemic racism is a strong activator of the stress response, which may help explain the origins of racial disparities in chronic illness.14

People of color have less access to high-quality education, health services, economic opportunities, and pathways to wealth accumulation. All of these cast light on how structural racism has created a culture that disproportionately undermines the health and development of children of color.14

Many studies show how the stress of everyday racism on caregivers—like being associated with negative stereotypes—can harm caregiver behaviors and mental health. When a caregiver's mental health is affected, this can cause an excessive stress response in their children.14

Lasting harm in children can be prevented by creating new strategies to address inequalities that threaten the health and well-being of children of color. This means challenging biases in ourselves and social economic policies, such as anti-bias training and fair hiring and lending practices.

The psychodynamics of racism

Until recently, the psychological understanding of racism has been focused on a solely social-psychological approach, i.e., how the behaviors and beliefs of individuals drive racism. However, this approach has some limitations.

An increasing number of researchers are looking at racism through a cultural-psychological lens, which sees racism as practices and beliefs embedded in culture. Individuals shape this culture and vice versa.15 Racism doesn’t just exist in terms of an individual’s actions and beliefs; it also exists within systems, organizations, and cultures, i.e., embedded in the reality of everyday life. This can make it difficult for people to recognize how normalized ideas can promote racist views and behaviors.15

There are several possible psychological explanations as to why racism has become so ingrained in our society:15

  • Personal insecurity: Those with insecurity may seek group or community membership, which can lead to hostility and alienation of non-group members.
  • Lack of compassion: Alienation can lead to a lack of compassion and empathy.
  • Poor mental health: Narcisim and paranoid personality disorder, for example, are mental health disorders that are characterized in part by insecurity, which can make an individual more likely to harbor racist beliefs.
  • Hatred and fear: Fear of people a person views as “different” can manifest as extreme hatred.
  • Projection of flaws: When people feel bad about themselves, they can project their self-hatred onto others, such as alienated groups.

A 2020 paper published in American Psychologist theorized about the major factors that contribute to racism, which include:16

  • Categories: We learn to group people into race categories at a young age, which can promote stereotypes.
  • Factions: Categories lead to factions in which people begin to strongly identify with the racial group. Strong feelings of empathy and loyalty to their group can lead to hostility towards others.
  • Segregation: Lack of contact with other racial groups can narrow a person’s beliefs, which can go unchallenged as the segregation persists.
  • Hierarchy:  A hierarchical system assigns power, wealth, and influence unevenly across groups, which leads to the dominant group believing they are superior.
  • Power: When a group has power, they also can control resources and exploit others.
  • Media: The media plays a dual role in sustaining racism. First is the lack of representation, and second is the stereotypical portrayal of racial groups.
  • Passivism: When racism is ingrained in society, all it needs to remain is inaction. Racism persists when people do nothing to challenge racist systems.

Racial stigmatization and the brain

A study at the University of California, Santa Barbara, found that negative stereotyping can change the behavior of the subcortical nucleus accumbens (the area of the brain associated with reward and punishment).17

While the results of this study are inconclusive, they do suggest that racial stigmatization can cause a blunted sensitivity to positive and rewarding information, leading an individual to be more sensitive to the frustrating and negative things in life without a positive buffer.17

Types of traumatic stressors

There are three types of traumatic stressors:18

  • Direct traumatic stressors: Include all direct trauma impacts of being on the receiving end of individual racist attacks or living within a society of structural racism.
  • Vicarious traumatic stressors: Indirect traumatic impacts of living with systemic racism and individual racist acts, e.g., viewing videos of police brutality against black people, such as the video of the murder of George Floyd.
  • Transmitted traumatic stressors: Traumatic stressors that are transferred from generation to generation. These stressors can come from personal traumas passed through families and communities or historically racist sources, e.g., the descendants of Holocaust survivors have an increased risk of developing mental health issues.

Modes of trauma transmission

Intergenerational trauma refers to trauma that is passed from a survivor or trauma to their descendants. Individuals experiencing intergenerational trauma may undergo the emotional and psychological effects of trauma experienced by previous generations.19 There are several primary modes of intergenerational trauma transmission: psychodynamic, sociocultural, family systems, and biological.


“The massive psychic trauma shapes the internal representations of reality, becoming an unconscious organizing principle passed on by parents and internalized by children” (Auerhahn & Laub). For example, a child of a Holocaust survivor becomes a “reservoir” for the unwanted, troublesome parts of an older generation.


Social learning theory emphasizes the conscious and direct effects of parents on their children. The theory proposes that learning occurs through observation, imitation, and modeling and is influenced by attention, attitudes, and emotions.20

Essentially, learning occurs because individuals observe the consequences of other people’s behaviors. Actions that are rewarded are likely to be imitated, while those that are punished are  to be avoided. 

Family systems

In the more pathological families, parents are fully committed to their children, and children are overly concerned with the welfare of their parents.  While parents live vicariously through their children, the children live vicariously in the horrific past of their parents. This can result in the child of a trauma survivor feeling both angry and guilty.


New research suggests that the traumatic experiences of parents may lead to the general disposition of PTSD in children. 

PTSD is associated with an underlying genetic vulnerability. More than 30% of the variance associated with PTSD is related to a heritable componentt.21

Impacts of trauma

There are many ways that childhood trauma can have an impact, including, but not limited to:22

  • Loss of safety with the world feeling like a place where anything can happen.
  • Re-enactment via recreating the childhood dynamic expecting the same result, yet hoping for a different one.
  • Loss of self-worth. Trauma survivors can hold grandiose beliefs, an elaborate defense against feeling unworthy of love.
  • Loss of danger cues as it’s difficult to understand what’s “normal” after someone you trust hurts you.
  • Loss of trust, which is particularly true if the abuser is a family member or close friend.
  • Loss of sense of self. One of the key roles of a caregiver is to help up find our identity by reflecting who we are back at us. If a caregiver is the abuser, our sense of self is poorly developed.
  • Loss of physical connection to the body. Survivors of abuse often feel a disconnection from their bodies.
  • Shame, overwhelming and debilitating shame. A child of trauma may grow into an adult who can’t bear to be wrong because the accompanying shame is such a trigger.
  • Loss of intimacy. Survivors of sexual abuse can either avoid sexual relationships or be entered into as a method to gain approval.
  • Dissociation, which during trauma, is a mechanism used to disconnect from what is happening. Later in life, it becomes a coping strategy whenever a person feels overwhelmed.

The impact of “allowing” trauma into treatment

By considering the impact of trauma on individuals, new interventions could be developed in the field of eating disorder treatment including:

  • Trauma-focused cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT)
  • Eye movement desensitization processing (EDMR)
  • Somatic experiencing
  • Many other modalities explored as part of trauma treatment

2. Weight-stigma awareness

THE GAMECHANGER: Chevese Turnet. Chevese dedicates her ability to make significant social change on issues concerning eating disorders, weight stigma and discrimination, and intersectional social justice.

Not so long ago, BMI (body mass index) was improperly considered a benchmark for health. BMI was never designed to measure an individual’s health but simply as a method of statistical analysis of a group. 

The primary flaw of BMI is that it’s an indirect measure of body fat that doesn’t consider age, sex, ethnicity, muscle mass, smoking, and disordered eating. BMI doesn’t distinguish between excess fat, muscle, or bone mass, nor does it provide any information on the distribution of fat or muscle within an individual.23

Using BMI as an indicator of health can lead to weight stigma, i.e., stereotyping a person based on their weight, even amongst professionals treating eating disorders. A 2014 study found negative weight stereotypes among some professionals who specialize in treating eating disorders, with 29% reporting that their colleagues have negative attitudes toward patients with larger bodies.24

Furthermore, the study revealed that professionals with stronger weight bias were more likely to attribute larger bodes to behavioral causes.24 This weight bias is sure to be a barrier to eating disorder treatment and a source of misdiagnosis.

Binge eating disorder (BED) and weight bias

Binge eating disorder (BED) is the most common eating disorder in the United States, yet it wasn't until 2013 that BED was declared as an eating disorder in the DSM-5.25 Even once it was recognized, restriction was not acknowledged as a symptom of the disorder.

Initial treatment protocols for BED would involve restrictive meal plans and aggressive exercise.25 It’s weight-biased to believe that weight loss is the answer to issues with binge eating, and in fact, efforts to lose weight during treatment may exacerbate the problem, causing intense shame and potentially further weight gain.

Thankfully, the attitudes towards eating disorder treatment—particularly for BED—have changed to focus on reducing binge eating behaviors with weight-neutral treatments and not on weight loss. 

Health at Every Size (HAES)

The Health at Every Size (HAES) principles were established in 2003 by the Association of Size Diversity and Health. The idea behind HAES is simple: to reject the idea that BMI, weight, or body size should be considered indicators of health.

The goal of the movement is to shift the focus from weight change to helping individuals of every size to learn compassionate ways t support their health. A big part of this is campaigning to end weight discrimination and promote equal access to quality healthcare, regardless of size.

The principles of HAES aim to reinforce the idea that the weight of health status should never be used to judge, oppress, or determine a person’s value:26

  • Weight inclusivity: Accept the diversity of body shapes and sizes and reject the idealizing and pathologizing of certain body weights.
  • Health enhancement: Improve access for everyone to services that boost physical and mental well-being, with a focus on the social, economic, physical, and emotional needs of the individual.
  • Eating for well-being: Learning to eat based on nutritional needs, hunger, satiety, and enjoyment rather than following a restrictive eating plan designed for weight control.
  • Respectful care: Campaign towards ending weight discrimination, stigma, and bias and support environments that tackle these issues.
  • Life-enhancing movement: Encourage and support enjoyable movement that allows people of all shapes and sizes to participate at a level they choose.

Research has shown that the HAES principles improve health habits, psychological well-being, metabolic health, and self-esteem - with or without weight loss. Long-term health outcomes of HAES include:27

  • Lower levels of disordered eating
  • Improved eating and activity habits
  • Improved mood
  • Boosted self-esteem and body image
  • Greater resilience to weight stigma
  • No weight cycling

By rejecting the weight stigma associated with diet culture and embracing HAES principles, everyone - no matter their size - can receive high-quality eating disorder treatment.

3. Diversity and inclusion

THE GAME CHANGER: Dr. Sand Chang. Dr. Chang is “actively interested in helping people who tend to get excluded by the mainstream, white, Western, dominant culture norms” and provides [Diversity, Equity, and Inclusion] consultations and training to leaders and organizations.

There is a perception that the typical person with an eating disorder is a young, thin, heterosexual, young woman. This depiction of eating disorders can lead people to believe that those that look different are somehow excluded or exempt. This belief that only a certain type of person can suffer from disordered eating is a dangerous misconception.

For example, research has shown that those who identify as BIPOC (black, indigenous, or person of color) are significantly less likely than white people to be asked by a doctor about their disordered eating behaviors and only half as likely to get a diagnosis or treatment for an eating disorder.28

Eating disorders don’t discriminate, and neither should treatment. These serious illnesses affect people of all ethnic and racial backgrounds, body types, gender identities, sexual orientations, and socioeconomic statuses. 

When diversity and inclusion occur in eating disorder treatment, marginalized voices are heard, and more people with disordered eating behaviors can receive the help they need.

4. Dialectical behavioral therapy

THE GAME CHANGER: Dr. Marsha Linehan, developer of dialectical behavioral therapy (DBT), a groundbreaking therapeutic intervention used in eating disorder treatment.

A few decades ago, therapy lacked a true connection between psychological awareness and behavioral change, then dialectical behavioral therapy (DBT) came along. Barely known in 2000, DBT is now mainstream and among the most widely used treatment modalities.

Developed in the 1970s by Dr. Marsha Linehan, DBT focuses on balancing change with acceptance, two seemingly opposing therapy strategies, hence the term “dialectical.” DBT aims to reduce or stop the symptoms of an eating disorder that provide temporary relief from difficult emotions or vulnerability via a balance of change and acceptance techniques.29

  • Change techniques: Help you replace behaviors that harm you with those that benefit you. This typically involves challenging unhelpful thoughts and encouraging new coping methods.
  • Acceptance techniques: Focus on understanding yourself and why you might engage in certain disordered behaviors.

DBT treatment stages

1. Getting behavior under control

The first stage of DBT therapy involves trying to keep the client from further deterioration. Once the client has shown stabilization in their behaviors, can allow nutrition, and follows program guidelines, they can move on to the next stage.

2. Focus on emotional experiencing

While still using the program for meal completion, clients are learning to acknowledge hunger and satiety cues. They can tolerate added calories to restore weight and/or allow optimal functioning.

The client starts to address the function of their eating disorder in their life and begins learning how to differentiate between the voice of their eating disorder and their true self.

3. Solve the problems of everyday living

In the third stage of DBT, a client can successfully navigate meals alone with support and monitoring and may be able to experiment with self-reliance (self-portioning). The client can use their growing connection to their true self to manage their relationship with food.

The client’s relationship with their body continues to improve with their ability to tolerate their body without reacting to negative self-talk or body image.

At this stage, the client is self-motivated to recover and can experience joy and contentment through activities outside their eating disorder. 

4. Achieving transcendence

A client is consistently flexible and adaptable and experiences satisfaction and self-confidence by managing their own recovery. At this point in DBT, a person can manage food independently outside of a care environment and weight restoration is complete.

With increasing self-confidence, a client is now able to recognize vulnerabilities and make requests for support when they need it. They no longer feel rewarded by negative attention in response to eating disorder symptoms, instead seeking social approval by involvement in life-sustaining activities.

A final word on DBT

Research has found that DBT is an effective treatment for eating disorders regardless o a person’s gender identity, sexual orientation, ethnicity, race, and age.30 DBT is known to improve relationships, boost the quality of life, and teach skills—such as mindfulness and distress tolerance—that can be transferred to many other aspects of life.

5. Virtual (remote) eating disorder treatment

During the COVID-19 pandemic, many brick-and-mortar treatment providers went virtual with newer modalities of treatment designed intentionally for in-home care, including the likes of family-based treatment and individual and group therapies.

Advantages and disadvantages of virtual treatment

There can be a misconception that virtual treatment may not be as effective as in-person treatment. A 2021 study found no difference in outcomes between multidisciplinary eating disorder treatment delivered in person and the same team-based care approach delivered virtually. In both groups, researchers recorded reduced eating disorder symptoms, positive weight outcomes, improved mental well-being, and fewer perfectionism traits at discharge.31

Additional advantages of virtual treatment include:

  • Easier to enter treatment, particularly for those who have experienced “treatment trauma” in the past.
  • Treatment is accessible in areas where none existed previously
  • Makes treatment accessible to underserved populations (e.g., males and transgender individuals)
  • Interrupts the progression of eating disorders
  • Families find it easier to be “together” in treatment
  • Enhanced step-down process
  • No need to transfer treatment teams or treatment environment
  • Cohesion in group treatments can facilitate a sense of belonging and purposeful/recovery-oriented behavior
  • Less inclination for leaned behavior

There are a few disadvantages to virtual treatment, which include:

  • Lack of physical content with treatment providers
  • Extreme behaviors may not be possible to interrupt or protect against
  • May be harder to monitor meal completion
  • In some programs, there is a lack of food included in treatment
  • Easier to exit treatment.

Despite these few disadvantages to virtual eating disorder care programs they have been shown to be just as effective as traditional in-person treatment. For example, a recent study showed that virtual family-based therapy delivered by a multidisciplinary team resulted in 78% of clients reaching the required weight restoration, eating disorder symptoms reduced by 50%, and the symptoms of depression and anxiety shrunk by a third.32


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