A pathway from posttraumatic stress disorder to eating disorders might be through the maladaptive coping mechanism of expressive suppression, a study of 860 older veterans shows.

“Expressive suppression reflects attempts to reduce outward expression of emotion and may be adaptive in the short term; however, this strategy becomes less effective over the long term,” wrote Karen S. Mitchell, PhD, and Erika J. Wolf, PhD., both of the National Center for PTSD, VA Boston Healthcare System. “This finding aligns with previous … work suggesting that in some individuals, [eating disorder] symptoms may be used to cope with negative affect.”

“We weren’t surprised by the findings,” Dr. Mitchell said in an interview. “They were consistent with our hypothesis that for some people, disordered eating may be used to cope with PTSD symptoms.”

She said the clinical implications of the study are direct. “It is important to assess eating habits and other potentially harmful coping strategies among patients with trauma histories and PTSD. On the other hand, it would be helpful to assess trauma histories in patients with eating disorders to determine if trauma reminders or other PTSD symptoms serve as a maintaining factor for the eating disorder.”

Dr. Mitchell and Dr. Wolf randomly selected 1,126 veterans who had reported trauma exposure in the GfK Knowledge Networks study ( Depress Anxiety. 2013 May;30[5]:432-4 ), which looked at psychological resilience in a sample of U.S. veterans aged 60 and older. The veterans in the randomly selected group were asked to participate in a survey about PTSD, dissociation, and disordered eating, and 860 responded, 787 of whom were men ( Psychiatry Res. 2016;243:23-9 ).

The participants’ age range was 22-96 years; mean age was 63. Most were white (85%) and married (77%), and had attended some college (87%).

Participants were asked to complete several surveys, including the Eating Disorder Diagnostic Scale (EDDS), the Yale Food Addiction Scale, the Emotion Regulation Questionnaire, and the National Stressful Events Survey (NSES).

The investigators said the sudden, unexpected death of a loved one (17.5%), and the aftermath of combat (13.6%) were cited as the worst traumatic experiences most cited by the participants. They also cited the violent death of a loved one (7.3%), the witnessing of dead bodies or body parts (6.3%), and physical or sexual assault (5.5%) as traumatic experiences.

Meanwhile, 23 participants (18 men [2.8%] and 5 women [9.1%]) met the criteria for bulimia nervosa; 20 met the criteria for binge eating disorder (16 men [2.5%] and 4 women [7.3%]); and 16 people (12 men [1.9%] and 4 women [7.3%]) met the proposed criteria for food addiction, reported Dr. Mitchell and Dr. Wolf, who also both are affiliated with the department of psychiatry at Boston University.

After analyzing the data, the researchers found that “the indirect path from PTSD to expressive suppression to [eating disorder] symptoms was significant in the full sample (P = .002; 95% confidence interval, 0.069-0.314) and in the male subsample (P = .029; 95% CI, 0.014-0.255).”

The researchers cited several limitations. For example, the participants’ diagnoses were not confirmed by interviews. In addition, “the validity of DSM-5 diagnoses using the EDDS and NSES has not yet been established,” they wrote.

Nevertheless, Dr. Mitchell and Dr. Wolf wrote, their findings highlight the importance of looking at eating disorders and food addiction in populations that traditionally have been underserved.

The study was funded by National Institutes of Health grant and an award from the Department of Veterans Affairs.


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