Eating disorder patients with and without PTSD treated in residential care: discharge and 6-month follow-up results

Outcomes and associated clinical features of people with eating disorders participating in residential treatment facilities: a scoping review

Residential treatment programs for eating disorders (EDs) have gained popularity in recent years, expanding beyond the United States to countries such as Canada, Italy, and the United Kingdom. These programs offer a "home-like" environment where individuals reside for several weeks or months, emphasising both physical restoration and psychological recovery. This scoping review aimed to provide an update since the most recent reviews on the literature regarding outcomes of residential treatment programs for EDs and to explore clinical features that were associated with these outcomes. Methods used followed the Joanna Briggs Institute guidelines for scoping reviews. A systematic search of electronic databases was conducted, and 12 studies met the inclusion criteria. All studies reported improvements in various outcomes from admission to discharge, including changes in eating psychopathology, weight restoration, depression, anxiety, and quality of life. Additionally, three studies reported positive outcomes at intervals after discharge and three predictive factors (self-compassion, personality organisation, and resistance to emotional vulnerability) were reported in a small number of studies. While residential treatment facilities consistently showed positive outcomes, the review highlights the need for randomised controlled studies to establish the efficacy of these programs for EDs. Future research should include controlled studies comparing residential facilities to other treatment settings and incorporate long-term follow-up outcomes and further studies of emergent predictive factors identified in this review.

The treatment of dissociative identity disorder in an eating disorder residential treatment setting

OBJECTIVE

Child maltreatment, dissociation and dissociative disorders have been noted in relationship to eating disorders (EDs) for decades, and their co-occurrence generally is associated with greater morbidity, self-harm and mortality. The concomitant presentation of dissociative identity disorder (DID) with an ED (ED + DID) is especially challenging, and there is limited information on approaches to and the effects of integrated treatment for this serious comorbidity, especially in higher levels of care. There are also limited treatment resources for such patients, since they are often turned away from specialty units due to lack of expertise with or bias toward one or the other disorder.

METHOD

We report our experience with a case series of 18 patients with DSM-5 defined ED + DID (mean age (SD) = 32.6 (11.8) years) admitted to residential treatment (RT) and assessed using validated measures for symptoms of ED, major depression (MD), PTSD, state-trait anxiety, quality of life (QOL), age of ED onset, and family involvement during treatment. All patients received integrated, multimodal, trauma-focused approaches including those based on DID practice guidelines, principles of cognitive processing therapy (CPT), and other evidence-based approaches. Fifteen of 18 patients also completed discharge reassessments, which were compared to admission values using paired t-tests.

RESULTS

Following integrated, trauma-focused RT, patients with ED + DID demonstrated statistically significant improvements in all measures, with medium (anxiety) to high (ED, PTSD, MD, QOL) effect sizes.

DISCUSSION

These results provide positive proof of concept that patients with ED + DID can be effectively treated in a specialty, trauma-focused ED program at higher levels of care.

PUBLIC SIGNIFICANCE

EDs and dissociative identity disorder (DID) are related conditions, but little is known about treating patients with both conditions. We describe the clinical features and integrated treatment of 18 such patients, 15 of whom completed discharge assessments. Significant clinical improvements were found in multiple domains (ED, PTSD, mood, anxiety, quality of life), which demonstrate positive proof of concept that ED + DID can be effectively treated in a specialty, trauma-focused ED program.

Associations between posttraumatic stress disorder and eating disorder symptoms among women veterans

Recent research suggests high rates of posttraumatic stress disorder (PTSD) and eating disorder (ED) comorbidity in women veterans. This study aims to expand the literature by examining associations between PTSD and ED diagnoses and symptoms in this population. We assessed probable PTSD diagnosis and symptom clusters (intrusion, avoidance, arousal and reactivity, and negative alterations in cognition and mood [NACM]), as well as probable Binge Eating Disorder (BED) diagnosis and ED subscales (dietary restraint, shape/weight overvaluation, and body dissatisfaction) in a sample of women veterans (N = 371). We investigated significance at the standard p < .05, and the Bonferroni-corrected p < .005 cut-off to adjust for experiment-wise error. Overall, we found that probable PTSD was associated with provisional BED (p < .001) using logistic regression at both cut-offs. Probable PTSD was associated with all ED subscales (all p's < 0.003) using linear regression models also at both cut-offs. Provisional BED was associated with NACM at p < .05 (p = .046), though it did not meet significance at our conservative cut-off. NACM was also associated with shape/weight overvaluation (p = .02) and a global ED score (p = .01) at p < .05, but not at our conservative cut-off; arousal was associated with shape/weight overvaluation (p = .04) and the global ED score (p = .02) at p < .05, but not at our conservative cut-off. Our findings may further guide how ED-related topics can be integrated in PTSD treatment for women veterans with comorbid PTSD and ED.

Psychogenic Nonepileptic Seizures Associated with an Eating Disorder and PTSD Are Responsive to Cognitive Processing Therapy

Objective

Eating disorders (EDs) are often associated with prior histories of trauma, subsequent PTSD and related psychiatric comorbidities. There is a paucity of information about their relationship to somatic symptom disorders, specifically psychogenic nonepileptic seizures (PNES), a type of functional neurological symptom disorder or conversion disorder.

Methods

We report a case of a 39-year-old bisexual female with bulimia nervosa (BN), PTSD, recurrent major depressive disorder (MDD), cannabis use disorder, and PNES who responded to integrated trauma-focused treatment during residential ED treatment using cognitive processing therapy (CPT). Symptoms of ED, PTSD, major depression, and state-trait anxiety were measured using validated assessment instruments.

Results

During the course of CPT treatment, the patient's total scores on the PTSD Symptom Checklist for DSM-5 (PCL-5) went from 59 to 26, which is below the diagnostic threshold for PTSD. In addition, she demonstrated improvements in the Eating Disorder Examination Questionnaire (EDE-Q) Global Severity score, the Eating Disorder Inventory (EDI-2) total score, the Patient Health Questionnaire (PHQ-9) total score, the Spielberger State and Trait Anxiety Inventory scores, and the Eating Disorder Quality of Life (EDQOL) total score. Furthermore, her PNES also abated, and she remained seizure free for ∼1 year following discharge with the exception of one short seizure, per report of the patient.

Conclusion

The use of CPT as part of an integrated trauma-informed treatment approach during residential ED treatment was successful in a woman with PNES, BN, PTSD, MDD, and cannabis use disorder.

The integrated treatment of eating disorders, posttraumatic stress disorder, and psychiatric comorbidity: a commentary on the evolution of principles and guidelines

Psychiatric comorbidity is the norm in the assessment and treatment of eating disorders (EDs), and traumatic events and lifetime PTSD are often major drivers of these challenging complexities. Given that trauma, PTSD, and psychiatric comorbidity significantly influence ED outcomes, it is imperative that these problems be appropriately addressed in ED practice guidelines. The presence of associated psychiatric comorbidity is noted in some but not all sets of existing guidelines, but they mostly do little to address the problem other than referring to independent guidelines for other disorders. This disconnect perpetuates a "silo effect," in which each set of guidelines do not address the complexity of the other comorbidities. Although there are several published practice guidelines for the treatment of EDs, and likewise, there are several published practice guidelines for the treatment of PTSD, none of them specifically address ED + PTSD. The result is a lack of integration between ED and PTSD treatment providers, which often leads to fragmented, incomplete, uncoordinated and ineffective care of severely ill patients with ED + PTSD. This situation can inadvertently promote chronicity and multimorbidity and may be particularly relevant for patients treated in higher levels of care, where prevalence rates of concurrent PTSD reach as high as 50% with many more having subthreshold PTSD. Although there has been some progress in the recognition and treatment of ED + PTSD, recommendations for treating this common comorbidity remain undeveloped, particularly when there are other co-occurring psychiatric disorders, such as mood, anxiety, dissociative, substance use, impulse control, obsessive-compulsive, attention-deficit hyperactivity, and personality disorders, all of which may also be trauma-related. In this commentary, guidelines for assessing and treating patients with ED + PTSD and related comorbidity are critically reviewed. An integrated set of principles used in treatment planning of PTSD and trauma-related disorders is recommended in the context of intensive ED therapy. These principles and strategies are borrowed from several relevant evidence-based approaches. Evidence suggests that continuing with traditional single-disorder focused, sequential treatment models that do not prioritize integrated, trauma-focused treatment approaches are short-sighted and often inadvertently perpetuate this dangerous multimorbidity. Future ED practice guidelines would do well to address concurrent illness in more depth.