CBT is clearly the most empirically supported form of psychotherapy for eating disorders and for most forms of trauma-related comorbidity, including PTSD, major depression, other anxiety disorders, and substance use disorders. Consequently, CBT has nearly universal application in this highly comorbid group and can serve as the foundation on which other therapeutic interventions may be supplemented, such as interpersonal psychotherapy, pharmacotherapy, family therapy, or psychodynamic psychotherapy.

Although CBT for PTSD has a number of key ingredients, such as anxiety reduction skills training, rec-ord keeping, cognitive therapy, and relapse prevention, the inclusion of prolonged exposure with cognitive reprocessing appears to be critical to the successful resolution of PTSD.21,22,34-36 EMDR seems to include most of these components and can be an acceptable treatment alternative for PTSD.37 Studies indicate that EMDR is as efficacious as CBT with PE as well as fluoxetine, at least in the short term.38,39 More recent comparison studies indicate that CBT with PE may have more lasting benefit than EMDR (B. Rothbaum, unpublished data, January 2008).

Diagnostic issues and complications
There are several issues that may arise in the course of evaluating and treating the traumatized patient with an eating disorder. To some extent, this depends on the level of skill, training, and experience of the clinician, but these patients are challenging to even the most seasoned clinicians. A common mistake made by therapists inexperienced in the treatment of eating disorders is to not fully appreciate the need for nutritional rehabilitation (relative normalization of weight and eating) before beginning actual exposure work. Another error is to fail to properly teach and demonstrate anxiety reduction skills or stress inoculation training before tackling traumas directly. In either case, it is easy for patients to become so overwhelmed with emotionally laden material that they are unable to process physiologically, psychologically, or both, and they, in turn, revert back to their familiar coping methods involving self-destructive but nevertheless numbing and avoidant disordered eating behaviors.

Some clinicians may not be familiar with the empirically based treatments for PTSD and/or bulimia nervosa, particularly CBT, and require specialized supervision and/or training before real progress can be made. In these situations, the clinician would do well to consider making a referral to someone who specializes in this area in order to better serve the patient's needs. Another common mistake is to not continue the "prolonged" exposure long enough until there is true extinction of hyperarousal and avoidance responses. Clinicians who are not versed in behavior therapy may unintentionally and unconsciously collude with the avoidance of the patient.

Vicarious traumatization can be a valid concern for therapists who are doing trauma work, and it is important to acknowledge that patients' recounting of their traumatic experiences may trigger therapists' own issues. The control and processing of both negative and positive countertransference is especially critical in this work given the dangers of retraumatization.

In general, patients will show a relative readiness (or decreased resistance) to commence more intensive trauma work when their eating disorder symptoms are under sufficient control, their brains are being well-nourished (thereby normalizing neurotransmitter function),40 and they have mastered some anxiety reduction skills. Patients are consequently much better able to adequately process painful experiences and integrate them emotionally and cognitively.

Given the significant trust issues that these patients often have, it is common for them to not feel safe enough to disclose abuse or important details about their abuse until they have progressed well into their course of therapy. Previous threats to patients made by perpetrators not to disclose abuse may remain operative in the form of maladaptive beliefs. As a result, an occasional re-assessment of any relevant trauma history can be productive.

It is important to note that once nutritional and weight stabilization occurs, delayed PTSD may emerge de novo or previously diagnosed PTSD may get worse in the absence of the patient's usual avoidance and numbing strategies. Sometimes patients do not begin to even recognize that they have been abused until the precise definitions of abuse and neglect have been explained to them. Once their cognitive set changes in such a way that they can perceive past traumatic experiences as abusive, delayed PTSD symptoms may appear. Recovering patients may even remember earlier traumatic events or significant details of events that they had previously forgotten once full nutritional stabilization has taken place and they feel safer, stronger, and more supported.

It is important for therapists to contain any "rescue" fantasies that they may harbor and refrain from using techniques designed to recover memories, such as hypnosis or amobarbital interviews, because these are fraught with dangers such as the induction of false memories. Traumatized eating disorder patients may be particularly vulnerable to this given their high degree of hypnotizability.41 In addition, if any previous traumatic events are reported by patients, it is imperative that clinicians recognize and observe all reporting laws mandated by their discipline and national, state, and local governments.
 
Pages: 1  2  3