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

Abstract

Introduction We studied whether provisional posttraumatic stress disorder (PTSD) moderated discharge (DC) and 6-month follow-up (FU) outcomes of multi-modal, integrated eating disorder (ED) residential treatment (RT) based upon principles of cognitive processing therapy (CPT). Methods ED patients [N = 609; 96% female; mean age (± SD) = 26.0 ± 8.8 years; 22% LGBTQ +] with and without PTSD completed validated assessments at admission (ADM), DC and 6-month FU to measure severity of ED, PTSD, major depressive disorder (MDD), state-trait anxiety (STA) symptoms, and eating disorder quality of life (EDQOL). We tested whether PTSD moderated the course of symptom change using mixed models analyses and if ED diagnosis, ADM BMI, age of ED onset and LGBTQ + orientation were significant covariates of change. Number of days between ADM and FU was used as a weighting measure. Results Despite sustained improvements with RT in the total group, the PTSD group had significantly higher scores on all measures at all time points (p ≤ .001). Patients with (n = 261) and without PTSD (n = 348) showed similar symptom improvements from ADM to DC and outcomes remained statistically improved at 6-month FU compared to ADM. The only significant worsening observed between DC and FU was with MDD symptoms, yet all measures remained significantly lower than ADM at FU (p ≤ .001). There were no significant PTSD by time interactions for any of the measures. Age of ED onset was a significant covariate in the EDI-2, PHQ-9, STAI-T, and EDQOL models such that an earlier age of ED onset was associated with a worse outcome. ADM BMI was also a significant covariate in the EDE-Q, EDI-2, and EDQOL models, such that higher ADM BMI was associated with a worse ED and quality of life outcome. Conclusions Integrated treatment approaches that address PTSD comorbidity can be successfully delivered in RT and are associated with sustained improvements at FU. Improving strategies to prevent post-DC recurrence of MDD symptoms is an important and challenging area of future work.

Associations between major depressive and bipolar disorders and eating disorder, PTSD, and comorbid symptom severity in eating disorder patients

“…Our findings point to the importance of evaluating patients with EDs for a plethora of psychiatric comorbidities, including major mood disorders, such as MDD and BD, PTSD, SUDs and anxiety disorders, all of which may complicate the treatment and course of EDs. In addition, these results echo the call for careful evaluation of trauma histories and the implementation of trauma-focused treatments for those suffering with PTSD, who are more likely to have BD, as well as greater severity of illness, worse quality of life, and more treatment refractoriness (Brewerton et al, 2020(Brewerton et al, , 2023. Patients admitted to higher levels of care have generally failed lower levels of care and have been relatively less responsive to common treatment approaches as outpatients.…”

“…Both BD and MDD are known to be associated with higher rates of prior trauma and PTSD compared to individuals without mood disorders and to individuals in the general population (Brady et al, 2000;Goldstein et al, 2016;Kessler et al, 1995;Nabavi et al, 2015;Pavlova et al, 2015). Prior trauma histories and the presence of PTSD in patients with mood disorders have been associated with a worse quality of life, greater comorbidity, and a more complicated course (Andreu Pascual et al, 2020;Chou, 2012;Dvir et al, 2014;Etain et al, 2013;Hosang et al, 2018;Jaworska-Andryszewska & Rybakowski, 2019;Negele et al, 2015;Quarantini et al, 2010;Schalinski et al, 2016), findings which have also been reported in ED patients (Brewerton, 2007;Brewerton et al, 2020;Brewerton et al, 2023;Scharff et al, 2019;Scharff et al, 2021).…”

“…During admission to RT there is the opportunity and obligation to do more careful diagnostic assessments and to institute appropriate integrative treatments. Depression in EDs tends to be chronic and may be an early indicator of relapse and non-responsiveness (Brewerton et al, 2023;Keshishian et al, 2021;Liechty & Lee, 2013;McClelland et al, 2020;Puccio et al, 2016;Puccio et al, 2017).…”

“…Significantly higher prevalence rates of PTSD are seen in EDs, MDD, and bipolar disorder (BD) (Ferrell et al, 2020;Kiefer et al, 2020;Qassem et al, 2021). In addition, PTSD may negatively influence the course of illness in patients with EDs treated in higher levels of care (Brewerton et al, 2023;Scharff et al, 2021). Conversely, comorbid mood disorders may negatively influence the course of PTSD and make it more difficult to treat (Dore et al, 2012;Kline et al, 2021;Marmar et al, 2015;McLaughlin et al, 2013;Quarantini et al, 2010).…”

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

“…(2-3/week) were delivered by licensed psychotherapists within the safe and protected environment of RT, which incorporated several evidence-based treatment (EBT) approaches as described elsewhere (Brewerton, 2023;Brewerton et al, 2023b). Staff also received supervision from one of the authors (TDB) regarding treatment of DID according to published practice guidelines (ISSTD, 2011).…”