Trauma, PTSD, and Obesity: Healing the Hidden Root Cause

Key Points

• Adverse Childhood Experiences (ACEs) increase adult obesity risk by 50-90%, with a dose-response relationship
• Childhood trauma affects stress hormones, inflammation, and eating behaviors throughout life
• PTSD is strongly associated with obesity through multiple biological and behavioral mechanisms
• Trauma creates dysregulated eating patterns as survival adaptations, not character flaws
• Standard weight loss approaches often fail or cause harm when trauma is unaddressed
• Trauma-informed care is essential – addressing weight without addressing trauma is ineffective and potentially retraumatizing
• Effective treatment integrates trauma therapy (EMDR, somatic work) with metabolic interventions
• Healing trauma often unlocks weight changes that were impossible before

This might be the most important article in this series.

Because underneath a significant percentage of cases where someone struggles with both depression and obesity, there’s trauma.

Not always. But far more often than most providers recognize or ask about.

I’m talking about childhood abuse or neglect. Sexual assault. Domestic violence. Combat exposure. Medical trauma. Accidents. Loss of parents. Growing up with addiction or mental illness in the home. Being bullied relentlessly. Experiencing racism, discrimination, or marginalization. Any of countless experiences that overwhelm someone’s ability to cope and leave lasting effects.

The research is unequivocal: trauma, particularly childhood trauma, dramatically increases the risk of adult obesity. The ACE Study (Adverse Childhood Experiences) showed that people with four or more ACEs had a 50-90% increased risk of obesity compared to people with no ACEs. That’s enormous.

But it’s not just correlation. We understand the mechanisms. Trauma affects stress hormone regulation. It increases inflammation. It alters brain development. It creates patterns of using food for emotional regulation that persist decades later.

And here’s what makes this clinically crucial: if you try to treat obesity without addressing underlying trauma, you will fail most of the time. Or you might succeed temporarily, but the weight comes back because the root cause – the dysregulated nervous system, the unhealed trauma, the eating patterns that developed as survival adaptations – remains untreated.

I see this constantly. Someone has tried every diet. Lost and regained weight multiple times. Feels like a failure. But when we do trauma-focused therapy alongside metabolic treatment, suddenly the changes that seemed impossible become achievable. The binge eating that felt uncontrollable becomes manageable. The weight that wouldn’t budge starts moving. The self-hatred transforms into self-compassion.

Trauma isn’t just a psychological issue that coincidentally occurs in people with obesity. It’s often a root cause that must be addressed for healing to occur.

Let me walk you through the connections between trauma and obesity, why they matter so much, and how to address trauma as part of comprehensive metabolic-psychiatric treatment.

The ACE Study: Revolutionary Findings

In the 1990s, Kaiser Permanente and the CDC conducted the Adverse Childhood Experiences (ACE) Study – one of the largest investigations of childhood abuse/neglect and adult health outcomes.

What they measured:

Ten types of childhood adversity:

1. Physical abuse
2. Emotional abuse
3. Sexual abuse
4. Physical neglect
5. Emotional neglect
6. Mother treated violently
7. Household substance abuse
8. Household mental illness
9. Parental separation or divorce
10. Incarcerated household member

Each present counts as one point. ACE scores range from 0-10.

The findings were shocking:

ACEs are extremely common:

• 64% of adults have at least one ACE
• 12.5% have four or more ACEs

ACEs show dose-response relationships with numerous health outcomes – more ACEs mean worse health outcomes:

For obesity specifically:

• People with ACE score of 4+ had 1.5 times the risk of obesity
• In some populations, the risk increase was even higher
• The more ACEs, the greater the obesity risk
• The relationship was stronger for severe obesity

But ACEs predict much more than obesity:

• Depression (4-5 fold increased risk with high ACEs)
• Suicide attempts (12 fold increase)
• Alcoholism (7 fold increase)
• Drug abuse (5 fold increase)
• Heart disease (2-3 fold increase)
• Diabetes (1.6 fold increase)
• COPD, liver disease, STDs, and more

ACEs are powerful predictors of adult mental and physical health across the lifespan.

Why this matters:

This wasn’t just correlation. The study showed:

• Dose-response relationship (more trauma = worse outcomes)
• Biological plausibility (clear mechanisms)
• Temporal relationship (childhood trauma predicts adult outcomes)

This is causation. Childhood trauma causes obesity (among many other health problems) through multiple mechanisms.

The implications:

When someone with obesity walks into a doctor’s office, there’s a very high probability they have significant trauma history. Yet we rarely ask about it. We rarely address it. We prescribe diets and medications and never touch the root cause.

This has to change.

How Trauma Causes Obesity: The Mechanisms

Understanding HOW trauma leads to obesity is essential for effective treatment. These aren’t just correlations – there are clear biological and behavioral pathways.

1. Chronic stress hormone dysregulation

Trauma, particularly chronic childhood trauma, fundamentally alters stress hormone systems.

Normal stress response:

• Stressor occurs → cortisol rises → stressor ends → cortisol normalizes

Traumatized stress response:

• Baseline cortisol often elevated or dysregulated
• Exaggerated cortisol response to stressors
• Prolonged cortisol elevation after stress
• Or blunted cortisol (burnout from chronic activation)

Effects on weight:

High cortisol promotes:

• Increased appetite, particularly for high-calorie comfort foods
• Preferential storage of visceral (abdominal) fat
• Insulin resistance
• Breakdown of muscle tissue
• Difficulty losing weight despite caloric restriction

Even decades after childhood trauma, stress hormone dysregulation persists. You’re walking around with chronically elevated or dysregulated cortisol, promoting weight gain.

This isn’t “just stress” that meditation fixes. It’s neurobiological adaptation to early adverse experiences, often requiring therapeutic intervention to heal.

2. Inflammation

Trauma increases inflammation throughout the body, including the brain. This is well-documented.

Studies show:

• Adults with high ACE scores have elevated inflammatory markers (CRP, IL-6, TNF-alpha)
• The inflammation persists decades after childhood trauma
• PTSD is associated with chronic inflammation
• Trauma-related inflammation is independent of current stress levels

Inflammation promotes obesity through:

• Insulin resistance
• Dysregulated appetite hormones
• Increased fat storage
• Difficulty losing weight
• Fatigue that reduces activity

We’ve discussed inflammation extensively throughout this series. Trauma is one of the major sources of chronic inflammation that maintains both depression and obesity.

3. Altered brain development and function

Childhood trauma occurs during critical periods of brain development. It literally changes how the brain develops.

Effects on brain regions:

Prefrontal cortex (executive function, impulse control): Reduced volume and function. This affects ability to resist cravings, plan healthy meals, delay gratification – all essential for weight management.

Amygdala (fear/threat detection): Often enlarged and hyperactive. Results in heightened stress reactivity and anxiety.

Hippocampus (memory, emotional regulation): Reduced volume. Affects ability to regulate emotions and form new patterns.

Reward circuits: Altered dopamine signaling. Affects how rewarding food feels and contributes to seeking food for pleasure and comfort.

Insula (body awareness): Altered function. Affects ability to accurately perceive hunger, fullness, and body sensations.

These brain changes aren’t character flaws. They’re adaptations to survive traumatic environments. But they make weight management genuinely difficult, not just “requiring more willpower.”

4. Autonomic nervous system dysregulation

Trauma affects the autonomic nervous system – the system regulating involuntary functions like heart rate, digestion, breathing.

Many trauma survivors are stuck in:

• Chronic sympathetic activation (fight/flight – always on edge)
• Or dissociation/shutdown (dorsal vagal – numbed out)
• Or oscillating between the two

Effects on eating and weight:

Sympathetic activation (fight/flight):

• Suppresses appetite acutely
• But increases cravings for high-calorie foods
• Disrupts digestion
• Promotes stress eating

Dissociation/shutdown:

• Disconnection from body signals (don’t notice hunger or fullness accurately)
• Emotional numbing that may lead to eating for feeling
• Low energy and motivation

Polyvagal theory (developed by Stephen Porges) explains how trauma affects the vagus nerve and nervous system regulation. Many trauma therapies specifically target autonomic regulation.

5. Dissociation and disconnection from body

Many trauma survivors develop dissociation – a disconnection from body awareness and sensations. This is protective during trauma but problematic long-term.

Effects on eating:

Can’t accurately perceive:

• When you’re hungry
• When you’re full
• What your body actually needs
• Internal body signals

Results in:

• Eating past fullness (can’t feel satiety signals)
• Not eating when actually hungry (can’t feel hunger)
• Difficulty with intuitive eating approaches
• Disconnect between body and eating behavior

Healing requires reconnecting to body – which is exactly what trauma therapy addresses.

6. Eating behaviors as trauma responses

This is crucial to understand: many eating patterns that look like “lack of willpower” or “food addiction” are actually trauma responses.

Binge eating as dissociation: Entering an altered state where awareness narrows, body sensations fade, and only the eating remains. This is dissociation used to escape overwhelming feelings.

Restrictive eating as control: When the world feels chaotic and unsafe, controlling food intake provides sense of control.

Emotional eating as self-soothing: Using food to regulate overwhelming emotions when healthy co-regulation (soothing from caregivers) wasn’t available during development.

Eating in secret/shame: When eating was criticized or controlled during childhood, eating becomes something to hide.

Using food to feel safe: Weight gain as protective barrier. Larger body feels safer, particularly for survivors of sexual abuse. This is unconscious but powerful.

These aren’t character flaws or moral failures. They’re survival adaptations. They made sense in the context of trauma, even if they’re no longer adaptive.

Approaching them with judgment and trying to eliminate them through willpower alone fails because it doesn’t address the underlying purpose they serve.

7. Developmental disruption of attachment and self-regulation

Childhood is when we learn emotional regulation, self-soothing, and self-care through relationships with caregivers.

When caregivers are:

• Abusive
• Neglectful
• Unpredictable
• Overwhelmed by their own trauma/addiction/mental illness

Children don’t learn:

• How to identify and tolerate emotions
• How to self-soothe effectively
• How to ask for help
• How to care for their body
• How to regulate arousal and stress

Instead, they develop:

• Food as primary self-soothing mechanism
• Difficulty identifying emotions (alexithymia common in trauma survivors)
• Shame about needs
• Disconnection from body

These developmental deficits affect eating and self-care throughout life.

8. Sleep disruption

Trauma severely disrupts sleep through:

• Hypervigilance (can’t relax enough to sleep)
• Nightmares
• Hyperarousal
• Fear of vulnerability that comes with sleep

Poor sleep worsens:

• Appetite regulation (increased ghrelin, decreased leptin)
• Impulse control
• Emotional regulation
• Insulin sensitivity
• Inflammation

Sleep disruption creates another pathway from trauma to weight gain.

9. Increased substance use and smoking

Trauma survivors have much higher rates of substance use and smoking. Both affect weight:

• Alcohol is calorie-dense and affects metabolism
• Substances affect appetite and eating patterns
• Smoking cessation (when it occurs) often causes weight gain
• Substances used for emotion regulation instead of developing healthier strategies

10. Social and economic pathways

Trauma has social and economic consequences that indirectly affect weight:

• Educational disruption
• Poverty (ACEs associated with lower SES)
• Limited access to healthy food
• Unsafe neighborhoods (less opportunity for physical activity)
• Social isolation
• Difficulty maintaining employment

These create environments where obesity becomes more likely.

The cumulative effect:

Any one of these mechanisms alone would increase obesity risk. Together, they create a perfect storm where maintaining healthy weight becomes genuinely difficult without addressing the underlying trauma.

PTSD and Weight Gain: Specific Considerations

PTSD (Post-Traumatic Stress Disorder) deserves specific attention because the obesity connection is particularly strong.

PTSD prevalence and weight:

Studies consistently show:

• People with PTSD have 2-3 times higher rates of obesity than general population
• PTSD predicts future weight gain
• More severe PTSD symptoms correlate with greater obesity
• The relationship holds across different types of trauma (combat, sexual assault, accidents, natural disasters)

PTSD-specific mechanisms:

Hyperarousal and hypervigilance: Constant state of physiological arousal:

• Elevated cortisol and catecholamines
• Increased appetite and cravings
• Metabolic effects of chronic stress
• Exhaustion despite constant arousal

Avoidance: Core PTSD symptom is avoiding trauma reminders. This can include:

• Avoiding exercise (triggers body sensations that feel unsafe)
• Avoiding certain foods or situations
• Social withdrawal (limits activity)

Intrusive symptoms: Flashbacks, nightmares, intrusive thoughts:

• Severely disrupt sleep
• Create emotional distress that triggers eating
• Maintain chronic stress response

Negative alterations in mood and cognition: Depression, guilt, shame, negative self-beliefs:

• “I’m worthless” → “Why bother taking care of myself?”
• Shame about body → avoidance of healthcare
• Depression reduces motivation for self-care

Numbing and dissociation: Emotional numbing leads to:

• Using food to feel something
• Disconnection from body signals
• Difficulty engaging in healthy behaviors

Medications for PTSD:

Many medications used for PTSD cause weight gain:

• Antipsychotics (sometimes used for PTSD)
• Mirtazapine
• Some mood stabilizers

This creates additional challenges – the medication helps PTSD but worsens weight.

Combat veteran specific issues:

Combat veterans face particular challenges:

• Transition from very active military life to civilian life
• Loss of structured routine and physical training
• Service-connected disabilities limiting mobility
• Military culture around food and eating
• Difficulty accessing trauma-specific treatment

Studies show dramatic weight gain is common in veterans transitioning to civilian life, particularly those with combat PTSD.

Complex PTSD (C-PTSD):

Complex PTSD (from prolonged, repeated trauma particularly in childhood) has additional features:

• Severe emotion regulation difficulties
• Relationship problems
• Negative self-concept
• Dissociation

C-PTSD may have even stronger weight connections than single-incident PTSD because it affects development and creates more pervasive difficulties.

Why Standard Weight Loss Approaches Fail with Trauma

Understanding why typical approaches don’t work for trauma survivors is essential.

“Eat less, move more” is insufficient:

This advice:

• Ignores the biological dysregulation (cortisol, inflammation, brain changes)
• Ignores that eating may serve essential emotional regulation functions
• Ignores autonomic nervous system dysregulation
• Treats the symptom (excess weight) not the cause (trauma and its effects)

Restrictive dieting can be retraumatizing:

For trauma survivors, restrictive diets often:

• Recreate feeling of deprivation from childhood
• Trigger fear and stress response
• Remove the one reliable source of comfort and soothing
• Lead to rebellion and binge eating
• Reinforce shame and sense of failure

Exercise challenges for trauma survivors:

Exercise is often recommended but particularly difficult for trauma survivors:

• Increased heart rate and breathing can feel like panic
• Body awareness required for exercise feels unsafe
• Gyms feel exposing and vulnerable
• Past experiences (bullying about body, assault during exercise) create associations
• Dissociation makes body-based activities difficult

Without trauma-informed approaches, exercise recommendations often fail.

Weight loss triggering for sexual assault survivors:

This is really important and often missed: for survivors of sexual assault, weight loss can trigger trauma responses.

The extra weight may serve protective function:

• “If I’m not attractive, I won’t be assaulted again”
• Larger body feels safer, less vulnerable
• Weight becomes armor

As weight decreases:

• Trauma memories may surface
• Anxiety increases
• Feeling visible and vulnerable is frightening
• Sexual attention increases, which may feel threatening

Many sexual assault survivors unconsciously sabotage weight loss for these reasons. Without addressing the trauma, weight loss feels dangerous and the body resists.

Shame-based approaches are harmful:

Most weight loss culture involves shame:

• “Before” photos designed to show how bad you looked
• Language of “cheating” and “being good/bad”
• Focus on appearance and attractiveness
• Moral judgment about eating choices

For trauma survivors who already carry enormous shame, this is harmful and counterproductive. It reinforces trauma rather than healing it.

The weight loss-regain cycle as retraumatization:

Repeatedly losing and regaining weight:

• Confirms beliefs about being “unable to control themselves”
• Reinforces sense of failure
• Creates more shame
• Can feel like being abused again (by their own body, by the programs that promised success)

Each failed attempt compounds trauma rather than healing it.

Programs don’t address emotional regulation:

Most weight loss programs focus exclusively on food and exercise. They don’t teach:

• How to regulate emotions without food
• How to cope with trauma triggers
• How to tolerate distress
• How to reconnect with body
• How to develop self-compassion

Without these skills, sustainable change is impossible for trauma survivors.

Trauma-Informed Care: Essential Principles

Trauma-informed care means structuring treatment in ways that:

• Recognize trauma’s pervasive impact
• Avoid retraumatization
• Support safety and empowerment
• Address root causes

SAMHSA’s principles of trauma-informed care:

1. Safety: Physical and emotional safety must be established before other work.

For weight treatment:

• No shame or judgment
• Collaborative approach, not authoritarian
• Respect boundaries
• Create predictable, safe environment

2. Trustworthiness and transparency: Clear about what treatment involves, why, and what to expect.

For weight treatment:

• Explain rationale for interventions
• No hidden agenda
• Be honest about challenges and timelines
• Keep commitments

3. Peer support: Connection with others who’ve had similar experiences.

For weight treatment:

• Support groups with other trauma survivors
• Understanding that others have similar struggles
• Reducing isolation and shame

4. Collaboration and mutuality: Shared decision-making, not provider as expert imposing treatment.

For weight treatment:

• Patient determines goals and pace
• Provider offers expertise but patient makes choices
• Work together to find what works for this person

5. Empowerment, voice, and choice: Patient has agency and control throughout treatment.

For weight treatment:

• Patient decides when ready for weight-focused work
• Can say no to interventions
• Has voice in treatment decisions
• Focus on increasing sense of control and capability

6. Cultural, historical, and gender issues: Recognize how trauma interacts with identity, marginalization, and systemic oppression.

For weight treatment:

• Acknowledge weight stigma as form of trauma
• Recognize how racism, sexism, homophobia compound trauma
• Understand cultural contexts
• Address systemic factors affecting access to care

Specific trauma-informed practices in weight treatment:

Ask about trauma: Don’t assume. Use trauma screening questions:

• “Have you experienced events in your life that were very frightening or traumatic?”
• “Have you experienced abuse or neglect, particularly in childhood?”
• “Is there anything in your history that you think might affect your eating or weight?”

This should be routine, not only for people who “look like” trauma survivors.

Understand eating behaviors as adaptations: Reframe binge eating, emotional eating, restriction as survival adaptations rather than failures.

“Your binge eating makes sense given what you experienced. It was a way to cope with overwhelming feelings when you didn’t have other tools. Now we’ll work on developing other tools while respecting what that behavior did for you.”

Move at patient’s pace: Don’t push for rapid weight loss or aggressive interventions. Trauma survivors need:

• Time to build safety
• Gradual approach
• Ability to maintain coping mechanisms until new ones are established

Address trauma directly: Don’t try to treat weight without treating trauma. They’re inseparable for trauma survivors.

Body safety work: Help patient develop sense of safety in their body through:

• Nervous system regulation techniques
• Somatic practices
• Grounding exercises
• Reconnection with body in safe, gradual ways

Avoid triggering language and approaches: No:

• Shame or judgment
• Before/after photos unless patient wants them
• Food as “good/bad”
• Body scrutiny or harsh assessment
• Exercise that feels unsafe

Yes:

• Compassion and understanding
• Focus on health and wellbeing over appearance
• Neutral language about food
• Respect for body and its wisdom
• Movement that feels safe and empowering

My Comprehensive Trauma-Informed Approach

When I work with patients where trauma is a factor in obesity and depression (which is very often), here’s my approach:

Comprehensive assessment including trauma history:

I ask about:

• ACEs (using ACE questionnaire or narrative exploration)
• Adult trauma experiences
• Current PTSD symptoms if relevant
• How trauma affects eating, body image, self-care
• Previous therapy, particularly trauma-focused
• Current sense of safety and stability

I’m explicit that this matters: “Trauma affects both mood and weight through biological mechanisms. Understanding your history helps me provide better treatment.”

Assess current safety and stability:

Before intensive trauma work or weight-focused interventions:

• Is the person currently safe from ongoing abuse?
• Do they have housing and basic needs met?
• Are they actively suicidal or in crisis?
• Do they have minimal support system?

If safety and stability are lacking, these are addressed first. You can’t do trauma work from a place of ongoing danger.

Collaborate on treatment priorities and pace:

I discuss: “There are several things we could work on – mood symptoms, weight, trauma, sleep, stress. What feels most urgent to you? What are you ready to address?”

Some people want to address trauma immediately. Others need to stabilize mood or feel more secure before trauma work. I follow their lead while providing guidance.

Establish foundational safety and regulation:

Before intensive trauma processing, we build:

Nervous system regulation skills:

• Breathing exercises
• Grounding techniques (5-4-3-2-1 sensory awareness, others)
• Vagal toning exercises
• Identifying window of tolerance (Siegel’s model – optimal arousal zone)
• Noticing and managing activation/shutdown

Emotion identification and tolerance:

• Learning to identify emotions (many trauma survivors have alexithymia)
• Building distress tolerance
• Developing self-soothing strategies beyond food

Container exercises: Visualization techniques to “contain” overwhelming material until ready to process it in therapy.

Safety planning: For PTSD symptoms, self-harm urges, or other safety concerns.

This foundation is essential. Without it, trauma work can be overwhelming and destabilizing.

Trauma therapy – the core intervention:

I either provide trauma therapy myself (I’m trained in EMDR and Internal Family Systems) or refer to trauma specialists, depending on severity and my current caseload.

Evidence-based trauma therapies:

EMDR (Eye Movement Desensitization and Reprocessing):

• Uses bilateral stimulation while processing trauma memories
• Helps reprocess memories so they’re less triggering
• Strong evidence base for PTSD
• What I use most commonly

Prolonged Exposure (PE):

• Gradual, repeated, prolonged exposure to trauma memories and triggers
• Reduces avoidance and anxiety
• Strong evidence for PTSD

Cognitive Processing Therapy (CPT):

• Addresses unhelpful beliefs resulting from trauma
• Particularly helpful for guilt and shame
• Strong evidence for PTSD

Somatic Experiencing:

• Body-based trauma therapy
• Focuses on releasing trauma held in the body
• Particularly helpful for people with significant dissociation

Sensorimotor Psychotherapy:

• Integrates body awareness into trauma processing
• Addresses how trauma affects movement and body patterns

Internal Family Systems (IFS):

• Works with different parts of self (the part that binges, the part that restricts, the traumatized child part, etc.)
• Helps these parts communicate and heal
• Very effective for trauma and eating issues

The specific modality matters less than:

• Therapist is trained and competent
• Patient feels safe with therapist
• Approach fits patient’s needs and preferences

I work closely with trauma therapists:

If I refer out for trauma work, I:

• Maintain regular communication with trauma therapist
• Provide medication support that complements therapy
• Monitor safety and stability
• Coordinate care so all providers are working together

Psychiatric medication thoughtfully:

For trauma survivors with depression and obesity:

Medication choices considering:

• Avoid medications that worsen weight if possible
• SSRIs can help PTSD (sertraline and paroxetine FDA-approved for PTSD, though I avoid paroxetine due to weight gain)
• Prazosin sometimes helpful for PTSD nightmares
• Consider medications that support both mood and weight management

Medication doesn’t replace trauma therapy: Medication can help with:

• Sleep (essential for trauma recovery)
• Reducing hyperarousal
• Stabilizing mood
• Making trauma therapy more tolerable

But medication alone doesn’t heal trauma. It supports the trauma therapy work.

Metabolic interventions integrated with trauma work:

Gentle nutrition changes:

• No restrictive dieting
• Focus on adding nutritious foods, not eliminating
• Anti-inflammatory nutrition (helps both trauma-related inflammation and mood)
• Adequate nutrition to support healing

Movement that feels safe:

• Start with gentle movement (walking, gentle yoga, swimming)
• Emphasize how movement feels, not calories burned
• Trauma-sensitive yoga specifically designed for trauma survivors
• Build gradually as safety in body increases

Low-dose GLP-1 medication when appropriate: For trauma survivors with significant obesity and metabolic dysfunction, I use low-dose tirzepatide (2.5mg weekly or less) because:

• Reduces inflammation (high in trauma survivors)
• Helps with emotional eating through reward pathway effects
• Doesn’t require intensive behavioral changes before benefits appear
• Supports metabolic health while trauma work proceeds

I’m explicit that this supports the work but doesn’t replace trauma therapy.

Sleep optimization: Essential for trauma recovery and weight management. Address:

• PTSD nightmares if present (imagery rehearsal therapy, prazosin)
• Hyperarousal preventing sleep (relaxation training, sleep hygiene, medication)
• Sleep apnea if present (common with obesity)

Addressing stress and nervous system dysregulation:

• Mindfulness practices
• Breathwork
• Yoga (trauma-sensitive)
• Time in nature
• Social connection
• Anything that supports parasympathetic activation (rest/digest)

Building self-compassion: Essential for trauma survivors who often carry enormous self-blame and shame.

Practices:

• Self-compassion exercises (Kristin Neff’s work)
• Challenging self-critical thoughts
• Understanding eating behaviors compassionately
• Recognizing the courage it takes to heal

The timeline is individualized:

Some people stabilize quickly and begin trauma processing within months. Others need a year or more of stabilization and skill-building before intensive trauma work.

Some people address trauma and weight simultaneously. Others focus on trauma first, then metabolic health naturally improves.

I follow the patient’s pace and readiness rather than imposing a timeline.

Monitoring for both progress and safety:

I’m tracking:

• PTSD/trauma symptoms
• Mood
• Eating patterns and relationship with food
• Sleep
• Weight (but not as primary measure)
• Sense of safety and empowerment
• Ability to regulate emotions
• Self-compassion

If someone is destabilizing, we slow down. If they’re ready for more intensive work, we proceed.

Case Example: When Trauma Healing Unlocks Everything

Let me share a case that illustrates how central trauma can be.

Initial presentation:

Maria is 52, presents with severe depression, obesity (BMI 42), and multiple failed weight loss attempts. She’s been depressed on and off for 20+ years, tried numerous antidepressants with minimal benefit.

She describes intense binge eating 4-5 times weekly – “I go into a trance and eat huge amounts, then feel disgusting.” She’s tried multiple weight loss programs, usually loses 20-30 pounds then regains it plus more. She feels hopeless and like a failure.

Sleep is poor with nightmares several times weekly. She’s hypervigilant and anxious. Relationships are difficult – she struggles with trust and often feels threatened when people get close.

Current medications: sertraline 200mg, which she says “barely helps.”

Trauma history emerges:

As we talk, significant trauma history becomes clear (though she didn’t initially volunteer it, thinking it was “irrelevant” to her depression and weight):

Severe childhood sexual abuse by stepfather from ages 7-14. Mother didn’t believe her when she tried to disclose. She left home at 16.

Adult intimate partner violence in her 20s. Later sexual assault in her 30s.

She’s never had trauma-focused therapy. She’s “dealt with it on my own and moved on.”

Assessment shows:

She meets criteria for complex PTSD:

• Intrusive symptoms (nightmares, flashbacks)
• Avoidance (of certain places, dissociation)
• Hyperarousal (always on edge, hypervigilant)
• Negative self-beliefs (“I’m damaged,” “It’s my fault”)
• Severe emotion regulation difficulties
• Relationship difficulties

ACE score: 8 out of 10 (extremely high)

Her depression has clear trauma underpinnings. The binge eating is dissociative – she describes it as “checking out” and “escaping my head.”

She consciously maintained higher weight after the adult sexual assault: “If I’m not attractive, maybe I’ll be safer.” Weight became protective armor.

Labs show severe inflammation (CRP 11.3 mg/L), prediabetes, severe vitamin D deficiency, gut dysfunction on stool testing.

The picture is clear:

This isn’t just depression and obesity. This is severe complex PTSD with eating behaviors that are trauma responses. Treating with more antidepressants and weight loss attempts without addressing trauma won’t work – which her history has proven.

Treatment plan:

Establishing safety and stability first:

• Continue current medication initially
• Work on basic nervous system regulation (breathing, grounding)
• Establish safe therapeutic relationship
• Address immediate safety concerns (she’s safe now)
• Begin developing emotion regulation skills
• Sleep support (trazodone added for nightmares and sleep)

First 2-3 months is stabilization. No weight focus yet. Building foundation for trauma work.

Trauma therapy begins:

After 3 months of preparation, we begin EMDR trauma processing. (I’m doing this work since I’m trained in EMDR and she feels safe with me.)

We process:

• Most severe abuse memories
• Sexual assault in adulthood
• Experiences of not being believed/protected
• Shame and self-blame

This is hard work. Sessions are intense. She needs the regulation skills we built to manage the process.

Simultaneously, I refer her to body-based trauma therapist for weekly somatic experiencing sessions. The trauma is held in her body – she needs body-based work alongside EMDR.

Metabolic support continues alongside trauma work:

• Start tirzepatide 2.5mg weekly for inflammation, metabolic support
• Anti-inflammatory nutrition
• Gut healing protocol
• Continue sleep support
• Gentle movement (walking) as she can tolerate

No explicit weight loss focus: We’re not “trying to lose weight.” We’re healing trauma, reducing inflammation, supporting her body’s natural healing.

What happened:

Months 3-6: As trauma processing begins, things are difficult. Memories surface. Emotions are intense. But she’s managing with skills she’s built.

Nightmares decreasing. Sleep improving with EMDR. Hypervigilance reducing somewhat.

Months 6-12: Significant progress in trauma work. Many memories processed. She’s developing more compassion for her younger self. Self-blame reducing. “I’m beginning to understand it wasn’t my fault.”

Binge eating decreasing dramatically. From 4-5 times weekly to 1-2 times monthly. “I don’t need to escape my feelings as much now that I’m processing the trauma.”

Lost 32 pounds without “dieting” – she’s just naturally eating differently as emotional eating decreases and inflammation reduces.

CRP down to 4.6 mg/L. Sleep much better. Energy increasing.

She’s reconnecting with her body through somatic work. Beginning to feel safe in her body for the first time.

Year 2: Trauma work continuing but less intensive. Most processing complete. Now integrating and building new patterns.

Depression much improved. She’s actually happy sometimes – “I didn’t know I could feel this way.”

Maintained 38-pound weight loss. She’s not focused on weight but on healing and feeling good in her body.

She’s begun dating cautiously – able to tolerate vulnerability and connection in ways she couldn’t before.

Most importantly, she feels like she’s healing at a fundamental level. Not just managing symptoms but actually healing trauma that’s affected her entire life.

The key insight:

All those failed diets weren’t failures of willpower. The binge eating wasn’t a character flaw. The weight wasn’t just from “eating too much.”

It was all trauma. The eating was a trauma response. The weight was protective. The depression was trauma-based. Without addressing the trauma directly, sustainable change was impossible.

Once trauma was addressed, everything else became possible.

Special Populations and Considerations

Sexual assault survivors:

Require particular sensitivity:

• Weight loss may trigger trauma memories and feel unsafe
• Body focus can be retraumatizing
• Exercise recommendations need careful consideration
• Therapist gender may matter (patient choice)
• Timeline may be longer as safety in body is established

Combat veterans:

Specific considerations:

• Military culture and identity around physical fitness
• Service-connected disabilities may limit mobility
• Transition challenges (structure, activity, purpose)
• Camaraderie lost
• VA system complexities

Treatment often benefits from:

• Veteran-specific support groups
• Understanding military culture
• Acknowledging service and sacrifice
• Peer support with other veterans

Childhood neglect (not just abuse):

Emotional or physical neglect has similar effects to abuse:

• Didn’t learn self-care or self-soothing
• May have food insecurity history (eating whenever food available)
• Difficulty recognizing and meeting own needs
• May require teaching basic self-care

Complex developmental trauma:

Multiple, chronic childhood adversities:

• Often require longer treatment
• May need more intensive stabilization before trauma processing
• Personality patterns (attachment difficulties, identity issues) need addressing
• Require therapist experienced with complex trauma

Intergenerational trauma:

Trauma transmitted across generations:

• Historical trauma (slavery, genocide, colonization)
• Family trauma patterns
• Cultural trauma
• Requires culturally-informed approaches

Medical trauma:

Often overlooked but significant:

• Childhood medical procedures
• Serious illness or injury
• Healthcare maltreatment
• Weight-related medical trauma (judgmental providers, forced weigh-ins, fat shaming)

Can make engaging with healthcare retraumatizing.

For Providers: Creating Trauma-Informed Practice

If you’re a provider working with patients with obesity:

Assume trauma is present:

Given how common ACEs are (64% have at least one), assume most patients have trauma history. Structure care accordingly.

Screen for trauma routinely:

Include trauma screening in assessment. Simple questions:

• “Have you experienced frightening or traumatic events?”
• “Any history of abuse or violence?”
• “ACE questionnaire” (widely available)

Avoid retraumatizing:

Common practices that can retraumatize:

• Public weigh-ins
• Judgmental comments about weight
• Before/after photos without consent
• Shame-based motivation
• Rigid rules and demands
• Not respecting “no”

Refer for trauma therapy:

Most providers aren’t trained in trauma therapy. Know trauma therapists in your area for referral.

Explain: “I think some trauma work would be really helpful alongside the metabolic/psychiatric treatment we’re doing.”

Collaborate with trauma therapists:

If patient is in trauma therapy, communicate with trauma therapist (with patient consent). Coordinated care produces better outcomes.

Be patient with timeline:

Trauma healing takes time. Expecting rapid weight loss from trauma survivors sets up failure. Sustainable change requires healing trauma first or simultaneously.

Focus on health, not weight:

Shift focus from “weight loss” to “healing” and “taking care of yourself.” This is less triggering and more sustainable.

Recognize your own responses:

Working with trauma can trigger providers’ own trauma history or create vicarious trauma. Get supervision/consultation. Take care of yourself.

For Patients: If This Resonates With You

If you’re reading this and recognizing yourself:

Your struggle with weight likely has roots in trauma:

This isn’t an excuse or cop-out. It’s understanding root causes so you can address them effectively.

The eating behaviors make sense:

Binge eating, emotional eating, using food for comfort – these are adaptations. They helped you survive. They’re not failures.

You deserve trauma-focused treatment:

Don’t just keep trying diets and wondering why they don’t work. Address the trauma. That’s the path to sustainable healing.

Trauma therapy works:

EMDR, PE, CPT, somatic work – these therapies are effective. You don’t have to live with unhealed trauma forever.

Find trauma-informed providers:

Seek:

• Trauma therapist (EMDR, somatic work, PE, CPT trained)
• Medical providers who understand trauma-weight connections
• Support groups with other trauma survivors

Be patient with yourself:

Healing takes time. You’re not just losing weight – you’re healing trauma that’s affected your entire life. That’s profound work that deserves time.

The weight may resist initially:

As you begin healing, weight may not change immediately. That’s okay. The trauma healing is happening. Weight changes often follow trauma healing, not precede it.

You deserve compassion:

The most important thing is treating yourself with compassion. You survived. You’re working on healing. That takes courage.

The Future: Trauma-Informed Obesity Treatment

I envision a future where:

Trauma screening is routine: Every person seeking obesity treatment is screened for trauma history and PTSD.

Trauma-informed care is standard: All providers working with obesity understand trauma’s role and structure care accordingly.

Integrated treatment is available: Access to both trauma therapy and metabolic treatment, coordinated and integrated.

Research clarifies specifics: More studies on:

• Best ways to integrate trauma therapy with metabolic treatment
• Which trauma therapies work best for this population
• Neurobiological mechanisms
• Predictors of who benefits most from trauma-focused approaches

Stigma decreases: Understanding that obesity often has trauma roots reduces blame and shame.

We’re not there yet. But we’re moving in this direction. More providers are recognizing trauma’s role. More research is being conducted. More integrated treatment programs are emerging.

The paradigm is shifting from “calories in, calories out” to understanding root causes including trauma.

Conclusion: Addressing What’s Really Wrong

Throughout this series, I’ve emphasized that treating obesity and depression requires addressing root causes, not just suppressing symptoms.

Trauma is often the deepest root cause.

The chronic inflammation. The stress hormone dysregulation. The eating behaviors that look like “lack of willpower” but are actually trauma responses. The weight that serves protective functions. The nervous system stuck in fight/flight or shutdown.

All of this comes from trauma. And all of it needs to be addressed for genuine healing.

This isn’t about pathologizing obesity or saying everyone with obesity has trauma (not true). But it is saying that trauma is incredibly common in people struggling with both obesity and depression, and when it’s present, it must be addressed.

You can’t medicate or diet your way out of unhealed trauma. You have to address the trauma itself.

The good news: trauma can heal. With appropriate therapy, nervous system regulation work, body-based healing, and comprehensive support, trauma’s effects can be resolved or significantly reduced.

When trauma heals, the depression often improves dramatically. The eating behaviors that felt uncontrollable become manageable. The weight that wouldn’t budge starts moving. The self-hatred transforms into self-compassion.

Healing trauma is often the key that unlocks everything else.

If you’re struggling with both depression and obesity, and you have trauma history, please consider trauma-focused therapy. It might be the missing piece that makes everything else possible.

You deserve healing. You deserve to feel safe in your body. You deserve to be free from trauma’s grip on your life.

That healing is possible. It takes courage, time, and appropriate support. But it’s absolutely possible.

In our final article of this extended series, we’ll provide a comprehensive medication guide – every psychiatric medication rated for metabolic effects.

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