Repeated traumatic experiences in eating disorders and their association with eating symptoms

The maltreated eco-phenotype of eating disorders: A new diagnostic specifier? A systematic review of the evidence and comprehensive description

This systematic review aimed to summarize the evidence on the existence of a distinct phenotypic expression of Eating Disorders (EDs) associated with childhood maltreatment (CM), the so-called maltreated eco-phenotype of EDs. PRISMA standards were followed. Articles providing data about the characteristics of individuals with an ED reporting CM were included. Relevant results were extracted and summarized. A quality assessment was performed. A total of 1207 records were identified and screened, and 97 articles published between 1994 and 2023 were included. Findings revealed distinct biological and clinical features in patients with EDs reporting CM, including neuroanatomical changes, altered stress responses, ghrelin levels, inflammation markers, and gut microbiota composition. Clinically, CM correlated with severer eating behaviors, higher psychiatric comorbidity, impulsivity, emotional dysregulation, and risky behaviors. Additionally, CM was associated with poorer treatment outcomes, especially in general psychopathology and psychiatric comorbidities. This review highlighted the need to move towards an etiologically informed nosography, recognizing CM not merely as a risk factor, but also as an etiologic agent shaping different eco-phenotypic variants of EDs.

A longitudinal study of potentially traumatic events and binge-purge eating disorder onset in children

Although the association between childhood trauma and subsequent binge-purge spectrum eating disorders (BP-EDs) is established in adult samples, little is known about the temporal association between potentially traumatic life events and BP-ED onset in children. Using longitudinal data from the U.S.-nationwide Adolescent Brain Cognitive Development (ABCD) study with children aged 9-10 at baseline, logistic regression with complex sampling assessed the longitudinal association of exposure to potentially traumatic events (PTEs) at baseline and meeting BP-ED criteria one year later. Children exposed to PTEs prior to baseline had 1.91 times greater odds of being diagnosed with a BP-ED one year later (95% CI: 1.26 - 2.90; p = .004), compared to those who had not experienced a PTE. The current study extends previous cross-sectional research to show a significant temporal association between childhood PTEs before ages 9-10 and the subsequent onset of BP-EDs one year later. Future research should consider specific timing of PTE exposure as well as examining children diagnosed with restrictive eating disorders.

Trauma Experiences Are Common in Anorexia Nervosa and Related to Eating Disorder Pathology but Do Not Influence Weight-Gain during the Start of Treatment

OBJECTIVE

The main characteristics of Anorexia Nervosa (AN) in adults are restriction of energy intake relative to requirements leading to significant weight loss, disturbed body image, and intense fear of becoming fat. Traumatic experiences (TE) have been reported as common, although less is known about the relationship with other symptoms in severe AN. We investigated the presence of TE, PTSD, and the relation between TE, eating disorder (ED) symptoms, and other symptoms in moderate to severe AN (n = 97) at admission to inpatient weight-restoration treatment. All patients were enrolled in the Prospective Longitudinal all-comer inclusion study on Eating Disorders (PROLED).

METHODS

TE were assessed using the Post-traumatic stress disorder checklist, Civilian version (PCL-C), and ED symptoms using the Eating Disorder Examination Questionnaire (EDE-Q); depressive symptoms were assessed using the Major Depression Inventory (MDI), and the presence of Post-traumatic Stress Disorder (PTSD) was diagnosed according to ICD-10 criteria.

RESULTS

The mean score on PCL-C was high (mean 44.6 SD 14.7), with 51% having a PCL-C score at or above 44 (n = 49, suggested cut-off for PTSD), although only one individual was clinically diagnosed with PTSD. There was a positive correlation between baseline scores of PCL-C and EDE-Q-global score (r = 0.43; p < 0.01) as well as of PCL-C and all EDE-Q subscores. None of the included patients were admitted for treatment of TE/PTSD during the first 8 weeks of treatment.

CONCLUSIONS

In a group of patients with moderate to severe AN, TE were common, and scores were high, although only one had a diagnosis of PTSD. TE were related to ED symptoms at baseline, but this association diminished during the weight restoration treatment.

Novel ketamine and zinc treatment for anorexia nervosa and the potential beneficial interactions with the gut microbiome

Anorexia nervosa (AN) is a severe illness with diverse aetiological and maintaining contributors including neurobiological, metabolic, psychological, and social determining factors. In addition to nutritional recovery, multiple psychological and pharmacological therapies and brain-based stimulations have been explored; however, existing treatments have limited efficacy. This paper outlines a neurobiological model of glutamatergic and γ-aminobutyric acid (GABA)-ergic dysfunction, exacerbated by chronic gut microbiome dysbiosis and zinc depletion at a brain and gut level. The gut microbiome is established early in development, and early exposure to stress and adversity contribute to gut microbial disturbance in AN, early dysregulation to glutamatergic and GABAergic networks, interoceptive impairment, and inhibited caloric harvest from food (e.g., zinc malabsorption, competition for zinc ions between gut bacteria and host). Zinc is a key part of glutamatergic and GABAergic networks, and also affects leptin and gut microbial function; systems dysregulated in AN. Low doses of ketamine in conjunction with zinc, could provide an efficacious combination to act on NMDA receptors and normalise glutamatergic, GABAergic and gut function in AN.

Life Events in the Etiopathogenesis and Maintenance of Restrictive Eating Disorders in Adolescence

Life events (traumatic and protective) may be critical factors associated with eating disorders and their severity. To date, there is little literature concerning the role of life events in adolescence. The main goal of this study was to explore in a sample of adolescent patients with restrictive eating disorders (REDs) the presence of life events in the year before enrolment and to characterize them according to timing. Furthermore, we investigated correlations between REDs severity and the presence of life events. In total, 33 adolescents completed the EDI-3 questionnaire to assess RED severity using EDRC (Eating Disorder Risk Composite), GPMC (General Psychological Maladjustment Composite), and the Coddington Life Events Scales-Adolescent (CLES-A) questionnaires to define the presence of life events in the last year. Of these, 87.88% reported a life event in the past year. A significant association emerged between elevated clinical GPMC and the presence of traumatic events: patients who had experienced at least one traumatic life event in the year before enrolment presented higher clinically elevated GPMC compared to patients who had not. These results suggest that obtaining early information about traumatic events in clinical practice may help prevent the occurrence of new events and improve patient outcomes.

Risk factors for eating disorders: findings from a rapid review

BACKGROUND

Risk factors represent a range of complex variables associated with the onset, development, and course of eating disorders. Understanding these risk factors is vital for the refinement of aetiological models, which may inform the development of targeted, evidence-based prevention, early intervention, and treatment programs. This Rapid Review aimed to identify and summarise research studies conducted within the last 12 years, focusing on risk factors associated with eating disorders.

METHODS

The current review forms part of a series of Rapid Reviews to be published in a special issue in the Journal of Eating Disorders, funded by the Australian Government to inform the development of the National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2021, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, or population studies). Data pertaining to risk factors for eating disorders were synthesised and outlined in the current paper.

RESULTS

A total of 284 studies were included. The findings were divided into nine main categories: (1) genetics, (2) gastrointestinal microbiota and autoimmune reactions, (3) childhood and early adolescent exposures, (4) personality traits and comorbid mental health conditions, (5) gender, (6) socio-economic status, (7) ethnic minority, (8) body image and social influence, and (9) elite sports. A substantial amount of research exists supporting the role of inherited genetic risk in the development of eating disorders, with biological risk factors, such as the role of gut microbiota in dysregulation of appetite, an area of emerging evidence. Abuse, trauma and childhood obesity are strongly linked to eating disorders, however less conclusive evidence exists regarding developmental factors such as role of in-utero exposure to hormones. Comorbidities between eating disorders and mental health disorders, including personality and mood disorders, have been found to increase the severity of eating disorder symptomatology. Higher education attainment, body image-related factors, and use of appearance-focused social media are also associated with increased risk of eating disorder symptoms.

CONCLUSION

Eating disorders are associated with multiple risk factors. An extensive amount of research has been conducted in the field; however, further studies are required to assess the causal nature of the risk factors identified in the current review. This will assist in understanding the sequelae of eating disorder development and in turn allow for enhancement of existing interventions and ultimately improved outcomes for individuals.

Young Patients with Anorexia Nervosa: The Contribution of Post-Traumatic Stress Disorder and Traumatic Events

Background and Objectives: Anorexia nervosa (AN) is a complex disorder whose etiopathogenesis involves both biological and environmental factors. The aims of the present study were to retrospectively analyze risk factors in young patients with AN and to assess differences in clinical and eating-related symptoms between patients with and without a diagnosis of post-traumatic stress disorder (PTSD) and with or without a history of acknowledged risk factors. Materials and Methods: Sixty-four patients with AN (<25 years old) were recruited and completed an anamnestic evaluation and the following self-report measures: Eating Disorder Examination Questionnaire (EDE-Q), Childhood Trauma Questionnaire (CTQ), State-Trait Anxiety Inventory (STAI-Y), Beck Depression Inventory (BDI), Life Events Checklist (LEC), and Dissociative Experience Scale (DES). The PTSD diagnosis was assigned according to the Structured Clinical Interview for the DSM-5 (SCID-5). Results: The most frequent risk factors were those associated with relational traumatic events and familiarity for psychiatric disorders. Higher severity of body-related symptoms (i.e., those symptoms impacting on body image and perception and leading to body concerns) emerged in patients with PTSD, versus patients without PTSD diagnosis; however, after controlling for dissociative symptoms, only differences in BMI remained significant. Concerning other risk factors, those with a history of childhood trauma were more depressed than patients without such history and those with familiarity with eating disorders reported more AN-related hospitalizations in the past than those individuals without familiarity. Conclusion: These results suggest the importance of investigating the presence of risk factors and PTSD diagnosis in patients with AN, and to treat post-traumatic symptoms in young patients in order to decrease the risk of developing severe forms of AN. Moreover, a particular focus on those patients with a family member affected by an eating disorder could be of clinical utility.

Child Trauma Experiences and Dissociative Symptoms in Women with Eating Disorders: Case-Control Study

Background: many people with different diagnoses, including eating disorders, have suffered traumatic experiences in childhood. Method: a case-control study was performed. The objective of this study was to evaluate the presence of child trauma and dissociative symptoms in people with eating disorders and compare the results obtained with a control group. Participants were administered the Mini International Neuropsychiatric Interview (MINI) and the Structured Clinical Interview for Personality Disorders (SCID-II) to confirm diagnostic criteria and explore possible comorbidities. Traumatic experiences in childhood were evaluated with the Child Trauma Questionnaire in its abbreviated version (CTQ-SF), psychoform dissociation was measured with the Scale of Dissociative Experiences (DES-II) and somatoform dissociation with the Somatoform Dissociation Scale (SDQ-20). Results: women with eating disorders reported a greater severity and higher prevalence of child trauma than the control group. Significant differences were found by groups in dissociative symptoms. Conclusions: our results, in a Spanish sample, confirm the findings of previous studies.

Relationship between Trauma History and Eating Disorders in Adolescents

Reasons for developing an eating disorder (ED) are complex, yet one plausible risk factor gaining more relevance in adolescents with EDs is childhood trauma. The current study is the first to examine the presence of childhood trauma in relation to ED symptomatology in adolescents using DSM-5 criteria. It was hypothesized that patients with more traumatic experiences also have more severe ED symptoms. 112 therapists currently treating adolescent patients diagnosed with an ED completed an online survey consisting of a DSM-5 ED symptom checklist and a childhood trauma questionnaire on a current adolescent patient whom they have seen for at least eight sessions. Children with multiple traumatic experiences and the severity of those experiences demonstrated a relationship to overall ED (r = .179, p = .059) and bulimia symptoms (r = .183, p = .054), specifically binging (r = .188, p = .047). and purging (r = .217, p = .021). In addition, logistic regression analyses indicated that adolescents high on bulimia nervosa (B = 4.694, p = .044) were more likely to have been traumatized victims of violence. Exploratory analyses support prior literature that suggest similarities between adolescents' lack of control of the experienced trauma(s) with lack of control of ED symptoms. These findings highlight the importance of exploring trauma history when treating an adolescent with an ED, especially bulimia.

Traumatic events and post-traumatic symptoms in anorexia nervosa

Background: Traumatic Events (TEs) are often seen as risk factors not only for the development of eating disorders (EDs) but also for their impact on the severity of clinical presentation and psychiatric comorbidities. Objective: This study aimed to assess the prevalence and time of occurrence of TEs in the two subtypes of anorexia nervosa (AN; restricting [RAN] and binge-purging [BPAN]) and to investigate differences in TEs (number, type, frequency) as well as clusters of post-traumatic symptoms and emotional dysregulation between the two groups. Method: Seventy-seven hospitalized women were recruited and divided into two subgroups according to their AN subtype. Participants completed the following self-reported measures: Eating Disorder Inventory-2 (EDI-2), Life Events Checklist (LEC), Impact of Events Scale-Revised (IES-R) and the Difficulties in Emotion Regulation Scale (DERS). Results: A higher occurrence of TEs was found in patients with BPAN than in those with RAN. In particular, there were significantly more women in the BPAN group than in the RAN group who had been sexually assaulted. Exposure to TEs happened before the onset of illness in most patients, regardless of the AN subtype. Finally, the BPAN group had significantly higher scores in terms of post-traumatic symptoms and emotional dysregulation than RAN patients. Conclusions: Patients with BPAN showed a higher occurrence of TEs, post-traumatic symptom clusters, and emotional dysregulation than those with RAN. These findings are of interest as treatments could benefit from trauma-informed interventions for those affected by AN, and particularly for those with the binge-purging subtype.

Childhood Traumatic Experiences and Dissociative Phenomena in Eating Disorders: Level and Association with the Severity of Binge Eating Symptoms

The aim of the current study is to evaluate the presence of childhood trauma, psychoform, and somatoform dissociation in eating disorders (ED). Eighty-six ED outpatients participated in this study, 20 of them were diagnosed with restrictive anorexia (AN-R), 10 of them with anorexia nervosa binge-purging subtypes (AN-B), 25 with bulimia nervosa (BN), and 31 with binge eating disorder (BED). They were matched by sex and age with a control group consisting of 86 healthy subjects (HC). Traumatic experiences were assessed by means of the Childhood Trauma Questionnaire (CTQ), psychological, and somatoform dissociation, respectively, by means of the Dissociative Experience Scale (DES-II) and Somatoform Dissociation Questionnaire (SDQ-20), and binge eating symptoms by means of Binge Eating Scale (BES). ED subjects showed higher levels of childhood trauma, and both psychoform and somatoform dissociation compared to HC subjects. ED patients showed higher levels of childhood trauma compared to the HC group. No significant differences were shown between ED subgroups with respect to all forms of childhood trauma. BN and AN-B subgroups showed higher levels of both psychological and somatoform dissociation. Dissociation and childhood trauma predicted the severity of binge eating symptoms. Our results confirm previous studies in the same field.

The influence of childhood polyvictimization on disordered eating symptoms in emerging adulthood

Children who endure multiple victimization experiences, or "polyvictims," are vulnerable to maladaptive outcomes. Yet, little research exists evaluating the relationship between childhood polyvictimization and disordered eating symptoms (DES) in emerging adulthood. The current study examines the relationship between childhood polyvictimization and DES in emerging adults. Data were collected from 288 participants across two universities using online self-report measures. Hierarchical regression analyses revealed a significant positive relationship between number of childhood victimization experiences and DES in young adulthood (ß=0.14; p=0.016). Female participants were more likely to demonstrate DES (ß=0.14; p=0.008). Further, high levels of emotion dysregulation during young adulthood were associated with more DES (ß=0.33; p<0.001). Findings suggest that exposure to victimization experiences in childhood increases individuals' risk for exhibiting DES in young adulthood. Results also highlight the strong relationship between individuals' emotion regulation abilities and the presence of DES. Findings align with the theory that children who have endured high levels of victimization often feel overwhelmed by their emotions and circumstances, demonstrate emotion regulation difficulties, and may rely on maladaptive coping strategies, including disordered eating, to manage adversities. Study results emphasize the importance of considering victimization history when working with emerging adults displaying disordered eating symptomatology.

Childhood neglect in eating disorders: A systematic review and meta-analysis

Individuals with eating disorders (EDs) often report a history of early traumatization. Although great attention has been paid to certain types of trauma, such as sexual and emotional abuse, less is known about the occurrence of childhood neglect in individuals with EDs. The aim of the present meta-analysis was to provide an estimate of the prevalence of childhood emotional neglect (EN) and physical neglect (PN) in individuals with EDs. A systematic literature search, a critical appraisal of the collected studies, and a meta-analysis were conducted. An electronic search of EMBASE, PsycINFO, PubMed, and the Cochrane Library from the inception of these databases up to July 2015 was performed. The final meta-analyzed data set included 7 studies focusing on EN in EDs (N = 963) and 6 on PN in EDs (N = 665). Our meta-analytic data showed that among individuals with EDs, the prevalence of childhood EN is 53.3%, whereas 45.4% reported experience of childhood PN. These preliminary findings confirm the high prevalence of childhood EN and PN in ED samples compared to the general population and underline the importance of systematically screening for the presence of neglect as a possible traumatic experience in individuals with EDs, as its presence may have important consequences for the therapeutic approach.

Is childhood trauma associated with lifetime suicide attempts in women with bulimia nervosa?

PURPOSE

The purpose of this study was to explore the association between specific forms of childhood abuse and neglect with lifetime suicide attempts in women with bulimia nervosa (BN).

METHODS

Two hundred and four women aged 18-65 (mean 25.6 years, SD 9.13) with full or subclinical BN were recruited in five US Midwestern communities and specialized eating disorder clinics. Participants completed questionnaires including the Childhood Trauma Questionnaire (CTQ) and self-reported whether they had ever had a lifetime suicide attempt. Logistic regression analyses were used to predict lifetime suicide attempts from each subscale of the CTQ.

RESULTS

Childhood emotional, physical, and sexual abuse were significantly associated with the presence of a lifetime suicide attempt in women with BN. Childhood emotional and physical neglect were not associated with suicide attempts.

CONCLUSIONS

Individuals with BN who have experienced childhood emotional and sexual abuse are at increased risk of a lifetime suicide attempt. Future research is needed to understand the mechanism to address in treatment and prevention efforts. It is important for clinicians to be aware of the potential increased risk of suicide in individuals with BN with a history of childhood abuse.