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

Autistic traits are associated with the presence of post-traumatic stress symptoms and suicidality among subjects with autism spectrum conditions and Anorexia nervosa

INTRODUCTION

Recently, growing attention has been paid to the presence of undetected Autism Spectrum Disorder (ASD) and subthreshold autistic traits (ATs) among females, and on their gender specific manifestation. In particular, the recent literature focused on the overlap between autism spectrum and eating disorders, which share with ASD not only features such as of cognitive inflexibility but also a link with trauma- and stress-related disorders. In this framework, we aimed to assess the interaction between ATs, stress- or trauma-related symptoms, and the risk of suicidality in subjects with different mental conditions.

METHODS

184 subjects were divided in three diagnostic groups: Broad autism phenotype (BAP), Anorexia Nervosa (AN) and Healthy Controls (HCs) and assessed with the Adult Autism Subthreshold Spectrum (AdAS Spectrum) questionnaire, the Trauma and Loss Spectrum - Self Report (TALS - SR) questionnaire and the Mood Spectrum - Self Report (MOODS - SR) questionnaire.

RESULTS

AN subjects reported notable ATs reinforcing the hypothesis that AN might represent an atypical ASD manifestation more common in women. Furthermore, both AN and BAP subjects showed a considerable presence of trauma/stress associated symptoms. The dimension of trauma/stress related symptoms also appeared to be associated with ATs, and to significantly mediate the relationship between ATs and suicidality risk. Lastly, AN were found to have a stronger correlation with the presence of post-traumatic stress symptoms.

CONCLUSIONS

the results support the presence of a link between ATs and AN. Moreover, AN seems to be more strongly associated with post-traumatic stress symptoms than BAP. ATs and trauma/stress related symptoms may interact in shaping suicidality risk in these patients.

Non-interpersonal traumatic events in patients with eating disorders: a systematic review

Objectives

The purpose of the systematic review was to synthesize literature on eating disorders (ED) and non-interpersonal traumatic events (NTE) and consolidate the reported prevalence of NTE in patients with an ED.

Methods

The literature search was performed in Embase, PsycInfo, and PubMed. The keywords in the search were "eating disorder," "trauma" and "non-interpersonal," using index-terms and free-search keywords related to NTE and ED. The PRISMA guidelines were followed. Relevant studies were screened using Rayyan.

Results

Of the 16 studies included in the quantitative synthesis, five overall types of NTE were identified: accidents, illness, injury, natural disaster and war. Findings provided tentative evidence for illness and injury being more prevalent in patients suffering from an ED compared to controls. The remaining subtypes of NTE did not show a higher prevalence in patients with an ED when compared to controls. Findings also suggest that those with binge/purge subtype of anorexia nervosa (AN) had a higher prevalence of non-interpersonal traumatic events compared to the restrictive subtype of AN.

Discussion

This systematic review provided a clear synthesis of previous findings related to NTE among patients with an ED. Noteworthy, is that many studies do not take into account if the trauma happened prior or after to ED onset, which may affect the association. Furthermore, the body of research on NTE in patients with ED is exceedingly limited, and more research is needed.

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.

Eye movement desensitisation and reprocessing as add-on treatment to enhanced cognitive behaviour therapy for patients with anorexia nervosa reporting childhood maltreatment: A quasi-experimental multicenter study

OBJECTIVE

This quasi-experimental study aimed to compare the outcome of patients with Anorexia Nervosa (AN) reporting moderate/severe childhood maltreatment (CM) treated exclusively with Enhanced Cognitive Behaviour Therapy (CBT-E) or with CBT-E plus Eye Movement Desensitisation and Reprocessing (EMDR).

METHOD

A total of 75 patients with AN reporting moderate/severe CM were initially assessed regarding body mass index (BMI), general and eating disorder (ED)-specific psychopathology, and dissociative symptoms, and re-evaluated after 40 CBT-E sessions (T1). Then, 18 patients received EMDR, whereas the others were placed on a waiting list and continued CBT-E. T2 assessment was performed after 20-25 sessions of EMDR or CBT-E. A control group of 67 patients without CM was also enroled and treated with CBT-E.

RESULTS

Contrary to patients without CM, neither of the traumatised groups improved in BMI, general and ED psychopathology, or dissociation at T1. However, at T2, both traumatised groups improved in BMI and ED-specific psychopathology, with the CBT + EMDR group demonstrating greater improvements. Moreover, only the CBT + EMDR group improved in general psychopathology and dissociative symptoms. The reduction of ED symptoms in traumatised patients was mediated by the amelioration of dissociation.

DISCUSSION

The addition of EMDR to CBT-E may benefit patients with AN reporting moderate/severe CM.

The Association Between Childhood Maltreatment and Body (dis)satisfaction in Adolescents and Young Adults from the General Population

Adolescents with a history of childhood maltreatment are vulnerable to body dissatisfaction and associated psychopathology such as eating disorders. The aim of this study was to expand the understanding of the association between childhood maltreatment and body dissatisfaction in adolescents and young adults. In an epidemiological cohort study, N = 1,001 participants aged 14-21 years from Dresden, Germany, completed self-report measures on childhood maltreatment, body image, and self-esteem. Lifetime mental disorders were assessed in standardized clinical interviews. Data analyses included multiple regression and mediation analyses. More than one-third of the participants reported experiences of childhood maltreatment (37.4%), in which emotional neglect and abuse were the most frequent subtypes. Individuals with a history of childhood maltreatment showed significantly less satisfaction with their physical appearance than participants without such adverse experiences. In a single mediator model, self-esteem emerged as potential mediator in the association between child maltreatment and body (dis)satisfaction. Experiences of childhood maltreatment may be considered as risk factor for the development of body dissatisfaction in adolescents, and the role of potential mediator variables such as self-esteem warrants further prospective research.

The impact of trauma-related symptoms and neuroticism on compensatory behaviors in a sample of adults with eating disorders

INTRODUCTION

Inappropriate compensatory behaviors (ICBs), including purging, restricting, and excessive exercising, are key symptoms of several eating disorders (EDs). Studies have found positive associations between trauma and ICBs, although few studies have explored mechanisms that may explain these relationships. Emotion dysregulation has been posited as a mechanism that explains associations among ICBs and trauma. Given that individuals with high neuroticism may be particularly likely to use ICBs to regulate emotions following a trauma, the purpose of this study was to test whether neuroticism moderated the relationship between trauma-related symptoms and each type of ICB (purging, restricting, and excessive exercise).

METHOD

A community sample of adults with a DSM-5 ED (N = 263; 83.7 % female) completed measures of trauma-related symptoms, ED psychopathology, and personality.

RESULTS

Zero-inflated negative binomial models revealed that trauma-related symptoms alone predicted restricting and purging behavior. In addition, we found that neuroticism alone predicted the presence of excessive exercise. We found no significant interaction between trauma-symptoms and neuroticism.

CONCLUSION

Although past research has documented high rates of co-occurring ED and PTSD, the connections between trauma-related symptoms and ICBs are complex and may be unique to each type of ICB. Given that neuroticism may not influence the relationship between trauma-related symptoms and ICBs, more research should be done to establish an understanding of factors that could explain the relationship between ICBs and trauma-related symptoms. Novel interventions that simultaneously target restricting, purging, and trauma-related symptoms could be beneficial to explore.

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.

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.

Mechanisms by which adverse childhood experiences, other traumas and PTSD influence the health and well-being of individuals with eating disorders throughout the life span

BACKGROUND

Multiple published sources from around the world have confirmed an association between an array of adverse childhood experiences (ACEs) and other traumatic events with eating disorders (EDs) and related adverse outcomes, including higher morbidity and mortality.

METHODS

In keeping with this Special Issue's goals, this narrative review focuses on the ACEs pyramid and its purported mechanisms through which child maltreatment and other forms of violence toward human beings influence the health and well-being of individuals who develop EDs throughout the life span. Relevant literature on posttraumatic stress disorder (PTSD) is highlighted when applicable.

RESULTS

At every level of the pyramid, it is shown that EDs interact with each of these proclaimed escalating mechanisms in a bidirectional manner that contributes to the predisposition, precipitation and perpetuation of EDs and related medical and psychiatric comorbidities, which then predispose to early death. The levels and their interactions that are discussed include the contribution of generational embodiment (genetics) and historical trauma (epigenetics), social conditions and local context, the ACEs and other traumas themselves, the resultant disrupted neurodevelopment, subsequent social, emotional and cognitive impairment, the adoption of health risk behaviors, and the development of disease, disability and social problems, all resulting in premature mortality by means of fatal complications and/or suicide.

CONCLUSIONS

The implications of these cascading, evolving, and intertwined perspectives have important implications for the assessment and treatment of EDs using trauma-informed care and trauma-focused integrated treatment approaches. This overview offers multiple opportunities at every level for the palliation and prevention of EDs and other associated trauma-related conditions, including PTSD.

Anorexia nervosa and familial risk factors: a systematic review of the literature

Anorexia Nervosa (AN) is a psychological disorder involving body manipulation, self-inflicted hunger, and fear of gaining weight.We performed an overview of the existing literature in the field of AN, highlighting the main intrafamilial risk factors for anorexia. We searched the PubMed database by using keywords such as “anorexia” and “risk factors” and “family”. After appropriate selection, 16 scientific articles were identified. The main intrafamilial risk factors for AN identified include: increased family food intake, higher parental demands, emotional reactivity, sexual family taboos, low familial involvement, family discord, negative family history for Eating Disorders (ED), family history of psychiatric disorders, alcohol and drug abuse, having a sibling with AN, relational trauma. Some other risk factors identified relate to the mother: lack of maternal caresses, dysfunctional interaction during feeding (for IA), attachment insecurity, dependence. Further studies are needed, to identify better personalized intervention strategies for patients suffering from AN.

Are the Effects of Malnutrition on the Gut Microbiota–Brain Axis the Core Pathologies of Anorexia Nervosa?

Anorexia nervosa (AN) is a disabling, costly, and potentially deadly illness. Treatment failure and relapse after treatment are common. Several studies have indicated the involvement of the gut microbiota–brain (GMB) axis. This narrative review hypothesizes that AN is driven by malnutrition-induced alterations in the GMB axis in susceptible individuals. According to this hypothesis, initial weight loss can voluntarily occur through dieting or be caused by somatic or psychiatric diseases. Malnutrition-induced alterations in gut microbiota may increase the sensitivity to anxiety-inducing gastrointestinal hormones released during meals, one of which is cholecystokinin (CCK). The experimental injection of a high dose of its CCK-4 fragment in healthy individuals induces panic attacks, probably via the stimulation of CCK receptors in the brain. Such meal-related anxiety attacks may take part in developing the clinical picture of AN. Malnutrition may also cause increased effects from appetite-reducing hormones that also seem to have roles in AN development and maintenance. The scientific background, including clinical, microbiological, and biochemical factors, of AN is discussed. A novel model for AN development and maintenance in accordance with this hypothesis is presented. Suggestions for future research are also provided.

Multiple perspectives and dialogue in understanding experiences of living with eating disorders: Two narratives-four unpackings

BACKGROUND

This is a response to Conti et al.'s article, "Listening in the dark: why we need stories of people living with severe and enduring anorexia nervosa" (published in JED, 2016), and its call for relational metaphors and a relational approach to supplement the traditional medical/psychological diagnostic language used to describe the life experiences and complex emotions of people affected by an eating disorder.

METHODS

Four authors with different backgrounds unpack two narratives, 'The Prima Donna with the Green Dress' and 'Breaking down the Wall', both narrated during fieldwork in multifamily therapy. The narratives are unpacked from the perspective of a therapist within multifamily therapy, a researcher who conducted the fieldwork, a researcher based in phenomenology and a researcher based in narrative inquiry. The authors enter into dialogue with the narratives, and with each other.

RESULTS

The four authors focus on different elements within the narratives and understand them differently. One, focuses on strength and pride, and art expression as a different form of language for people living with an eating disorder. Another, on the experience of isolation, boundaries, and balancing openness and closedness. A third, sees the narratives as expressing a wish to see and be seen, and the fourth focuses on the absence of, and longing for, a shared space to explore.

CONCLUSION

The aim is not to reach a correct or shared interpretation of the narratives but to explore how different perspectives may contribute to different insights, not only about one family in particular but about, more generally, the experiences of people living with an eating disorder. Our work shows the significance of engaging with multiple perspectives and dialogue as supplements to the traditional medical/psychiatric diagnostic language in both clinical practice and research.

Associations Between Trauma, Early Maladaptive Schemas, Personality Traits, and Clinical Severity in Eating Disorder Patients: A Clinical Presentation and Mediation Analysis

Background: The literature has shown a significant association between traumatic experiences and eating psychopathology, showing a greater symptomatology in patients with trauma history. Less is known about the associations between trauma and cognitive schemas, and personality traits and the differences between childhood and adulthood trauma experiences. Thus, this paper aims to assess the clinical and psychological characteristics of eating disorder (ED) patients, looking for differences between patients without a history of trauma and patients with trauma experiences, as well as at possible differences between exposure in childhood, adulthood, or repeated events. Another aim of the paper is to evaluate the possible mediation role of cognitive schemas and personality traits in the relationship between early trauma and eating psychopathology.

Methods: From January to November 2020, 115 consecutive inpatients admitted for a specific multidisciplinary ED treatment in a dedicated Unit were evaluated for trauma, differentiating between trauma occurring in childhood and adulthood. The subjects were evaluated for early maladaptive schemas (EMS), personality traits, trauma symptomatology, quality of life, and specific psychopathologies linked to EDs. Mediation analyses between childhood and adulthood trauma and eating psychopathology were performed, with EMS and personality traits as mediators.

Results: Patients with a history of trauma showed higher physical and psychological symptomatology scores, with a more impaired clinical profile in patients with both childhood and adulthood trauma exposure. The mediation analysis showed a specific mediator role for the “disconnection and rejection (DR)” EMS factor in the relationship between childhood trauma (cT) and eating psychopathology.

Conclusion: Trauma experiences are associated with more severe clinical symptomatology in EDs and may need a specific assessment in patients with failed outpatient standard treatments. Specific cognitive schemas linked to DR domain should be evaluated in treatments for ED patients with history of trauma due to the mediation role between trauma and eating psychopathology. The need for outcome studies about treatment approaches for ED patients with history of trauma is discussed.