Childhood emotional abuse and eating symptoms in bulimic disorders: an examination of possible mediating variables

A network analysis of eating disorder, PTSD, major depression, state-trait anxiety, and quality of life measures in eating disorder patients treated in residential care

BACKGROUND

The network approach in the eating disorder (ED) field has confirmed important links between EDs and posttraumatic stress disorder (PTSD) symptoms. However, studies including comorbid symptoms are scarce, which limits our understanding of potentially important connections. We hypothesised that anxiety, depression and poor quality of life (QOL) would provide a more complete picture of central, maintaining factors.

METHODS

Network analysis using R was performed in 2178 adult ED patients (91% female) admitted to residential treatment. Assessments included the ED Examination Questionnaire (EDEQ), the Eating Disorders Inventory (EDI-2), the PTSD Checklist for DSM-5 (PTSD clusters (PCL-5)), the Patient Health Questionnaire (PHQ-9), the Spielberger State-Trait Anxiety Scale (STAI), and the ED QOL Scale (EDQOL), which measure symptoms of EDs, PTSD, major depression, state-trait anxiety, and QOL, respectively.

RESULTS

EDI-2 ineffectiveness showed the highest centrality (expected influence) followed by EDI-2 interoceptive awareness, STAI state anxiety, EDEQ shape concern, EDQOL psychological subscale, and PTSD cluster D (hyperarousal) symptoms. Eating Disorder Quality of Life psychological and physical-cognitive subscales and PHQ-9 major depressive, STAI state anxiety and PCL-5 PTSD cluster E (negative alterations in mood and cognition) symptoms showed the highest bridge expected influence, suggesting their interactive role in maintaining ED-PTSD comorbidity.

CONCLUSIONS

This is the first network analysis of the interaction between ED and PTSD symptoms to include the comorbid measures of depression, anxiety, and QOL in a large clinical sample of ED patients. Our results indicate that several symptom clusters are likely to maintain ED-PTSD comorbidity and may be important targets of integrated treatment.

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.

The association between eating disorders and perfectionism in adults: A systematic review and meta-analysis

OBJECTIVE

Dimensions of perfectionism are associated with the onset and maintenance of eating disorder pathology in both clinical and non-clinical samples. The aim of this study was to conduct a systematic review and meta-analysis of the association between perfectionism and eating disorders in adults.

METHOD

A literature search was conducted using the PsycINFO, Medline, Scopus, Embase, Web of Science and ProQuest databases. Ninety-five studies met the inclusion criteria and included a total sample of 32,840 participants (clinical eating disorder diagnosis N = 2414, non-clinical N = 30,428). Correlation coefficients (r) for the association between eating disorders and perfectionism were pooled. A meta-analysis to determine the association between two dimensions of perfectionism and eating disorder symptoms was conducted. Subgroup analyses were conducted with studies using clinical samples, and studies using the Eating Disorder Examination Questionnaire.

RESULTS

The pooled effect size for the association between perfectionistic concerns and eating disorder symptoms was r = 0.33 [0.30, 0.37]; and r = 0.20 [0.14, 0.25] for the association between perfectionistic strivings and eating disorder symptoms. In the clinical subgroup analyses the effect sizes were r = 0.40 [0.22, 0.58]; and r = 0.35 [0.26, 0.44] respectively. Medium to high heterogeneity was identified across all subgroup analyses and a significant level of publication bias was also identified.

DISCUSSION

The findings indicate both perfectionistic strivings and perfectionistic concerns have significant associations with eating disorders, and further support the argument that both dimensions of perfectionism are important factors in the prevention and treatment of eating disorders.

Perfectionism and binge eating association: a systematic review and meta-analysis

BACKGROUND

Perfectionism is considered a vulnerability factor for eating disorders. However, the role of perfectionism in binge eating needs clarification due to notably inconsistencies between studies. The purpose to this study was to conduct a systematic review and meta-analysis to estimate the perfectionism-binge eating association.

METHOD

Systematic review was performed according to the PRISMA 2020 statement. Four databases (Web of Science, Scopus, PsycINFO and Psicodoc) were searched to identify studies published until September 2022. The literature search yielded 30 published articles (N = 9392) that provided 33 independent estimations of the correlation between the two variables.

RESULTS

Random-effects meta-analysis revealed a small-to-moderate positive average effect size between general perfectionism and binge eating (r₊ = .17) with a large heterogeneity. Perfectionistic Concerns showed a significant small-to-moderate relationship with binge eating (r₊ = .27), whereas Perfectionistic Strivings presented a negligible relationship with binge eating (r₊ = .07). Moderator analyses showed that the age, the type of the sample, the study design, and the tools for assessing both variables were statistically associated with the perfectionism-binge eating effect sizes.

CONCLUSIONS

Our findings suggest that Perfectionism Concerns are closely associated with binge eating symptomatology. This relationship might be moderated by certain variables, especially by the clinical or non-clinical nature of the sample and the instrument employed to assess binge eating.

The role of discrimination and adverse childhood experiences in disordered eating

BACKGROUND

In clinical research, there has been a call to move beyond individual psychosocial factors towards identifying cultural and social factors that inform mental health. Similar calls have been made in the eating disorders (ED) field underscoring the need to understand larger sociocultural influences on EDs. Discrimination is a social stressor that may influence mental health in similar ways to traumatic or adverse childhood experiences (ACEs). Given the high rates of EDs and discrimination among marginalized groups, it is vital to understand the role of discrimination and ACEs as predictors of ED symptoms in these populations. The aim of this study is to examine how perceived discrimination predicts ED pathology when statistically adjusting for gender, race, and ACEs.

METHODS

The diverse study sample consisted of 331 undergraduate students from a longitudinal cohort study (ages 18-24; 66% female; 35% White/non-Hispanic). Participants completed measures of everyday discrimination, ACEs, and ED pathology.

RESULTS

Following adjustment for multiple statistical comparisons, the frequency of daily discrimination predicted all ED symptoms above and beyond history of ACEs. In follow-up analyses, number of reasons for discrimination predicted cognitive restraint and purging. Differences in ED symptomatology were found based on the reason for discrimination, gender, and race. Specifically, those who experienced weight discrimination endorsed higher scores on all ED symptoms, and those experiencing gender discrimination endorsed higher body dissatisfaction, cognitive restraint, and restriction. People of color endorsed higher restriction, while female participants endorsed higher scores on all ED symptom with the exception of cognitive restraint.

CONCLUSION

Discrimination is a salient risk factor for ED symptoms even when accounting for individuals' history of ACEs. Future research should utilize an intersectional approach to examine how perceived discrimination affects ED pathology over time. (Word count: 234).

A Retrospective Literature Review of Eating Disorder Research (1990–2021): Application of Bibliometrics and Topical Trends

Despite the growing importance of eating disorders in society and academic literature, only a few bibliometric review studies using bibliometric analysis were available. Hence, this study aimed to explore and uncover hidden research topics and patterns in articles in terms of eating disorders over the last 30 years. In total, 4111 articles on eating disorders were analyzed using bibliometrics, network analyses, and structural topic modeling as the basis of mixed methods. In addition to general statistics about the journal, several key research topics, such as eating disorder (ED) treatment, ED symptoms, factors triggering ED, family related factors, eating behaviors, and social factors, were found based on topic correlations. This study found the key research variables that are frequently studied with EDs, such as AN, BN, BED, and ARFID. This study may help clinicians comprehend important risk factors associated with EDs. Moreover, the findings about key ED research topics and their association can be helpful for future studies to construct a comprehensive ED research framework. To our knowledge, this is the first study to use topic modeling in an academic journal on EDs and examine the diversity in ED research over 30 years of published research.

Childhood Maltreatment and Eating Disorders: A Prospective Investigation

OBJECTIVES

To determine whether childhood maltreatment is a risk factor for two eating disorders (anorexia nervosa and bulimia nervosa) using objective and subjective case definitions.

METHODS

Using a prospective cohorts design, children with documented cases of physical abuse, sexual abuse, and neglect (ages 0-11) from 1967 to 1971 in a Midwestern metropolitan county area were matched on age, race, sex, and approximate family socioeconomic status with non-maltreated children. Both groups were followed up. Retrospective self-reports about childhood maltreatment were collected at age 29. DSM-IV anorexia nervosa (AN) and bulimia nervosa (BN) disorders were assessed at age 41 (N = 807). Logistic and linear regression results are reported.

RESULTS

Using documented cases, childhood maltreatment was not a significant risk factor for AN or BN diagnoses or symptoms in adulthood. However, adults who retrospectively reported any maltreatment and physical and sexual abuse reported significantly more symptoms of AN than those who did not.

CONCLUSIONS

The prediction that childhood maltreatment is a risk factor for anorexia nervosa and bulimia nervosa was partially supported in this longitudinal study. While misattribution of cases might have occurred, these results suggest that researchers and clinicians should use caution in drawing inferences about these relationships and designing interventions.

The connection between childhood maltreatment and eating disorder psychopathology: a network analysis study in people with bulimia nervosa and with binge eating disorder

PURPOSE

Childhood maltreatment (CM) experiences are associated with heightened risk of Eating disorders (EDs). The psychopathological pathways promoting this association in people with Bulimia nervosa (BN) and in those with Binge eating disorder (BED) are under-investigated.

METHODS

One hundred and eighty-one people with BN and 144 with BED filled in the Eating Disorder Inventory-2, to measure ED psychopathology, and the Childhood Trauma Questionnaire, to assess their early traumatic experiences. Network analysis was conducted to investigate the interplay between those variables. The shortest pathways function was employed to investigate the shortest out of all routes conveying the association between CM and ED-specific symptoms.

RESULTS

In both people with BN and with BED, all CM types were connected to the ED psychopathology through the emotional abuse node. The association between emotional abuse and ED-specific symptoms (bulimia and body dissatisfaction) differed in the two groups: in people with BN, it included ineffectiveness, while in people with BED, it involved impulsivity. Interoceptive awareness, an indirect measure of emotion regulation, was included in these pathways in both groups.

CONCLUSION

In the light of literature showing that emotional abuse has a connecting role between CM and ED psychopathology also in anorexia nervosa, the present findings support the idea that emotional abuse conveys such association in all the main ED diagnoses. Ineffectiveness and impulsivity may represent the specific psychopathological dimensions connected to emotional abuse and promoting the maintenance of ED-specific symptoms in BN and in BED, respectively. These findings are worth of attention by clinicians.

LEVEL OF EVIDENCE

Level III: evidence obtained from well-designed cohort or case-control analytic studies.

How Is the History of Early Traumatic Exposure Associated With the Psychopathological Outcomes of COVID-19 Related Lockdown and Subsequent Re-opening in People With Eating Disorders?

The negative impact of COVID-19 pandemic on people with Eating Disorders (EDs) has been documented. The aim of this study was to evaluate whether a history of traumatic experiences during childhood or adolescence was associated with a higher degree of psychopathological worsening during COVID-19 related lockdown and in the following re-opening period in this group of people. People with EDs undergoing a specialist ED treatment in different Italian services before the spreading of COVID-19 pandemic (n = 312) filled in an online survey to retrospectively evaluate ED specific and general psychopathology changes after COVID-19 quarantine. Based on the presence of self-reported traumatic experiences, the participants were split into three groups: patients with EDs and no traumatic experiences, patients with EDs and childhood traumatic experiences, patients with EDs and adolescent traumatic experiences. Both people with or without early traumatic experiences reported retrospectively a worsening of general and ED-specific psychopathology during the COVID 19-induced lockdown and in the following re-opening period. Compared to ED participants without early traumatic experiences, those with a self-reported history of early traumatic experiences reported heightened anxious and post-traumatic stress symptoms, ineffectiveness, body dissatisfaction, and purging behaviors. These differences were seen before COVID-19 related restrictions as well as during the lockdown period and after the easing of COVID-19 related restrictions. In line with the "maltreated ecophenotype" theory, these results may suggest a clinical vulnerability of maltreated people with EDs leading to a greater severity in both general and ED-specific symptomatology experienced during the exposure to the COVID-19 pandemic.

Posttraumatic stress disorder and eating disorders: maintaining mechanisms and treatment targets

Many individuals with lifetime histories of eating disorders (EDs) report exposure to interpersonal trauma and posttraumatic stress disorder (PTSD). However, this relationship is not well-understood, and there are no established, evidence-based therapies for the concurrent treatment of EDs and PTSD. This review focuses on studies of the mechanisms associating trauma exposure and/or PTSD with EDs. Possible mechanisms of the trauma-ED association identified from the literature include self-criticism, low self-worth, guilt, shame, depression, anxiety, emotion dysregulation, anger, and impulsivity/compulsivity. ED behaviors may be used as coping strategies to manage PTSD symptoms and negative affect. Avoidance of hyperarousal symptoms by engaging in binge eating, purging, and/or restriction may serve to maintain both the ED as well as the PTSD. Given the evidence of the bidirectional relationship between EDs and PTSD, we describe an integrated cognitive behavioral theory that may account for the persistence of comorbid PTSD and EDs. The integrated model is based on the theoretical models that underpin existing evidence-based treatments for PTSD and ED and incorporates many of the potential mechanisms highlighted to date. The primary aim of the model is to identify potential treatment targets as well as elucidate future directions for research.

Childhood trauma determines different clinical and biological manifestations in patients with eating disorders

PURPOSE

There is a significant relationship between childhood trauma and the development of an eating disorder in adolescence or adulthood, possibly influenced by circulating levels of inflammatory parameters. The main objective is to identify and describe a subgroup of patients with eating disorders and a history of trauma in childhood or adolescence with differential clinical features.

METHODS

An observational study on a sample of 55 patients who met the diagnostic criteria for any DSM-5 eating disorder was carried out. Inflammatory parameters in white blood cells were examined. Patients underwent different assessments, including clinical and personality scales.

RESULTS

Patients with a history of trauma had higher scores in the delirious and narcissistic items of the Millon Clinical Multiaxial Inventory (MCMI-II) (p < 0.05) and a higher score in the paranoid item of the SCID-5 Personality Disorders Version (SCID-5-PD) (p < 0.05). Patients with distinguishing personality features were grouped according to the Childhood Trauma Questionnaire sexual subscale. Tumor necrosis alpha (TNF-α) showed a significant association with childhood trauma history.

CONCLUSIONS

There is a profile of patients with eating disorders who have increased activity in the inflammatory pathways that, if identified precociously, can benefit from specifically aimed interventions.

LEVEL OF EVIDENCE

Level V, observational study.

Impact of trauma in childhood and adulthood on eating-disorder symptoms

Exposure to a traumatic event is concurrently and prospectively associated with disordered-eating behaviors such as binge eating, restricting, and purging. Specifically, purging has been found to be elevated in individuals with trauma histories, suggesting that purging may be a method for coping with trauma-related distress. However, there has been limited research investigating whether the time at which trauma occurs during development is differentially associated with disordered-eating behaviors and internalizing psychopathology. The purpose of this study was to examine the effect of trauma that occurred in childhood, adulthood, or childhood and adulthood on eating disorder (ED) and internalizing psychopathology. Participants were community-recruited adults with a current DSM-5 ED (N = 225) and were subsequently grouped into categories based on the time at which trauma occurred. Groups included: no trauma exposure ED controls (n = 54), child trauma group (n = 53), adult trauma group (n = 53), and child+adult trauma group (n = 65). We compared groups on their level of disordered-eating symptoms. Participants were administered the Structured Clinical Interview for DSM-IV, the Eating Pathology Symptoms Inventory (EPSI), and the Inventory of Depression and Anxiety Symptoms-II (IDAS-II). Univariate analyses revealed significantly higher levels of purging symptomatology in the child+adult trauma group compared to the no trauma, child trauma, and adult trauma groups. The current study highlights the importance of assessing the timing of trauma among individuals with EDs. In particular, our study indicates a need for further investigation to explain why individuals with ED and trauma histories engage in greater purging.

Child Maltreatment and Disordered Eating in Adulthood: a Mediating Role of PTSD and Self-Esteem?

The current study investigated relationships between different experiences of child maltreatment (CM) and disordered eating (DE) in a large population-based sample of Danish young adults. Participants completed a structured interview comprising socio-demographic, psychological and physical domains. Questions regarding CM, DE, PTSD symptoms and self-esteem were analyzed using chi-square-tests, ANOVAs, hierarchical regression, and multiple mediation analyses. Participants with a history of CM experienced higher levels of DE than non-abused individuals. PTSD symptoms and self-esteem appeared to differentially mediate the relationship between three classes of CM and DE. Whereas the relation between emotional and sexual abuse with DE was partially mediated via participants' level of PTSD symptoms and self-esteem with emotional abuse having a stronger impact on self-esteem and sexual abuse more strongly influencing PTSD symptoms, the relation between polyvictimization and DE was fully mediated by PTSD and self-esteem, mainly due to the indirect effect via PTSD.

What do I look like? Perceptual confidence in bulimia nervosa

Cognitive confidence, a type of metacognition referring to confidence in one's cognitive abilities (e.g., memory, perception, etc.), has been identified as relevant to eating disorders (EDs) using self-report measures. Repeated checking has been found to elicit decreases in perceptual confidence in obsessive compulsive disorder (OCD). The purpose of the present study was to experimentally investigate perceptual confidence, a type of cognitive confidence, in EDs. Specifically, this construct was investigated in the context of body checking, a behaviour with similarities to compulsive checking as observed in OCD. Women with bulimia nervosa (BN; n = 21) and healthy controls (HC; n = 24) participated in the study. There were no group differences with regards to perceptual confidence at baseline F(1, 43) = 0.5, p = 0.48, η_p² = 0.01, but a significant difference was observed post-checking F(1, 43) = 7.79, p = 0.008, η_p² = 0.15, which was accounted for by significant decreases in perceptual confidence in the BN group F(1, 43) = 13.31, p < 0.001, η_p² = 0.24. Similar to compulsive checking in OCD, body checking may paradoxically decrease confidence regarding one's appearance. LEVEL OF EVIDENCE: Level I, experimental study.

Childhood trauma, dissociation, and the internal eating disorder 'voice'

Many individuals diagnosed with eating disorders describe their disorder as being represented by an internal 'voice'. In line with cognitive models of voice-hearing, previous research has identified associations between voice appraisals and eating psychopathology in anorexia nervosa. Whether these findings generalise to other eating disorder subtypes remains unknown. The aetiology of the internal eating disorder voice also remains unclear. Traumatic-dissociative models of voice-hearing, which link such experiences to decontexualised material arising from early traumatic events, might also be relevant to eating disorder groups. To determine whether cognitive models of trauma and voice-hearing apply across eating disorder subtypes, 85 individuals fulfilling ICD-10 criteria for an eating disorder completed self-report measures regarding eating disorder cognitions, voice-related appraisals, childhood trauma, and dissociation. The relative power of the eating disorder voice was found to be positively associated with experiences of childhood emotional abuse, and this relationship was partly mediated by dissociation. In addition, eating disorder voices appraised as powerful and benevolent predicted more negative attitudes towards eating across diagnostic groups, but were unrelated to disordered eating behaviours or weight. These findings suggest that the eating disorder voice plays a meaningful role in eating pathology across diagnoses and that this experience might be related, in part, to experiences of childhood maltreatment. Therapeutic implications are discussed.

Child maltreatment and eating disorders among men and women in adulthood: Results from a nationally representative United States sample

OBJECTIVE

Child maltreatment is associated with an increased likelihood of having mood disorders, anxiety disorders, post-traumatic stress disorder, substance use disorders, and personality disorders, but far less is known about eating disorders. The objective of the current study was to examine the associations between child maltreatment, including harsh physical punishment, physical abuse, sexual abuse, emotional abuse, emotional neglect, physical neglect, and exposure to intimate partner violence, and eating disorders in adulthood among men and women.

METHOD

Data were from the National Epidemiologic Survey on Alcohol and Related Conditions wave 3 (NESARC-III) collected in 2012-2013. The sample was nationally representative of the United States adult population (N = 36,309). Lifetime eating disorders (anorexia nervosa [AN], bulimia nervosa [BN], and binge-eating disorder [BED]) were assessed using diagnostic and statistical manual of mental disorders, fifth edition (DSM-5) criteria and the alcohol use disorder and associated disabilities interview schedule-5 (AUDADIS-5).

RESULTS

The prevalence of any lifetime eating disorder was 1.7% (0.8% among men and 2.7% among women). All child maltreatment types were associated with AN, BN, and BED with notable differences among men and women. Overall, the types of child maltreatment with the strongest relationships with any eating disorder were sexual abuse and physical neglect among men and sexual abuse and emotional abuse among women.

DISCUSSION

Clinicians should be mindful that child maltreatment experiences are associated with increased odds of eating disorders including AN, BED, and BN. Such relationships are significant among men and women although notable gender differences in these relationships exist. Abstract word count = 248.

Update on Psychological Trauma, Other Severe Adverse Experiences and Eating Disorders: State of the Research and Future Research Directions

PURPOSE OF REVIEW

This paper provides an updated review of the literature on the relationship between psychological trauma exposure, other severe adverse experiences, and eating disorders.

RECENT FINDINGS

Trauma exposure and other severe adverse experiences (e.g., emotional abuse) in both childhood and adulthood are associated with eating disorders. The relationship between traumatic and other adverse experiences and eating disorders appears to be mediated by emotional and behavioral dysregulation, as well as by cognitive factors such as self-criticism. Biological vulnerabilities may also be relevant to this relationship. Overall, the literature is limited by predominantly cross-sectional designs. There is clear evidence of a correlational relationship between trauma exposure and other severe adverse events, and eating disorders. Both risk and maintenance factor hypotheses have been put forth; however, prospective research testing these hypotheses remains limited. Future research should use prospective designs and focus on trauma-related symptoms (rather than trauma exposure) in order to advance research on risk and maintaining factors for eating disorders and inform treatment directions.

'Not good enough:' Exploring self-criticism's role as a mediator between childhood emotional abuse & adult binge eating

Empirical studies have identified emotional abuse in childhood (CEA) as a risk factor with long-term implications for psychological problems. Indeed, recent studies indicate it is more prevalent than behavioral forms of abuse, (i.e. childhood sexual and physical abuse) and the childhood trauma most clearly associated with subsequent eating pathology in adulthood. However, relatively little is understood about the mechanisms linking these distal experiences. This study explores three psychological mechanisms - self-criticism (SC), depression and anxiety symptoms - as plausible mediators that may account for the relationship between CEA and binge eating (BE) among adult women. Detailed telephone interviews conducted with a community-based sample of 498 adult women (mean age 44) assess BE, CEA and SC along with the most frequently researched psychological variables, anxiety and depression. Regression analyses reveal that BE is partially explained by CEA along with the three mediators. Bootstrapping analysis, which compares multiple mediators within a single model using thousands of repeated random sampling observations from the data set, reveals a striking finding: SC is the only psychological variable that makes a significant contribution to explaining BE severity. The unique role of punitive self-evaluations vis-à-vis binge eating warrants additional research and, in the interim, that clinicians consider broadening treatment interventions accordingly.

Associations between adverse childhood experiences and clinical characteristics of eating disorders

Patients with eating disorders (EDs) frequently report a history of childhood trauma (CT). We investigated whether certain subtypes of CT are associated with more severe features of EDs, independently of psychiatric comorbidity, and whether they act additively. One hundred and ninety-two patients with DSM-V-defined EDs were consecutively recruited. Five clinical characteristics were assessed: restraint, eating, shape and weight concerns on the EDE-Q, and daily functioning. CT was assessed by the childhood traumatism questionnaire. The clinical features were associated with at least one CT subtype (emotional, sexual or physical abuse, emotional neglect). Multivariate analyses adjusted for lifetime comorbid psychiatric disorders revealed that emotional abuse independently predicted higher eating, shape and weight concerns and lower daily functioning, whereas sexual and physical abuse independently predicted higher eating concern. A dose-effect relationship characterised the number of CT subtypes and the severity of the clinical features, suggesting a consistent and partly independent association between CT and more severe clinical and functional characteristics in EDs. Emotional abuse seems to have the most specific impact on ED symptoms. Last, not all CT subtypes have the same impact but they do act additively.

A latent profile analysis of childhood trauma in women with bulimia nervosa: Associations with borderline personality disorder psychopathology

OBJECTIVE

The aim of this study was to empirically examine naturally occurring groups of individuals with bulimia nervosa (BN) based on their childhood trauma (CT) histories and to compare these groups on a clinically relevant external validator, borderline personality disorder (BPD) psychopathology.

METHOD

This study examined the relationship between CT and BPD psychopathology among 133 women with BN using latent profile analysis (LPA) to classify participants based on histories of CT. Participants completed the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P), the Diagnostic Interview for Borderlines-Revised (DIB-R), and the Childhood Trauma Questionnaire (CTQ).

RESULTS

The LPA revealed four trauma profiles: low/no trauma, emotional trauma, sexual trauma, and polytrauma. Results indicated that the sexual and polytrauma profiles displayed significantly elevated scores on the DIB-R and that the low/no and emotional trauma profiles did not differ significantly on the DIB-R. Secondary analyses revealed elevated levels of a composite CT score among those with both BN and BPD psychopathology compared to those with BN only.

DISCUSSION

These findings suggest that both childhood sexual abuse and the additive effects of childhood polytrauma may be linked to BPD psychopathology in BN. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:689-694).

Binge eating & childhood emotional abuse: The mediating role of anger

Recent studies reveal that childhood emotional abuse (CEA) is the trauma most clearly associated with adult eating pathology. Yet, relatively little is understood about psychological mechanisms linking these distal experiences. Anger's mediational role in the relationship between CEA and adult binge eating (BE) is explored in a community-based sample of 498 adult women (mean age 44). Detailed telephone interviews assess BE (7 items), CEA (single item), and unresolved anger (single item) along with self-criticism (modified Rosenberg self-esteem scale), depression and anxiety symptoms (BSI sub-scales). Statistical analyses include Pearson correlations, Baron and Kenny's steps for mediation, and Preacher and Hayes bootstrapping method to test proposed multiple mediators simultaneously. Findings reveal significantly more respondents (n = 476 with complete data) with serious BE behaviors report a history of CEA compared to women with considerable and/or minimal BE (53% vs 37%, p = 0.002 respectively). Significant correlations are found among all study variables. Mediation analyses focus on anger together with self-criticism, depression and anxiety. Findings reveal anger and self-criticism fully mediate the CEA-BE relationship. In contrast, depression and anxiety symptoms are not significant mediators in a model that includes anger and self-criticism. Although additional research is warranted to more fully understand complex causal processes, in the interim, treatment interventions should be broadened to include assessments of anger among adult women with BE behaviors, especially those with histories of childhood abuse. Additionally, prevention strategies that incorporate learning how to express anger directly and positively may be particularly effective in reducing various disordered eating behaviors among women and girls.

A systematic review of the existing models of disordered eating: Do they inform the development of effective interventions?

Despite significant advances in the development of prevention and treatment interventions for eating disorders and disordered eating over the last decade, there still remains a pressing need to develop more effective interventions. In line with the 2008 Medical Research Council (MRC) evaluation framework from the United Kingdom for the development and evaluation of complex interventions to improve health, the development of sound theory is a necessary precursor to the development of effective interventions. The aim of the current review was to identify the existing models for disordered eating and to identify those models which have helped inform the development of interventions for disordered eating. In addition, we examine the variables that most commonly appear across these models, in terms of future implications for the development of interventions for disordered eating. While an extensive range of theoretical models for the development of disordered eating were identified (N=54), only ten (18.5%) had progressed beyond mere description and to the development of interventions that have been evaluated. It is recommended that future work examines whether interventions in eating disorders increase in efficacy when developed in line with theoretical considerations, that initiation of new models gives way to further development of existing models, and that there be greater utilisation of intervention studies to inform the development of theory.

Disentangling the Association Between Child Abuse and Eating Disorders: A Systematic Review and Meta-Analysis

OBJECTIVES

The aim of this systematic review and meta-analysis was to estimate the association between distinct types of child abuse--sexual (CSA), physical (CPA), and emotional (CEA)--and different eating disorders (EDs).

METHODS

Electronic databases were searched through January 2014. Studies reporting rates of CSA, CPA, and CEA in people with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED), as compared with individuals without EDs, were included. Pooled analyses were based on odds ratios (ORs), with relevant 95% confidence intervals (CIs), weighting each study with inverse variance models with random effects. Risk of publication bias was estimated.

RESULTS

Thirty-two of 1714 studies assessed for eligibility met the inclusion criteria, involving more than 14,000 individuals. The association between EDs and any child abuse showed a random-effects pooled OR of 3.21 (95% CI = 2.29-4.51, p < .001) with moderate heterogeneity (I2 = 57.2%, p = .005), whereas for CSA, this was 1.92 (95% CI = 1.13-3.28, p = .017), 2.73 (95% CI = 1.96-3.79, p < .001), and 2.31 (95% CI = 1.66-3.20, p < .001), for AN, BN, and BED, respectively. However, adjusting for publication bias, the estimate for CSA and AN was not significant (OR = 1.06, 95% CI = 0.59-1.88, p = .85). Although CPA was associated with AN, BN, and BED, CEA was associated just with BN and BED.

CONCLUSIONS

BN and BED are associated with childhood abuse, whereas AN shows mixed results. Individuals with similar trauma should be monitored for early recognition of EDs.

TRIAL REGISTRATION

The protocol was registered in PROSPERO (an international prospective register of systematic reviews) with the reference number CRD42014007360.

Habilidades sociais: fator de proteção contra transtornos alimentares em adolescentes

Resumo O objetivo desse estudo foi revisar a literatura a cerca da relação entre transtornos alimentares e habilidades sociais em adolescentes. Pesquisou-se as bases de dados Medline, SciELO e Lilacs, cruzando os descritores “transtornos alimentares”, “anorexia nervosa”, “bulimia nervosa” e “comportamento alimentar”, com os descritores “psicologia social” e “isolamento social”, e com as palavras chave “competência social”, “habilidade social” e “relação interpessoal”. Incluiu-se estudos com adolescentes, nos idiomas português, inglês e espanhol, e publicações realizadas entre os anos de 2007 a 2012. A busca resultou em 63 artigos, sendo incluídos 50 nesta revisão. A maioria dos estudos foi conduzido no Brasil e nos Estados Unidos. Do total, 43 eram artigos originais. Os estudos visavam compreender como o estado emocional poderia influenciar no estabelecimento dos transtornos alimentares, assim como as relações interpessoais e a relação entre os pares. Os artigos também discutiram a influência da mídia e da sociedade neste processo. A partir da análise dos estudos, observou-se que quanto maior o repertório de habilidades sociais dos adolescentes, maior será o fator de proteção contra o desenvolvimento de transtornos alimentares.

Recent Advances in Developmental and Risk Factor Research on Eating Disorders

The Diagnostic and Statistical Manual of Mental Disorders (i.e., DSM-5) currently recognizes three primary eating disorders: anorexia nervosa, bulimia nervosa, and binge eating disorder. The origins of eating disorders are complex and remain poorly understood. However, emerging research highlights a dimensional approach to understanding the multifactorial etiology of eating disorders as a means to inform assessment, prevention, and treatment efforts. Guided by research published since 2011, this review summarizes recent findings elucidating risk factors for the development of eating disorders across the lifespan in three primary domains: (1) genetic/biological, (2) psychological, and (3) socio-environmental. Prospective empirical research in clinical samples with full-syndrome eating disorders is emphasized with added support from cross-sectional studies, where relevant. The developmental stages of puberty and the transition from adolescence to young adulthood are discussed as crucial periods for the identification and prevention of eating disorders. The importance of continuing to elucidate the mechanisms underlying gene by environmental interactions in eating disorder risk is also discussed. Finally, controversial topics in the field of eating disorder research and the clinical implications of this research are summarized.

Integrating fundamental concepts of obesity and eating disorders: implications for the obesity epidemic

Physiological mechanisms promote weight gain after famine. Because eating disorders, obesity, and dieting limit food intake, they are famine-like experiences. The development of the concept of meeting an ideal weight was the beginning of increasing obesity. Weight stigma, the perception of being fat, lack of understanding of normal growth and development, and increased concern about obesity on the part of health providers, parents, and caregivers have reinforced each other to promote dieting. Because weight suppression and disinhibition provoke long-term weight increase, dieting is a major factor producing the obesity epidemic. The integrated eating disorder-obesity theory included in this article emphasizes that, contrary to dieters, lifetime weight maintainers depend on physiological processes to control weight and experience minimal weight change.

Emotional maltreatment and disordered eating in adolescents: testing the mediating role of emotion regulation

The present study aimed to determine if emotion regulation mediates the relationship between emotional maltreatment and disordered eating behavior in adolescents. Participants were 222 secondary school pupils (aged 14-18 years) from a state high school in the UK. Standardized questionnaire measures were used to gather self-report data on emotional abuse and emotional neglect, functional and dysfunctional emotion regulation strategies and disordered eating behavior. Results showed that disordered eating was associated with emotional abuse, dysfunctional emotion regulation and being female. Multiple mediation analysis found an indirect relationship between emotional abuse and disordered eating through dysfunctional emotion regulation. Interestingly, emotional neglect predicted lower levels of functional emotion regulation. The findings support previous research showing emotion regulation to mediate the relationship between childhood abuse and disordered eating in adults and a differential effect of abuse and neglect on emotion regulation. Longitudinal studies are required to confirm the direction of relationships; however these data suggest that dysfunctional emotion regulation is a significant variable in the development of disordered eating and may be a useful target for intervention.

Emotion dysregulation and anorexia nervosa: an exploration of the role of childhood abuse

OBJECTIVE

Theoretical models of emotion regulation difficulties in anorexia nervosa (AN) specify a role for factors that predispose to or precipitate emotion dysregulation. The current study considered whether childhood abuse (i.e., emotional, sexual, physical) might be related to emotion regulation difficulties and eating disorder symptom severity in patients with AN. Childhood abuse was hypothesized to relate to AN symptoms indirectly via emotion dysregulation.

METHOD

Participants were 188 patients with AN presenting to an intensive treatment facility. The Childhood Trauma Questionnaire, Difficulties in Emotion Regulation Scale, and Eating Disorder Examination were used to assess childhood abuse, emotion dysregulation, and AN symptom severity, respectively.

RESULTS

Of the three forms of childhood abuse, reports of emotional abuse were most strongly related to emotion regulation difficulties and AN symptom severity. Mediation analyses revealed that emotion dysregulation significantly explained the relationship between childhood emotional abuse and AN symptomatology, and mediation effects did not differ by AN subtype (i.e., restricting vs. binge-eating/purging).

DISCUSSION

Findings provide initial support for a model in which childhood emotional abuse precipitates emotion dysregulation and the development of AN. Future studies with longitudinal designs and control groups are necessary to examine the direction and specificity of these cross-sectional associations

Impact of NEGR1 genetic variability on psychological traits of patients with eating disorders

Genetics variants in the NEGR1 gene, strongly expressed in the brain, have been reported to affect the neuronal control of food intake therefore inducing obesity. With the same rationale, we hypothesized that this genetic variability may be associated with psychological traits commonly displayed by eating disorder (ED) patients and/or with the risk for the disorder. We analyzed 21 tag-single-nucleotide polymorphisms (SNPs) in the coding sequence and adjacent regions of the NEGR1 gene. A total of 169 ED patients (106 with anorexia nervosa (AN) and 63 with bulimia nervosa (BN)) and 312 healthy subjects were genotyped. Personality traits and general psychopathological symptoms were assessed by the Eating Disorders Inventory Test-2 (EDI-2) and Symptom Checklist 90 Revised inventories. None of the SNPs or haplotypes analyzed were associated with a greater risk of ED or correlated with anthropometric parameters. However, in patients with BN, four SNPs (rs12740031, rs10789322, rs6659202 and rs591540) correlated with the scores in Drive for Thinness (DT), Ineffectiveness (I) and Interoceptive Awareness (IA) (Bonferroni-P<0.05 in all instances). The first two SNPs along with rs954299 and rs2422021 formed a haplotype block, which showed a consistent association with the EDI-2 score in BN patients (Bonferroni-P=0.01). A subsequent three-SNP sliding-window approach identified a central area, encompassing both the haplotype block and the individually relevant SNPs that strongly correlated with the scores of BN patients in DT, I, IA and Bulimia. No associations were identified in the AN group. These preliminary results indicate that NEGR1 could be an important locus influencing certain personality dimensions in BN patients.

Neonatal handling: an overview of the positive and negative effects

As one of the first rodent models designed to investigate the effects of early-life experiences, the neonatal handling paradigm has helped us better understand how subtle changes in the infant environment can powerfully drive neurodevelopment of the immature brain in typical or atypical trajectories. Here, we review data from more than 50 years demonstrating the compelling effects of neonatal handling on behavior, physiology, and neural function across the lifespan. Moreover, we present data that challenge the classical view of neonatal handling as an animal model that results only in positive/beneficial outcomes. Indeed, the overall goal of this review is to offer the suggestion that the effects of early-life experiences-including neonatal handling-are nuanced rather than unidirectional. Both beneficial and negative outcomes may occur, depending on the parameters of testing, sex of the subject, and neurobehavioral system analyzed.

Methylation of the dopamine D2 receptor (DRD2) gene promoter in women with a bulimia-spectrum disorder: associations with borderline personality disorder and exposure to childhood abuse

OBJECTIVE

Previous findings indicate that women with Bulimia Nervosa (BN), when compared to women with no eating disorder (NED), tend to display elevated methylation in the promoter region of the DRD2 gene. The preceding would be compatible with evidence of generally reduced dopamine activity in people with BN. However, altered DNA methylation has also been associated with adverse environmental exposures (such as to childhood abuse) and with psychiatric disturbances (such as Borderline Personality Disorder: BPD). In this study, we examined the extent to which DRD2 methylation was associated with the presence or absence of a bulimic eating disorder, to childhood abuse exposure, or to comorbid BPD.

METHOD

Women with a bulimia-spectrum disorder (BSD) and women with NED were assessed for childhood traumata, eating-disorder symptoms and BPD, and provided blood samples for methylation analyzes.

RESULTS

BSD and NED groups did not differ as to mean percent DRD2 promoter methylation. However, among the women with a BSD, those with BPD showed small, but significant increases in DRD2 methylation levels compared to women with NED (as indicated by Hochberg's post-hoc tests). Similarly, women with a BSD who reported a history of childhood sexual abuse showed a trend-level elevation of DRD2 methylation compared to our NED group.

DISCUSSION

Our findings imply that, in people with a BSD, increased methylation of the DRD2 gene promoter may be more strongly characteristic of comorbid psychopathology than it is a global correlate of the eating disorder per se. We discuss theoretical implications of our findings.

[Childhood abuse in adolescents with anorexia nervosa compared to a psychiatric and healthy control group]

OBJECTIVES

Some studies suggest that both early sexual and early physical abuse are non-specific risk factors for the later development of eating disorders (EDs). However, only little is known about the role of emotional abuse in EDs.

METHODS

The sample included 77 inpatients with Anorexia nervosa (AN-R: n = 50; AN-BP: n = 27), 26 psychiatric control participants and 44 healthy control participants, all of whom were females. The diagnosis of AN and the diagnosis of psychiatric control participants were confirmed by structured interviews (SIAB-EX, Fichter & Quadflieg, 1999; CIDI-DIA-X,Wittchen & Pfister, 1997). Childhood traumatization was assessed by a self-report questionnaire [Childhood Trauma Questionnaire (CTQ) German Version, Krischer & Sevecke, 2011].

RESULTS

The results indicated there were higher rates of sexual and physical abuse as well as physical and emotional neglect in patients with AN-BP than in patients with AN-R and in healthy control participants, with no significant differences between patients with AN-R and control participants. Furthermore, patients with AN-BP had significantly higher rates on the CTQ subscale "emotional abuse" than patients with AN-R, psychiatric control participants and healthy control participants.

CONCLUSIONS

Future studies should investigate whether emotional abuse is specific to adolescents with AN-BP compared to adolescents with other psychiatric disorders.

Dopamine-system genes, childhood abuse, and clinical manifestations in women with Bulimia-Spectrum Disorders

OBJECTIVE

We explored interaction effects involving polymorphisms of targeted dopamine system genes and selected forms of childhood abuse (sexual, physical and emotional) acting upon severity of binge-eating and psychopathological symptoms in women with Bulimia-Spectrum Disorders (BSDs).

METHODS

Women diagnosed with a BSD (n = 216) were assessed for childhood traumata, eating-disorder (ED) symptoms, and selected psychopathological features (sensation seeking, impulsivity, compulsivity and affective instability), and then provided blood samples for genotyping of main polymorphisms of dopamine-2 receptor (DRD2), dopamine transporter (DAT1) and catechol o-methyltransferase (COMT) genes.

RESULTS

Sensation Seeking was elevated in carriers of the low-function allele of the DRD2 Taq1A polymorphism who also reported childhood sexual abuse, relative to that in individuals showing other combinations of alleles and abuse exposures. In addition, carriers of a low-function allele of COMT scored higher on compulsivity, lower on impulsivity, and marginally lower on frequency of binge-eating than did individuals in whom the allele was absent.

DISCUSSION

Our results suggest that genes acting within the dopamine system may contribute, either directly or indirectly (i.e., in interaction with traumatic childhood experiences), to variations in the presentation of comorbid traits and, possibly, of bulimic symptoms.