The number of divergent purging behaviors is associated with histories of trauma, PTSD, and comorbidity in a national sample of women

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.

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.

Stressful life events among individuals with a history of eating disorders: a case-control comparison

BACKGROUND

Experiencing stressful life events (SLEs) can negatively impact mental health and increase risk for psychiatric disorders including eating disorders (EDs). Previous research has shown that childhood sexual abuse is associated with some EDs, but less is known about the association between other non-sexual SLEs and EDs.

METHOD

A case-control study of individuals with (n = 495, age mean ± SD = 29.1 ± 9.8 years) and without (n = 395, age = 30.2 ± 11.7) self-reported lifetime history of EDs was conducted to compare history of self-reported SLEs. Participants reported history of sexual (e.g., rape, other sexual assault) and non-sexual (e.g., emotional abuse, assault, bereavement) life events using an adaptation of the Stressful Life Events Screening Questionnaire. Individuals with EDs were divided into ED subtypes along the restricting - binge eating/purging spectrum to examine subtype differences. Logistic regressions were conducted for each SLE and ED subtype to obtain odds ratios (ORs). We report p-values corrected for multiple comparisons.

RESULTS

Exposure to any SLE was significantly more common in individuals with EDs than in controls (OR = 2.47, p < .001). Specifically, rape, other sexual assault, and emotional abuse were significantly more common among individuals with a history of binge-eating/purging ED subtypes (ORs = 2.15-3.58, p's < .01) compared with controls. Furthermore, history of life-threatening disease and loss of a close relative/partner/friend were associated with some ED subtypes. The association between SLEs and EDs was stronger for individuals who had experienced multiple SLEs.

CONCLUSION

By investigating a range of different SLEs, we showed that both sexual and non-sexual SLEs were more common in individuals with a history of EDs (binge-eating/purging subtypes) than controls. Results highlight the importance of assessing a variety of past SLEs in risk assessment for different EDs.

Network Analysis of Posttraumatic Stress and Eating Disorder Symptoms in a Community Sample of Adults Exposed to Childhood Abuse

Posttraumatic stress disorder (PTSD) and eating disorders (EDs) are individually debilitating and highly comorbid conditions. Childhood abuse is a prominent risk factor for PTSD and ED symptoms both individually and as a comorbid syndrome (PTSD-ED). There may be a functional association between comorbid PTSD-ED symptoms whereby disordered eating behaviors are used to avoid trauma-related thoughts and feelings. The current study used a network analytic approach to examine key associations between PTSD and ED symptom subscales (i.e., PCL-5 and EPSI, respectively) in a community sample of 120 adults who endorsed at least one experience of childhood abuse (i.e., physical, sexual, or emotional abuse; witnessing domestic violence). Participants completed an anonymous online survey using Amazon's Mechanical Turk Prime. We used three network analysis indices (i.e., strength centrality, key players, and bridge symptoms) to identify symptoms that may maintain the comorbid PTSD-ED network. The results indicated that reexperiencing symptoms had the highest strength centrality in the PTSD-ED network and bridged the PTSD and ED clusters. For ED, cognitive restraint was a bridge to all PTSD symptoms. Hyperarousal, negative alterations in cognitions and mood (NACM), and purging were key players, indicating they are integral to the network structure. If replicated in prospective studies, these results may indicate that reexperiencing and cognitive restraint are core drivers of PTSD-ED comorbidity, whereas hyperarousal, NACM, and purging may be downstream consequences maintaining the comorbid condition. Concurrent treatments that address PTSD and ED symptoms simultaneously may result in the best outcomes.

Binge eating and alcohol consumption: an integrative review

OBJECTIVE

To identify the relationship between binge eating and alcohol consumption.

METHODS

This is an integrative literature review of publications from 2015 to 2019, using the Pubmed, Cinhahl, Psynet, Lilacs, Embase and Web of Science virtual databases and the descriptors ("Binge-Eating" OR "Bulimia") AND Alcohol* in English, Spanish and Portuguese.

RESULTS

A total of 964 articles were found. After reading the titles and abstracts and excluding duplicates, 36 articles were included in the final sample (35 in English and one in Portuguese). They were grouped into three thematic categories: "sample profile and characterization", "genetic and environmental factors", and "emotions and behavior".

CONCLUSIONS

The data indicate the existence of a relationship between binge eating and alcohol use, and some factors were associated with this comorbidity. Still, there were few publications on the theme at the national level, indicating the need for developing more research. These findings may support therapeutic actions and strategies for identification of cases, embracing approaches and more effective treatments to meet the individual's biopsychosocial demands.

LEVEL OF EVIDENCE

Level V, narrative review.

Comparing the clinical presentation of eating disorder patients with and without trauma history and/or comorbid PTSD

This study examined whether clinical characteristics among patients presenting to residential eating disorder (ED) treatment differed according to patients' trauma history and current PTSD diagnostic status. Participants (699 girls and women) completed surveys at treatment onset. One-way analysis of covariance (ANCOVA) tests assessed cross-sectional differences between three groups of patients: those reporting no trauma history (No Trauma, n = 185), those with trauma history but without PTSD (Trauma, n = 263), and those with current PTSD (PTSD, n = 251). Relative to the No Trauma group, the combined Trauma and PTSD groups reported greater ED symptoms, anxiety and depressive symptoms, experiential avoidance, anxiety sensitivity, and lower mindfulness. The PTSD group reported greater ED, anxiety, and depressive symptoms, greater anxiety sensitivity, and lower mindfulness, relative to the Trauma group. In sum, ED patients with any history of trauma experienced more symptoms and other psychopathology relative to patients who did not report trauma history. Among patients reporting trauma, those with current PTSD experienced even greater symptom severity. Interventions focused on improving emotional functioning could be especially beneficial for ED patients with trauma histories.

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.

Extreme Risk-Taking Behaviors in Patients With Eating Disorders

BACKGROUND

Patients with eating disorders (EDs) engage in different self-inflicted at-risk behaviors, including suicide, attempted suicide and non-suicidal self-injury. Our aim was to describe the occurrence and underlying motivations of non-suicidal extreme risk-taking behaviors in patients with EDs.

METHODS

Four cases from different treatment centers in Israel were analyzed.

RESULTS

All patients were females hospitalized in inpatient settings because of long lasting anorexia nervosa (AN) with either binge/purge or purging episodes (AN-B/P/AN-P), including in most cases both self-induced voting and laxative abuse. Case [1] was an adolescent also diagnosed with type 1 diabetes mellitus. She abused insulin, both omission and overdose, was highly suicidal, and suffered from comorbid oppositional behavior, depression and anxiety. Case [2] was a 24-years old woman, transitioning from restricting to AN with vomiting and laxative use during inpatient treatment. She was also diagnosed with attention deficit hyperactivity disorder, depression, anxiety, and suicidal thoughts. In hospital, she developed excessive water consumption, leading to very low urine concentrations and sodium levels, and one episode of loss of consciousness. Case [3] was in her late thirties, demonstrating particularly massive laxative abuse. She also suffered from alcohol addiction, sexual trauma, and one attempted suicide. During hospitalization she developed laxative-abuse-related rectal prolapse that was successfully operated. Nonetheless, after operation she resumed laxative abuse. Case [4] was a 23-year old pregnant women with highly active AN-B/P during pregnancy. She was hospitalized at 23 weeks of gestation following abdominal pressure. She only partly complied with inpatient treatment, discharged herself against medical advice after 5 weeks, and gave birth at week 34.

DISCUSSION

All cases were females with long-standing B/P type AN, often with multiple purging behaviors, other impulsive and non-impulsive comorbidities, and many environmental vulnerabilities. Different motivations were found for these extreme behaviors in addition to ED-related factors, mostly not related to suicide. The severity of the medical and psychological condition required multimodal medical and psychological inpatient interventions. The patients mostly did not comply with their treatment, showing considerable indifference to their grave medical condition.

Trauma-informed care and practice for eating disorders: personal and professional perspectives of lived experiences

BACKGROUND

Learning about the life stories of patients who have experienced a severe eating disorder (ED), but also traumas that led to PTSD, dissociative disorders, and other comorbidities, has great value to clinicians in their efforts to deliver trauma-informed care (TIC). Many investigators have been researching and writing about these issues for years, and strong scientific evidence has emerged, indicating that trauma is a significant risk factor for the development of EDs, particularly in its bulimic forms.

PURPOSE

Peer-reviewed literature contains scarce input from people with "lived experiences". Hearing and "sitting with" such individuals are extremely useful in clinical practice and research. Further, encouraging patients to put words to their pain has recognized therapeutic effects. These lived experiences are often demonstrative of key elements of what professionals need to know about evaluating and treating patients with EDs and co-occurring trauma-related disorders.

METHOD/RESULTS

The principal author invited two courageous recovered ED advocates and writers (June Alexander and Jenni Schaefer), who have gone public about their ED-PTSD experiences, to recount their life stories and treatment experiences (both positive and negative). Dr. Brewerton then offers his professional perspectives on the course of their treatment experiences put in the context of ongoing relevant clinical research.

CONCLUSION

Their and other patients' experiences have great power to guide professionals toward trauma-informed care, more integrated practice, and theoretically improved outcomes.

LEVEL OF EVIDENCE

Level V.

Sensation seeking, binge-type eating disorders, victimization, and PTSD in the National Women's Study

OBJECTIVE

Higher degrees of sensation seeking (SS) are reported in community and clinical samples of individuals with eating disorders with binge-type features (BTEDs), but no reports exist in representative probability samples of adult women. Additionally, SS has been linked to victimization and PTSD, also associated with BTEDs, yet interrelationships between these variables are unexplored.

METHODS

A national, probability sample of 3006 adult women (≥18 y/o) completed structured telephone interviews including assessments for victimization, PTSD, bulimia nervosa (BN) and binge eating disorder (BED). The survey included the 6 items of the Disinhibition-Intentions for the Future (DIF) subscale of Zuckerman's Sensation Seeking Scale-VI, which asks how likely participants would be to engage in given activities. Total SS score (TSSS-DIFS) was the sum of the 6 items' scores. Differences among the 3 groups (BN, BED, non-BN/BED) were compared using ANOVA covaried by age and post-hoc t-tests. Multiple regression tested the effects of age, number of victimization experiences (NVE), lifetime PTSD, and BTEDs on TSSS-DIFS.

RESULTS

There were significant differences in TSSS-DIFS across BTED diagnoses (p ≤ .001). Participants with BN (p ≤ .002) and those with BED (p ≤ .01) had significantly higher scores than those without BTEDs. These findings persisted in both groups after correcting for NVE and lifetime PTSD. TSSS-DIFS was significantly higher in participants with BTED with PTSD versus those without (p ≤ .025).

DISCUSSION

SS traits related to disinhibition occur more commonly in U.S. adult women with BN and BED, even after controlling for NVE and PTSD, which were also associated with higher TSSS-DIFS.

Commissioning guidance for weight assessment and management in adults and children with severe complex obesity

The challenge of managing the epidemic of patients with severe and complex obesity disease in secondary care is largely unmet. In England, the National Institute of Health and Care Excellence and the National Health Service England have published guidance on the provision of specialist (non-surgical) weight management services. We have undertaken a systematic review of 'what evidence exists for what should happen in/commissioning of: primary or secondary care weight assessment and management clinics in patients needing specialist care for severe and complex obesity?' using an accredited methodology to produce a model for organization of multidisciplinary team clinics that could be developed in every healthcare system, as an update to a previous review. Additions to the previous guidance were multidisciplinary team pathways for children/adolescent patients and their transition to adult care, anaesthetic assessment and recommendations for ongoing shared care with general practitioners, as a chronic disease management pathway.

Understanding eating disorders within internalizing psychopathology: A novel transdiagnostic, hierarchical-dimensional model

BACKGROUND

Several problems with the classification and diagnosis of eating disorders (EDs) have been identified, including proliferation of 'other specified' diagnoses, within-disorder heterogeneity, and frequent diagnostic migration over time. Beyond problems within EDs, past research suggested that EDs fit better in a spectrum of internalizing psychopathology (characterized by mood and anxiety disorders) than in a separate diagnostic class.

PURPOSE

To develop a transdiagnostic, hierarchical-dimensional model relevant to ED psychopathology that: 1) reduces diagnostic heterogeneity, 2) includes important dimensions of internalizing psychopathology that are often excluded from ED diagnostic models, and 3) predicts clinical impairment.

PROCEDURES

Goldberg's (2006) method and exploratory structural equation modeling were used to identify a hierarchical model of internalizing in community-recruited adults with EDs (N=207).

FINDINGS

The lowest level of the hierarchy was characterized by 15 factors that defined specific aspects of eating, mood, and anxiety disorders. At the two-factor level, Internalizing bifurcated into Distress (low well-being, body dissatisfaction, suicidality, dysphoria, ill temper, traumatic intrusions) and Fear-Avoidance (claustrophobia, social avoidance, panic symptoms, dietary restricting, excessive exercise, and compulsions). Results showed that the lowest level of the hierarchy predicted 67.7% of the variance in clinical impairment. In contrast, DSM eating, mood, and anxiety disorders combined predicted 10.6% of the variance in impairment secondary to an ED.

CONCLUSIONS

The current classification model represents an improvement over traditional nosologies for predicting clinically relevant outcomes for EDs.

Food addiction as a proxy for eating disorder and obesity severity, trauma history, PTSD symptoms, and comorbidity

PURPOSE

Food addiction (FA) is a newly defined yet still controversial condition that has important etiological, developmental, treatment, prevention, and social policy implications. In this review, the case is made that FA (or high scores on the Yale Food Addiction Scale) may be used as a proxy measure for a matrix of interrelated clinical features, including greater eating disorder severity, greater obesity severity, more severe trauma histories, greater symptoms of posttraumatic stress disorder (PTSD), greater psychiatric comorbidity, as well as greater medical morbidity and mortality.

METHODS

A Medline search was undertaken using the following terms: food addiction cross-referenced with eating disorders (anorexia nervosa, bulimia nervosa, binge eating disorder, and binge eating), obesity, trauma, posttraumatic stress disorder, and comorbidity.

RESULTS

The thesis is that the identification and acknowledgment of the concept of FA, when integrated into an overall, trauma-focused and transdiagnostic treatment approach, are supported and can be useful in understanding clinically the "big picture."

CONCLUSIONS

Food addiction (FA) may be used as a proxy for (1) bulimic eating disorder severity, (2) complex trauma histories, (3) severity of PTSD and PTSD symptoms, (4) intensity of psychiatric comorbidity, (5) severity of obesity, as well as (6) their combination. Implications for developing treatment strategies are discussed. The case for a comprehensive management that requires careful attention to medical and psychiatric assessment and integrated care that incorporates trauma-focused treatment is made.

The association of posttraumatic stress disorder with fast food and soda consumption and unhealthy weight loss behaviors among young women

OBJECTIVE

This study examines the association of posttraumatic stress disorder (PTSD) symptoms with fast food and soda consumption, unhealthy dieting behaviors, and body mass index (BMI) in a group of young women.

METHODS

This study was conducted on cross-sectional data gathered from 3181 females 16-24 years of age attending five publicly funded clinics in Texas. The associations among PTSD, fast food consumption frequency, soda consumption frequency, unhealthy dieting behaviors, and BMI were examined using binary and ordinal logistic regression.

RESULTS

PTSD symptoms were associated with an increased frequency of consumption of fast food and soda as well as unhealthy dieting behaviors but not with increased body mass index (BMI).

CONCLUSIONS

PTSD symptoms adversely affect both eating and dieting behaviors of young women. These behaviors may have negative long-term consequences for the health of females with PTSD symptoms.