The effects of childhood maltreatment on brain structure in adults with eating disorders

Inflammatory biomarkers and childhood maltreatment: A cluster analysis in patients with eating disorders

Eating Disorders (EDs) are severe psychiatric disorders, with growing evidence pointing towards the role of childhood maltreatment (CM) influencing their onset, severity, and response to treatment. Preliminary evidence showed that CM could be associated with an elevation of inflammatory biomarkers across the different EDs. The objective of the study was to elucidate the interplay between CM, ED-specific psychopathology, and inflammatory biomarkers. The study involved 198 female participants, comprising 70 patients with anorexia nervosa (AN), 56 patients with bulimia nervosa (BN), and 72 healthy controls (HCs). K-means clustering was used to assess the hypothesis that latent clusters could be described between patients affected by EDs based on serum levels of inflammatory biomarkers alone (CRP, IL-6, suPAR). Additionally, the analysis included a comparison between patients with and without history of childhood maltreatment. Patients with AN exhibited significantly higher suPAR levels than HCs, regardless of the severity of psychopathology. A direct association between CM and elevated levels of inflammatory biomarkers, particularly CRP, IL-6, and suPAR were found. Cluster analysis identified two distinct populations among patients with EDs, with the group showing elevated inflammatory biomarkers likely to report more severe CM. Even though preliminary, the results of the present study support the existence of a biologically grounded "maltreated eco-phenotype" in EDs. The present study also reports results on CRP, IL-6 and suPAR, in patients with EDs. These findings might suggest future potential tailored treatments and interventions designed to target specific subgroups of patients, and potentially improving treatment efficacy.

Eating- and Weight-Related Disorders in the Armed Forces

BACKGROUND/OBJECTIVES

Like in the general population, the prevalences of eating- and weight-related health issues in the armed forces are increasing. Relevant medical conditions include the eating disorders (EDs) anorexia nervosa, bulimia nervosa, binge eating disorder, and avoidant restrictive food intake disorder (ARFID), as well as body dysmorphic disorder, muscle dysmorphia, and the relative energy deficiency in sport (RED-S) syndrome.

METHODS

We performed a narrative literature review on eating- and weight-related disorders in the armed forces.

RESULTS

Entry standards might exclude people with obesity, with EDs, or at high risk for EDs from entering the armed forces for military reasons and to protect the individual's health. Relevant potential risk factors of eating- and weight-related disorders in the military are the emphasis on appearance and fitness in the military, high levels of stress, military sexual trauma, post-traumatic stress disorder, deployment, relocation, long commutes, consumption of ultra-processed foods and beverages, limitations on food selection and physical exercise, and intensive combat training and field exercises. Eating- and weight-related disorders negatively impact professional military appearance and lead to problems with cardiorespiratory and neuromuscular fitness; daytime sleepiness; and a higher risk of musculoskeletal injuries, and other physical and mental health problems. Current and potential future therapeutic options include occupational health measures, psychosocial therapies, neuromodulation, and drug treatments.

CONCLUSIONS

Even though randomized controlled trials (RCTs) have been performed to test treatments for obesity in the armed forces, RCTs for the treatment of EDs, body dysmorphic disorder, muscle dysmorphia, and RED-S syndrome are lacking in the military context.

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.

Alterations in the white matter structure of major depressive disorder patients and their link to childhood trauma

Objectives

Major Depressive Disorder (MDD) is significantly influenced by childhood trauma (CT), affecting brain anatomy and functionality. Despite the unique disease trajectory in MDD patients with CT, the underlying neurobiological mechanisms remain unclear. Our objective is to investigate CT's impact on the white matter structure of the brain in patients with MDD.

Methods

This research employed tract-based spatial statistics (TBSS) to detect variations between groups in Fractional Anisotropy (FA) throughout the whole brain in 71 medication-free MDD patients and 97 HCs. Participants filled out the Childhood Trauma Questionnaire (CTQ) and assessments for depression and anxiety symptoms. The relationship between FA and CTQ scores was explored with partial correlation analysis, adjusting for factors such as age, gender, educational background, and length of illness.

Results

Compared to HCs, the MDD group showed decreased FA values in the right posterior limb of the internal capsule (PLIC), the inferior fronto-occipital fasciculus (IFOF), and bilateral superior longitudinal fasciculus (SLF). Simple effects analysis revealed that compared to HC-CT, the MDD-CT group demonstrated decreased FA values in right PLIC, IFOF, and bilateral SLF. The MDD-nCT group showed decreased FA values in right PLIC and IFOF compared to HC-nCT. The total scores and subscale scores of CTQ were negatively correlated with the FA in the right SLF.

Conclusion

The right SLF may potentially be influenced by CT during the brain development of individuals with MDD. These results enhance our knowledge of the role of the SLF in the pathophysiology of MDD and the neurobiological mechanisms by which CT influences MDD.

Practitioner Review: Neurobiological consequences of childhood maltreatment - clinical and therapeutic implications for practitioners

BACKGROUND

Childhood maltreatment is one of the most important preventable risk factors for a wide variety of psychiatric disorders. Further, when psychiatric disorders emerge in maltreated individuals they typically do so at younger ages, with greater severity, more psychiatric comorbid conditions, and poorer response to established treatments, resulting in a more pernicious course with an increased risk for suicide. Practitioners treating children, adolescents, and young adults with psychiatric disorders will likely encounter the highest prevalence of clients with early-onset maltreatment-associated psychiatric disorders. These may be some of their most challenging cases.

METHOD

In this report, we explore key validated alterations in brain structure, function, and connectivity associated with exposure to childhood maltreatment as potential mechanisms behind their patients' clinical presentations.

RESULTS

We then summarize key behavioral presentations likely associated with neurobiological alterations and propose a toolkit of established trauma and skills-based strategies that may help diminish symptoms and foster recovery. We also discuss how some of these alterations may serve as latent vulnerability factors for the possible development of future psychopathology.

CONCLUSIONS

Research on the neurobiological consequences of childhood adversity provides a vastly enriched biopsychosocial understanding of the developmental origins of health and pathology that will hopefully lead to fundamental advances in clinical psychology and psychiatry.

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.

Early traumatic experiences and the hypothalamus-pituitary-adrenal axis in people with eating disorders: A narrative review

Exposure to trauma during childhood is a non-specific risk factor for psychiatric disorders, including eating disorders (EDs), over the life course. Moreover, an association between stressful life events and the onset/maintenance of EDs has been documented. Therefore, the hypothalamus-pituitary-adrenal (HPA) axis, namely the main component of the endogenous stress response system, has been proposed to be implicated in the pathophysiology of EDs. In this narrative review the current knowledge concerning the effects of early trauma exposure on the HPA axis activity and their putative role in the pathophysiology of EDs will be illustrated. Research findings corroborate the idea that childhood trauma exposure has long-lasting dysregulating effects on the activity of the HPA axis, which may contribute to the biological background of the early trauma-related risk for the development of EDs across the life span. Moreover, literature data support the existence of a "maltreated ecophenotype" in EDs characterized by specific clinic and neuroendocrine features, which may have important implications in treatment programming for such a type of patients.

Internal capsule microstructure mediates the relationship between childhood maltreatment and PTSD following adulthood trauma exposure

Childhood trauma is a known risk factor for trauma and stress-related disorders in adulthood. However, limited research has investigated the impact of childhood trauma on brain structure linked to later posttraumatic dysfunction. We investigated the effect of childhood trauma on white matter microstructure after recent trauma and its relationship with future posttraumatic dysfunction among trauma-exposed adult participants (n = 202) recruited from emergency departments as part of the AURORA Study. Participants completed self-report scales assessing prior childhood maltreatment within 2-weeks in addition to assessments of PTSD, depression, anxiety, and dissociation symptoms within 6-months of their traumatic event. Fractional anisotropy (FA) obtained from diffusion tensor imaging (DTI) collected at 2-weeks and 6-months was used to index white matter microstructure. Childhood maltreatment load predicted 6-month PTSD symptoms (b = 1.75, SE = 0.78, 95% CI = [0.20, 3.29]) and inversely varied with FA in the bilateral internal capsule (IC) at 2-weeks (p = 0.0294, FDR corrected) and 6-months (p = 0.0238, FDR corrected). We observed a significant indirect effect of childhood maltreatment load on 6-month PTSD symptoms through 2-week IC microstructure (b = 0.37, Boot SE = 0.18, 95% CI = [0.05, 0.76]) that fully mediated the effect of childhood maltreatment load on PCL-5 scores (b = 1.37, SE = 0.79, 95% CI = [-0.18, 2.93]). IC microstructure did not mediate relationships between childhood maltreatment and depressive, anxiety, or dissociative symptomatology. Our findings suggest a unique role for IC microstructure as a stable neural pathway between childhood trauma and future PTSD symptoms following recent trauma. Notably, our work did not support roles of white matter tracts previously found to vary with PTSD symptoms and childhood trauma exposure, including the cingulum bundle, uncinate fasciculus, and corpus callosum. Given the IC contains sensory fibers linked to perception and motor control, childhood maltreatment might impact the neural circuits that relay and process threat-related inputs and responses to trauma.

Distinct gray matter abnormalities in children/adolescents and adults with history of childhood maltreatment

Gray matter (GM) abnormalities have been reported in both adults and children/adolescents with histories of childhood maltreatment (CM). A comparison of effects in youth and adulthood may be informative regarding life-span effects of CM. Voxel-wise meta-analyses of whole-brain voxel-based morphometry studies were conducted in all datasets and age-based subgroups respectively, followed by a quantitative comparison of the subgroups. Thirty VBM studies (31 datasets) were included. The pooled meta-analysis revealed increased GM in left supplementary motor area, and reduced GM in bilateral cingulate/paracingulate gyri, left occipital lobe, and right middle frontal gyrus in maltreated individuals compared to the controls. Maltreatment-exposed youth showed less GM in the cerebellum, and greater GM in bilateral middle cingulate/paracingulate gyri and bilateral visual cortex than maltreated adults. Opposite GM alterations in bilateral middle cingulate/paracingulate gyri were found in maltreatment-exposed adults (decreased) and children/adolescents (increased). Our findings demonstrate different patterns of GM changes in youth closer to maltreatment events than those seen later in life, suggesting detrimental effects of CM on the developmental trajectory of brain structure.

Association between childhood maltreatment and cortical folding in women with eating disorders

Childhood maltreatment (CM) is associated with distinct clinical and biological characteristics in people with eating disorders (EDs). The measurement of local gyrification index (lGI) may help to better characterize the impact of CM on cortical structure. Thus, the present study investigated the association of CM with lGI in women with EDs. Twenty-six women with anorexia nervosa (AN) and 24 with bulimia nervosa (BN) underwent a 3T MRI scan. All participants filled in the Childhood Trauma Questionnaire. All neuroimaging data were processed by FreeSurfer. LGI maps underwent a general linear model to evaluate differences between groups with or without CM. People with AN and BN were merged together. Based on the Childhood Trauma Questionnaire cutoff scores, 24 participants were identified as maltreated and 26 as non-maltreated. Maltreated people with EDs showed a significantly lower lGI in the left middle temporal gyrus compared with non-maltreated people, whereas no differences emerged in the right hemisphere between groups. The present study showed that in people with EDs, CM is associated with reduced cortical folding in the left middle temporal gyrus, an area that could be involved in ED psychopathology. This finding corroborates the hypothesis of a 'maltreated ecophenotype', which argues that CM may allow to biologically, other than clinically, distinguish individuals with the same psychiatric disorder.

Characteristics of white matter alterations along fibres in patients with bulimia nervosa: A combined voxelwise and tractography study

Accumulating evidence supports the hypothesis that white matter (WM) abnormalities are involved in the pathophysiology of bulimia nervosa (BN); however, findings from in vivo neuroimaging studies have been inconsistent. We aimed to investigate the possible brain WM alterations, including WM volume and microstructure, in patients with BN. We recruited 43 BN patients and 31 healthy controls (HCs). All participants underwent structural and diffusion tensor imaging. Differences in WM volume and microstructure were evaluated using voxel-based morphometry, tract-based spatial statistics, and automated fibre quantification analysis. Compared with HCs, BN patients showed significantly decreased fractional anisotropy in the middle part of the corpus callosum (nodes 31-32) and increased mean diffusivity in the right cranial nerve V (CN V) (nodes 27-33 and nodes 55-88) and vertical occipital fasciculus (VOF) (nodes 58-85). Moreover, we found decreased axial diffusivity in the right inferior fronto-occipital fasciculus (node 67) and increased radial diffusivity in the CN V (nodes 22-34 and nodes 52-89) and left VOF (nodes 60-66 and nodes 81-85). Meanwhile, WM microstructural changes were correlated with patients' clinical manifestations. We did not find any significant differences in WM volume and the main WM fibre bundle properties between BN patients and HCs. Taken together, these findings provide that BN shows significant brain WM reorganization, but primarily in microstructure (part of WM fibre bundle), which is not sufficient to cause changes in WM volume. The automated fibre quantification analysis could be more sensitive to detect the subtle pathological changes in a point or segment of the WM fibre bundle.

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.

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.

Decreased functional coupling within default mode network in major depressive disorder with childhood trauma

OBJECTIVE

Childhood trauma (CT) has been supported to be a high-risk factor for major depressive disorder (MDD), but the neural mechanism linking CT and depression remains unclear. The aim of this study is to deepen our understanding of this issue by establishing the neuroimaging correlations between CT and depression.

METHODS

A sample of 123 MDD patients (91 with moderate-to-severe CT and 32 with no or low CT) and 79 healthy controls (HC, 33 with moderate-to-severe CT and 46 with no or low CT) participated. All participants completed assessments of depression level, anxiety, recent perceived stress, and resting-state functional MRI scan.

RESULTS

Participants with moderate-to-severe CT showed elevated depression level and trait anxiety, and reduced spontaneous neural activity in left inferior temporal gyrus (ITG). Abnormalities of seed-based functional connectivity (FC) of left ITG - bilateral precuneus/posterior cingulate cortex (PCC), left middle temporal gyrus (MTG), left medial orbitofrontal cortex (mOFC), and bilateral medial prefrontal cortex (mPFC)/anterior cingulate cortex (ACC) were observed. CT was associated with decreased FCs in MDD, but with increased FCs in HC. The total altered FCs of left ITG - bilateral precuneus/PCC and left mOFC mediated relationship between CT and depression in MDD, and total altered FCs and trait anxiety have a significant chain mediation effect in the association between CT and depression in HC.

CONCLUSION

These findings highlight the changes of default mode network (DMN) functions and trait anxiety as targets of CT. The decreased functional coupling within DMN may be involved in the mechanism of MDD following CT.

Childhood maltreatment is associated with cortical thinning in people with eating disorders

Childhood maltreatment (CM) is a non-specific risk factor for eating disorders (ED) and is associated with a greater severity in their clinical presentation and poorer treatment outcome. These data suggest that maltreated people with ED may be biologically other than clinically different from non-maltreated people. The aim of the present study was to investigate cortical thickness (CT), a possible biomarker of neurodevelopment, in people with ED with or without history of CM and in healthy women. Twenty-four healthy women, 26 with anorexia nervosa and 24 with bulimia nervosa underwent a 3T MRI scan. All participants filled in the childhood trauma questionnaire. All neuroimaging data were processed by FreeSurfer. Twenty-four participants with ED were identified as maltreated and 26 participants with ED as non-maltreated. All healthy women were non-maltreated. Compared to healthy women, maltreated people with ED showed lower CT in the left rostral anterior cingulate gyrus, while compared to people with ED without history of CM showed lower CT values in the left superior frontal and in right caudal middle frontal and superior parietal gyri. No significant differences emerged in CT measures between healthy women and people with ED without history of CM. The present findings show for the first time that in adult people with ED childhood maltreatment is associated with cortical thinning in areas implicated in the modulation of brain processes that are acknowledged to play a role in the psychopathology of ED.

Altered regional brain activity and functional connectivity patterns in major depressive disorder: A function of childhood trauma or diagnosis?

Childhood trauma (CT) is a non-specific risk factor for major depressive disorder (MDD). However, the neurobiological mechanisms of MDD with CT remain unclear. In the present study, we sought to determine the specific brain regions associated with CT and MDD etiology. Fractional amplitude of low-frequency fluctuation (fALFF) and functional connectivity (FC) analyses were performed to assess alterations of intrinsic brain activity in MDD with CT, MDD without CT, healthy controls with CT, and healthy controls without CT. Two-by-two factorial analyses were performed to examine the effects of the factors "MDD" and "CT" on fALFF and FC. Moderator analysis was used to explore whether the severity of depression moderated the relationship between CT and aberrant fALFF. We found that the etiological effects of MDD and CT exhibited negative impacts on brain dysfunction including altered fALFF in the left postcentral gyrus, left lingual gyrus, left paracentral lobule (PCL), and left cuneus. Decreased FC was observed in the following regions: (i) the left lingual gyrus seed and the left fusiform gyrus as well as the right calcarine cortex; (ii) the left PCL seed and the left supplementary motor area, left calcarine cortex, left precentral gyrus, and right cuneus; (iii) the left postcentral gyrus seed and left superior parietal lobule, right postcentral gyrus, and left precentral gyrus. Furthermore, the severity of depression acted as a moderator in the relationship between CT and aberrant fALFF in the left PCL. These data indicate that MDD patients with and without trauma exposure are clinically and neurobiologically distinct.

Experience-dependent associations between distinct subtypes of childhood trauma and brain function and architecture

Background

Childhood trauma can alter brain-development trajectories and lead to a greater risk of psychopathology developing in adulthood. For this reason, understanding experience-dependent brain abnormalities associated with different trauma subtypes is crucial for identifying developmental processes disrupted by unfavorable early environments and for proposing early intervention measures to reduce trauma's negative effects.

Methods

This study used multimodal magnetic resonance imaging (MRI) to explore the neural correlates of distinct subtypes of childhood trauma. We recruited a large community sample of young adults (mean age, 24.1, SD 1.9 years) who completed a Childhood Trauma Questionnaire, were given behavioral scores, and underwent multimodal MRI. To quantify brain changes, we used functional connectivity density (FCD) mapping based on whole brain analysis, regions of interest (ROI) analysis, and morphological measurements. Experience-dependent brain abnormalities were identified by multivariable linear regression.

Results

We found that diverse brain regions in the FCD mapping were significantly related to 4 trauma subtypes and belonged to different cognitive components used for various behaviors. Experience-related influences on functional circuits and brain morphology were observed in extensive regions, including the sensorimotor, cingulum, accumbens, insula, and frontal-parietal areas, as well as in regions within the default mode network.

Conclusions

Identifying specific regions or systems may be a valid strategy for understanding the pathogenesis and development process of psychiatric disorders in people with different traumatic experiences and may facilitate better-targeted intervention strategies for maltreated children.

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.

Provisional posttraumatic stress disorder is associated with greater severity of eating disorder and comorbid symptoms in adolescents treated in residential care

OBJECTIVE

Past traumatic events, subsequent posttraumatic stress disorder (PTSD) and related psychiatric comorbidities are commonly associated with eating disorders (EDs) in adults but remain understudied in adolescents.

METHODS

Adolescent participants (mean [SD] age = 15.1 ± 1.5 years, 96.5% female) with EDs entering residential treatment (n = 647) at six sites in the United States completed validated self-report assessments of ED, PTSD, major depression, anxiety disorders and quality of life. Provisional DSM-5 PTSD diagnoses (PTSD+) were made via the Childhood Trauma Questionnaire, admission interviews and the PTSD Symptom Checklist for DSM-5.

RESULTS

PTSD+ occurred in 35.4% of participants, and those with ED-PTSD+ had significantly higher scores on all assessments (p ≤ 0.001), including measures of ED psychopathology, major depression, anxiety disorders and quality of life, as well as significantly higher rates of all forms of childhood trauma. Those with PTSD+ also exhibited a significantly higher percent median body mass index for age and sex and a lower propensity toward anorexia nervosa, restricting type.

CONCLUSIONS

Results confirm that adolescent patients in residential treatment with ED-PTSD+ are more symptomatic and have worse quality of life than their ED counterparts without PTSD. Integrated treatment approaches that effectively address ED-PTSD+ are greatly needed in ED programs that treat adolescents.

Recognizing and Responding to Child Maltreatment: Strategies to Apply When Delivering Family-Based Treatment for Eating Disorders

Child maltreatment encompasses a constellation of adverse parental behaviors that include physical, sexual, or emotional abuse, physical or emotional neglect, as well as exposure to violence between parents. A growing body of literature indicates that exposure to child maltreatment is a significant risk factor for the development and maintenance of eating disorders (EDs) and that practitioners experience challenges related to recognizing and responding to various forms of child maltreatment in their practice. Parent-child interactions signifying possible child maltreatment can be subtle; furthermore, the emotional and behavioral symptoms associated with an ED can overlap with those linked with child maltreatment, making it difficult for practitioners to distinguish whether children's symptoms are attributable to underlying psychopathology versus exposure to child maltreatment. This challenge can be further complicated in the context of delivering family-based treatment (FBT); FBT reaffirms that there is no single cause of EDs and asserts the leadership role of parents in their child's recovery process-both of which may lead practitioners to inadvertently miss indicators of child maltreatment. In this article, we provide an overview of the evidence linking child maltreatment to EDs among children and adolescents, as well as evidence-informed strategies for practitioners to safely recognize and respond to suspected child maltreatment when delivering FBT to children and adolescents in their practice.

Coping with childhood maltreatment: Avoidance and eating disorder symptoms

Childhood maltreatment is associated with eating disorder symptoms; however, the nature of this association is unclear. We found those who experienced childhood maltreatment had higher avoidant coping and eating disorder symptoms. We also found an additive effect for maltreatment, such that with more types of maltreatment experienced, avoidant coping and eating disorder symptoms were greater. We also found evidence of an indirect effect such that childhood maltreatment was related to eating disorder symptoms through avoidant coping. Future research is needed to better understand factors that may promote development of adaptive coping patterns and prevention of eating disorder symptoms.

Treatment-Resistant Blunted HPA Activity, but Reversible Cardiovascular Stress Reactivity in Young Women With Eating Disorders

Previous research has provided evidence for a reduced neuroendocrine stress response in women with eating disorders (EDs). In the present study female in-patients with Anorexia and Bulimia nervosa were compared to female healthy controls (HC) before and after completing an in-patient treatment program. Salivary cortisol, alpha-amylase (sAA), heart rate response (HR), high-frequency heart rate variability (HF-HRV) and negative affective state were measured before, during and after exposure to the Trier Social Stress Test (TSST) at pre- and post-treatment. Patients with EDs (n = 13) showed significantly less ED symptoms at post-treatment. Compared to HC (n = 22), patients displayed a blunted cortisol stress response combined with overall attenuated sAA levels at pre-treatment. At post-treatment, the blunted cortisol stress response was still observable, while the differences in sAA responses disappeared. HR was attenuated at pre-treatment in patients, also indicated by a stronger HF-HRV throughout the TSST. These cardiovascular differences disappeared at post-treatment. Patients reported in general (pre- and post-treatment) more negative affect compared to HC. This study provides further evidences of a hypo-reactive hypothalamus-pituitary-adrenal axis (HPA) in patients with EDs which persists even after symptom recovery while initial low cardiovascular stress reactivity apparently can be restored by psychotherapy. Given the small sample size the findings have to be considered preliminary.

Epigenetic Modifications in Stress Response Genes Associated With Childhood Trauma

Adverse childhood experiences (ACEs) may be referred to by other terms (e.g., early life adversity or stress and childhood trauma) and have a lifelong impact on mental and physical health. For example, childhood trauma has been associated with posttraumatic stress disorder (PTSD), anxiety, depression, bipolar disorder, diabetes, and cardiovascular disease. The heritability of ACE-related phenotypes such as PTSD, depression, and resilience is low to moderate, and, moreover, is very variable for a given phenotype, which implies that gene by environment interactions (such as through epigenetic modifications) may be involved in the onset of these phenotypes. Currently, there is increasing interest in the investigation of epigenetic contributions to ACE-induced differential health outcomes. Although there are a number of studies in this field, there are still research gaps. In this review, the basic concepts of epigenetic modifications (such as methylation) and the function of the hypothalamic-pituitary-adrenal (HPA) axis in the stress response are outlined. Examples of specific genes undergoing methylation in association with ACE-induced differential health outcomes are provided. Limitations in this field, e.g., uncertain clinical diagnosis, conceptual inconsistencies, and technical drawbacks, are reviewed, with suggestions for advances using new technologies and novel research directions. We thereby provide a platform on which the field of ACE-induced phenotypes in mental health may build.

Deranged emotional and cortisol responses to a psychosocial stressor in anorexia nervosa women with childhood trauma exposure: Evidence for a "maltreated ecophenotype"?

Exposure to trauma in the childhood and abnormal interpersonal stress reactivity are believed to contribute to the pathophysiology of anorexia nervosa (AN), which suggests a possible role of the hypothalamus-pituitary adrenal (HPA) axis. Although an effect of early traumatic experiences on the cortisol awakening response has been proved in patients with AN, the consequences of childhood trauma exposure on HPA axis reactivity to psychosocial stressors has been never investigated in such individuals. Therefore, we have assessed emotional and cortisol responses to an acute psycho-social stress in AN patients with a history of childhood trauma exposure. Twenty-four AN women and 17 healthy women were enrolled in the study. Patients were classified as maltreated (Mal) or non-maltreated (noMal) according to their Childhood Trauma Questionnaire scores. Participants underwent the Trier Social Stress Test (TSST) and their emotional responses were measured through the state scale of the State-Trait Anxiety Inventory. Saliva samples were collected to measure cortisol production. Compared to both healthy subjects and noMal AN patients, Mal AN women exhibited a blunted cortisol response to TSST. With respect to healthy controls, pre-TSST anxiety levels were enhanced in both AN groups; moreover, Mal AN patients displayed a reduced anxiety increase after TSST as compared to both noMal patients and healthy women. Our findings for the first time provide the evidence of deranged biological and emotional responses to an acute social stress in AN patients with childhood trauma exposure, corroborating the idea of a maltreated ecophenotype in AN as in other psychiatric disorders.