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Childhood Trauma and Eating Disorders: Childhood Trauma and Eating Disorders: From Collaboration to InterventionFrom Collaboration to Intervention
Steve Wonderlich, Ph.D.Steve Wonderlich, Ph.D.Professor and Associate ChairmanProfessor and Associate Chairman
Department of NeuroscienceDepartment of NeuroscienceUniversity of North Dakota School of University of North Dakota School of
Medicine & Health ScienceMedicine & Health ScienceDirector of Clinical ResearchDirector of Clinical Research
Neuropsychiatric Research InstituteNeuropsychiatric Research Institute
Today’s TalkToday’s Talk
• Eating Disorders – “Comorbidity”Eating Disorders – “Comorbidity”
• Traumatic ExperienceTraumatic Experience
• InterventionIntervention
• CollaboratingCollaborating
1987 – University of North Dakota1987 – University of North Dakota
• Assistant ProfessorAssistant Professor
• MeritCare Eating Disorders MeritCare Eating Disorders ProgramProgram
Personality Disorders and Eating DisordersPersonality Disorders and Eating Disorders
• 46 women treated for Eating Disorders 46 women treated for Eating Disorders at UWEDPat UWEDP
• SCID InterviewsSCID Interviews
• Paper/Pencil questionnairesPaper/Pencil questionnaires
Diagnostic Variation and PDDiagnostic Variation and PD
PersonalityPersonality
HistrionicHistrionic
Obsessive CompulsiveObsessive Compulsive
AvoidantAvoidant
ComparisonComparison
BN > ANBN > AN
AN > BNAN > BN
ANR > ANBPANR > ANBP
Wonderlich, Swift, Slotnick & Goodman, 1990
Borderline Versus Other Personality Borderline Versus Other Personality Disorders in the Eating DisordersDisorders in the Eating Disorders
BPDBPD OPDOPD NPDNPD ControlControl
Mother Mother AttacksAttacks
.17.17aa -.56-.56bb -.52-.52bb -.86-.86bb
I Withdraw I Withdraw MotherMother
.33.33aa -.32-.32bb -.57-.57b,cb,c -.82-.82dd
Wonderlich & Swift, 1990
72 27 0
Personality DisorderPersonality Disorder
BorderlineBorderline Other PDOther PD No PDNo PD
CSA (%)CSA (%) 7272 2727 00
Is this real??Is this real??CollaborationsCollaborations
• Village Family Service CenterVillage Family Service Center• U of W ED programU of W ED program• Rape and Abuse Crisis CenterRape and Abuse Crisis Center• Alliance for Sexual Abuse Alliance for Sexual Abuse
Prevention and TreatmentPrevention and Treatment
ED in Incest VictimsED in Incest Victims
Wonderlich, Donaldson, Carson, Staton, Gertz, Leach, Johnson, 1996
IncestIncest
(N = 38)(N = 38)
ControlControl
(N = 27)(N = 27)
BingeBinge
VomitVomit
LaxativeLaxative
42%42%
24%24%
11%11%
15%15%
4%4%
4%4%
Child Abuse in 712 Child Abuse in 712 ED Clinic PatientsED Clinic Patients
0
10
20
30
40
50
60
Alcohol Suicide Attempt Shoplifting
None
Sexual
Physical
Both
Fullerton et al., 1995
Trauma and Psychopathology
Thompson et al., 2002
UND/NRI Child Maltreatment ProjectUND/NRI Child Maltreatment ProjectEating Disorder/PurgingEating Disorder/Purging
(Ages 10 – 15)(Ages 10 – 15)
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Abused Children Nonabused Children
KEDS
Wonderlich et al., 2001
0
10
20
30
40
50
Year 1 Year 2 Year 3
CSA (n = 20)
Control (n = 20)
% 3 or More
Impulsive Behavior In Past 12
Months
Prospective Study of Multi Impulsivity in Sexually Abused Children (10 – 15 years)
Connolly et al., (2002)
What about Nonclinical Samples?What about Nonclinical Samples?
Abused
(N = 157)
N (%)
Not Abused (N = 497)
N (%)Odds Ratio
Binge Eat
Binge + Purge
30 (19.1)
12 (7.7)
39 (7.8)
10 (2.0)
1.96*
2.62*
Wonderlich, Wilsnack, Wilsnack, & Harris, 1996
The Relationship between Childhood The Relationship between Childhood Sexual Abuse and Eating Disorders Sexual Abuse and Eating Disorders
(Wonderlich, Brewerton, Jocic, Dansky & Abbott, 1997; (Wonderlich, Brewerton, Jocic, Dansky & Abbott, 1997; JAACP)JAACP)
• CSA is moderately supported as a risk factor for BN CSA is moderately supported as a risk factor for BN (need better control)(need better control)
• Unclear if risk factor for ANUnclear if risk factor for AN• CSA not a specific risk factor for ED and not related CSA not a specific risk factor for ED and not related
to severityto severity• CSA appears to be a risk factor for psychiatric CSA appears to be a risk factor for psychiatric
comorbidity in eating disordered individualscomorbidity in eating disordered individuals• Need prospective designs with better measurementNeed prospective designs with better measurement
So, how may early traumaSo, how may early traumaoperate to increase risk?operate to increase risk?
Possible Mediators/MechanismsPossible Mediators/Mechanisms
Trauma ED• Shame
• Dissociation
• Impulse Control
• Anxiety
• Substance Use
•Cognitions
Andrews, 1997; Kent et al., 1999; Hart & Waller, 2002; Murray & Waller, 2002; Wonderlich et al., 2001
Psychobiological MediationPsychobiological Mediation(Animal Studies)(Animal Studies)
Early Stress Early Stress BehavioralBehavioralDisturbanceDisturbance
Suomi, 1991 Suomi, 1991 Kraemer, 1992 Kraemer, 1992 McEwen, 1998 McEwen, 1998 Meaney et al., 1988 Meaney et al., 1988 Sapolsky et al., 1986Sapolsky et al., 1986
Altered Biological
Stress Response
Psychobiological Mediation/MechanismPsychobiological Mediation/Mechanism(Human Studies)(Human Studies)
• Developmental TraumatologyDevelopmental Traumatology– Systematic investigation of the psychiatric Systematic investigation of the psychiatric
and psychobiological impact of adversity and psychobiological impact of adversity on the developing childon the developing child• Developmental psychopathologyDevelopmental psychopathology• Developmental neuroscienceDevelopmental neuroscience• Stress and trauma researchStress and trauma research
DeBellis, 2006
Psychobiological Stress Response Psychobiological Stress Response Systems and Child TraumaSystems and Child Trauma
• Sympathetic Nervous System Data in Sympathetic Nervous System Data in Abused Children and AdultsAbused Children and Adults 24 hour urinary Norepinephrine and 24 hour urinary Norepinephrine and
DopamineDopamine Norepinephrine Norepinephrine PTSD PTSD SNS responsiveness following orthostatic SNS responsiveness following orthostatic
challenge (heart rate)challenge (heart rate)De Bellis et al., 1994, 1999 De Bellis et al., 1994, 1999 Perry, 1994 Perry, 1994 Orr et al., 1998 Orr et al., 1998 Heim et al., 2000Heim et al., 2000
Psychobiological Stress Response Psychobiological Stress Response Systems and Child TraumaSystems and Child Trauma
• Limbic - Hypothalamus – Pituitary – Adrenal Limbic - Hypothalamus – Pituitary – Adrenal
(CRH)(CRH) (ACTH)(ACTH) (Cortisol)(Cortisol)
– ACTH dysregulation in adult CA/CN victimsACTH dysregulation in adult CA/CN victims
• • ACTHACTH
•• CRHCRH
Kaufman, 1991 Hart et al., 1996 De Bellis, 1994
depression/anxiety
Elevated ACTH in CA VictimsElevated ACTH in CA Victims(Heim et al., 2000, JAMA)(Heim et al., 2000, JAMA)
0
2
4
6
8
10
-15 0 15 30 45 60 75 90
Mea
n A
CT
H L
evel
pm
ol/L
Child Abuse
Controls
Time (Minutes)
Psychobiological Stress Response Psychobiological Stress Response Systems and Child TraumaSystems and Child Trauma
• Limbic – Hypothalamus – Pituitary – AdrenalLimbic – Hypothalamus – Pituitary – Adrenal(CRH)(CRH) (ACTH)(ACTH) (Cortisol)(Cortisol)
– Cortisol dyregulation in CA/CN victimsCortisol dyregulation in CA/CN victims• Acute response is elevationAcute response is elevation• Chronic response is normalization or suppression (down Chronic response is normalization or suppression (down
regulation at pituitary)regulation at pituitary)
De Bellis et al., 1999 Putnam et al., 1991 Carrion et al., 2002
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5
PreBreakfast
Pre Lunch Pre Dinner Pre Bed
Mea
n C
orti
sol L
evel
(M
g/dl
)
PTSD
Control
Elevated Cortisol in Abused Children Elevated Cortisol in Abused Children (Carrion et al., 2002)(Carrion et al., 2002)
Absence of Elevated Cortisol in AdultsAbsence of Elevated Cortisol in Adults
((Heim et al., 2000, JAMAHeim et al., 2000, JAMA))
0
50
100
150
200
250
300
350
-15 0 15 30 45 60 75 90
Mea
n C
orti
sol L
evel
nm
ol/L
Child Abuse
Controls
Time (minutes)
Does Stress Damage the Brain?Does Stress Damage the Brain?
In the developing brain elevated catecholamines In the developing brain elevated catecholamines and cortisol may lead to:and cortisol may lead to:
• Loss of neuronsLoss of neurons
• Delays in myelinationDelays in myelination• Deviant pruning processesDeviant pruning processes• Inhibiting of neurogenesisInhibiting of neurogenesis
Lauder, 1988; Sapolsky, 1990; DeBellis et al., 2002; Dunlop et al., Lauder, 1988; Sapolsky, 1990; DeBellis et al., 2002; Dunlop et al., 1997; Tanapat et al., 19981997; Tanapat et al., 1998
Biological CorrelatesBiological Correlates of Trauma in Adults - Neuroimaging of Trauma in Adults - Neuroimaging
PET/MRIPET/MRI
Medial prefrontal (anterior cingulate) blood flow in women Medial prefrontal (anterior cingulate) blood flow in women abused as children (Extinction of Conditioned Fear; abused as children (Extinction of Conditioned Fear; Limbic Inhibition; Executive Function)Limbic Inhibition; Executive Function)
Amygdaloid activity in child abuse victims (Anxiousness, Amygdaloid activity in child abuse victims (Anxiousness, Hyperarousal, Social Processing) in child abuse victimsHyperarousal, Social Processing) in child abuse victims
Hippocampal volume (Learning; Concentration; Memory) Hippocampal volume (Learning; Concentration; Memory) in child abuse victimsin child abuse victims
Stein et al., 1997; Shin et al., 1999; Bremmer et al., 1999Stein et al., 1997; Shin et al., 1999; Bremmer et al., 1999
Biological CorrelatesBiological Correlatesof Trauma in Children with PTSDof Trauma in Children with PTSD
MRI Based VolumeMRI Based Volume Total Brain (Early Onset, Duration)Total Brain (Early Onset, Duration)
Corpus Callosum (Processing Emotional Stimuli/Memory)Corpus Callosum (Processing Emotional Stimuli/Memory)
Prefrontal Cortex (Extinction of Conditioned Fear)Prefrontal Cortex (Extinction of Conditioned Fear)
Superior Temporal Gyrus (Language Production)Superior Temporal Gyrus (Language Production)
Hippocampal Volume (Learning; Concentration; Memory)Hippocampal Volume (Learning; Concentration; Memory)
Cerebellum (Autonomic regulation)Cerebellum (Autonomic regulation)
ØØ Pituitary (stress reaction)Pituitary (stress reaction)
Teicher et al., 1997; Carrion et al., 2001; DeBellis et al., 1999, 2002a, Teicher et al., 1997; Carrion et al., 2001; DeBellis et al., 1999, 2002a, 2002b; 2004; 2006; Thomas & DeBellis, 2004; Tupler & DeBellis, 2006 2002b; 2004; 2006; Thomas & DeBellis, 2004; Tupler & DeBellis, 2006
Telehealth Based Treatments for Telehealth Based Treatments for Traumatized ChildrenTraumatized Children
• SAMHSASAMHSA
• National Child Traumatic Stress National Child Traumatic Stress NetworkNetwork
Telehealth Based Treatments for Telehealth Based Treatments for Traumatized ChildrenTraumatized Children
• UND School of UND School of MedicineMedicine
• UND INPSYDEUND INPSYDE• NRINRI• ND Child ProtectionND Child Protection• Cass County Family Cass County Family
ServiceService
• Rape and Abuse Crisis Rape and Abuse Crisis CenterCenter
• Red River CACRed River CAC• Dakota CACDakota CAC
Allegheny General, North Shore University Hospital, University of Oklahoma, Medical University of South Carolina
Telehealth Based Treatments for Telehealth Based Treatments for Traumatized ChildrenTraumatized Children
Objectives Objectives • Evidence Based Treatments (SPARCS, Evidence Based Treatments (SPARCS,
TFCBT)TFCBT)• Native American AdaptationNative American Adaptation• Telehealth DeliveryTelehealth Delivery• Mental Health for CPSMental Health for CPS• Psychological Prep for Medical Psychological Prep for Medical
ProceduresProcedures
Treatment CollaborativeTreatment Collaborativefor Traumatized Youthfor Traumatized Youth
(TCTY)(TCTY)
Funded by Otto Bremer Funded by Otto Bremer Foundation,Foundation,
Dakota Medical Foundation,Dakota Medical Foundation,Department of Human ServicesDepartment of Human ServicesStern FoundationStern FoundationMDUMDU
Best Practice Treatments for Traumatized Best Practice Treatments for Traumatized Children in North DakotaChildren in North Dakota
• 13 clinicians trained in TFCBT/SPARCS13 clinicians trained in TFCBT/SPARCS• 2 training/supervision conferences in North 2 training/supervision conferences in North
DakotaDakota• Data basedData based• Native American Adaptation?Native American Adaptation?• Telehealth?Telehealth?• Sustaining Funding (SAMHSA?)Sustaining Funding (SAMHSA?)
I thought this guy didI thought this guy did
eating disorders stuffeating disorders stuff
Heterogeneity within Diagnostic ClassHeterogeneity within Diagnostic Class
““Patterned within category Patterned within category heterogeneity”heterogeneity”
Westen & Harnden-Fischer, 2001Westen & Harnden-Fischer, 2001
Northern Tier Research GroupNorthern Tier Research Group
S. WonderlichS. Wonderlich (ND)(ND)
J. MitchellJ. Mitchell (ND)(ND)
R. CrosbyR. Crosby (ND)(ND)
S. CrowS. Crow (MN)(MN)
C. PetersonC. Peterson (MN)(MN)
M. KleinM. Klein (WI)(WI)
D. LeGrangeD. LeGrange (Chicago)(Chicago)
A. BardoneA. Bardone (Missouri)(Missouri)
T. JoinerT. Joiner (Florida)(Florida)
Mood and Eating DisordersMood and Eating Disorders
• Eating Disorders and Impulsivity: A Eating Disorders and Impulsivity: A Longitudinal Study, NIMH, RO1 MH59674Longitudinal Study, NIMH, RO1 MH59674
• Ecological Momentary Assessment of Ecological Momentary Assessment of Anorexia Nervosa, NIMH, 5RO1 MH59674-5.Anorexia Nervosa, NIMH, 5RO1 MH59674-5.
Momentary Relationship of Mood and Binge Eating
15
20
25
30
35
40
45
-6 -4 -2 0 2 4 6
Negative AffectPositive Affect
Neg
ativ
e A
ffe
ct o
r P
osi
tive
Aff
ect
Hours Relative to Binge
ICAT CollaboratorsICAT Collaborators
Stephen Wonderlich, Ph.D.
Carol Peterson, Ph.D.
James Mitchell, M.D.
Scott Crow, M.D.
Tracey Smith, Ph.D.
ICAT ModelICAT Model
Self Discrepancy Negative CopingMood Instability
Self Discrepancy and BN
-2.5
-2
-1.5
-1
-0.5
0
0.5
1
1.5
AI AO AIP AOP
BN (N = 38)
Control (N = 38)
Self Directed Style and BN
10
20
30
40
50
60
70
Spontaneous Accept Nourish Protect Monitor Blame Reject Daydreaming
BN (N = 38)
Control (N = 38)
ICATICAT
• 20 session – manualized20 session – manualized
• Adult BNAdult BN
• Non PsychoticNon Psychotic
• 18 cases entered18 cases entered
• Addresses personality variationAddresses personality variation
0
2
4
6
8
10
Pre Post
Binge
Purge
ICT Pilot DataF
req
uen
cy P
er W
eek
0
1
2
3
4
Baseline EOT
Global EDE
Changes in EDE
0
5
10
15
20
Baseline EOT
# OBE Days
Changes in Binge Eating
0
5
10
15
20
25
30
35
40
45
50
Baseline EOT
Vomiting Episodes
Changes in Vomiting
-3
-2
-1
0
1
AI AO
Pre
Post
Changes in Self Discrepancy
0
1
2
3
4
5
Baseline EOT
Blame Self
Attack Self
Changes in Self Directed Style
2
4
6
8
Baseline EOT
Self Accept
Self Protect
Changes in Self Directed Style
Abstinence at EOTAbstinence at EOT(Both Waves)(Both Waves)
70% Binge Eat70% Binge Eat
65% Vomit65% Vomit
?
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