Childhood Trauma and Eating Disorders:
From Collaboration to Intervention
Steve Wonderlich, Ph.D.
Professor and Associate Chairman
Department of Neuroscience
University of North Dakota School of
Medicine & Health Science
Director of Clinical Research
Neuropsychiatric Research Institute
Today’s Talk
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Eating Disorders – “Comorbidity”
Traumatic Experience
Intervention
Collaborating
1987 – University of North Dakota
• Assistant Professor
• MeritCare Eating Disorders
Program
Personality Disorders and Eating Disorders
• 46 women treated for Eating Disorders
at UWEDP
• SCID Interviews
• Paper/Pencil questionnaires
Diagnostic Variation and PD
Personality
Histrionic
Obsessive Compulsive
Avoidant
Comparison
BN > AN
AN > BN
ANR > ANBP
Wonderlich, Swift, Slotnick & Goodman, 1990
Borderline Versus Other Personality
Disorders in the Eating Disorders
BPD
OPD
NPD
Control
Mother
Attacks
.17a
-.56b
-.52b
-.86b
I Withdraw
Mother
.33a
-.32b
-.57b,c
-.82d
Wonderlich & Swift, 1990
72
27
0
Personality Disorder
CSA (%)
Borderline
72
Other PD No PD
27
0
Is this real??
Collaborations
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•
•
•
Village Family Service Center
U of W ED program
Rape and Abuse Crisis Center
Alliance for Sexual Abuse
Prevention and Treatment
ED in Incest Victims
Binge
Vomit
Laxative
Incest
(N = 38)
Control
(N = 27)
42%
24%
11%
15%
4%
4%
Wonderlich, Donaldson, Carson,
Staton, Gertz, Leach, Johnson, 1996
Child Abuse in 712
ED Clinic Patients
60
50
None
Sexual
Physical
Both
40
30
20
10
0
Alcohol
Suicide Attempt
Shoplifting
Fullerton et al., 1995
Trauma
andLifetime
Psychopathology
SCID
Diagnoses
CSA + Rape
CSA
Rape
Control
100
90
80
Percent
70
60
50
40
30
20
10
0
Mood
Disorder
Anxiety
Disorder
(CSA)
Substance
Disorder
(CSA,Rape)
Eating
Disorder
(CSA)
Thompson et al., 2002
UND/NRI Child Maltreatment Project
Eating Disorder/Purging
(Ages 10 – 15)
1.4
1.2
1
K
E
D
S
0.8
0.6
0.4
0.2
0
Abused Children
Nonabused Children
Wonderlich et al., 2001
Prospective Study of Multi Impulsivity in
Sexually Abused Children (10 – 15 years)
50
40
% 3 or
More
Impulsive
Behavior
In Past 12
Months
30
CSA (n = 20)
Control (n = 20)
20
10
0
Year 1
Year 2
Year 3
Connolly et al., (2002)
What about Nonclinical Samples?
Abused
(N = 157)
N (%)
Binge Eat
Binge + Purge
30 (19.1)
12 (7.7)
Not Abused
(N = 497) Odds
N (%)
Ratio
39 (7.8)
10 (2.0)
1.96*
2.62*
Wonderlich, Wilsnack, Wilsnack, & Harris, 1996
The Relationship between Childhood
Sexual Abuse and Eating Disorders
(Wonderlich, Brewerton, Jocic, Dansky & Abbott, 1997; JAACP)
• CSA is moderately supported as a risk factor for BN
(need better control)
• Unclear if risk factor for AN
• CSA not a specific risk factor for ED and not related
to severity
• CSA appears to be a risk factor for psychiatric
comorbidity in eating disordered individuals
• Need prospective designs with better measurement
So, how may early trauma
operate to increase risk?
Possible Mediators/Mechanisms
Trauma
• Shame
ED
• Dissociation
• Impulse Control
• Anxiety
• Substance Use
•Cognitions
Andrews, 1997; Kent et al., 1999; Hart & Waller, 2002; Murray & Waller, 2002;
Wonderlich et al., 2001
Psychobiological Mediation
(Animal Studies)
Early Stress
Altered
Biological
Stress Response
Behavioral
Disturbance
Suomi, 1991
Kraemer, 1992
McEwen, 1998
Meaney et al., 1988
Sapolsky et al., 1986
Psychobiological Mediation/Mechanism
(Human Studies)
• Developmental Traumatology
– Systematic investigation of the psychiatric
and psychobiological impact of adversity
on the developing child
• Developmental psychopathology
• Developmental neuroscience
• Stress and trauma research
DeBellis, 2006
Psychobiological Stress Response
Systems and Child Trauma
• Sympathetic Nervous System Data in
Abused Children and Adults
–  24 hour urinary Norepinephrine and
Dopamine
–  Norepinephrine   PTSD
–  SNS responsiveness following orthostatic
challenge (heart rate)
De Bellis et al., 1994, 1999
Perry, 1994
Orr et al., 1998
Heim et al., 2000
Psychobiological Stress Response
Systems and Child Trauma
• Limbic - Hypothalamus – Pituitary – Adrenal
(CRH)
(ACTH)
(Cortisol)
– ACTH dysregulation in adult CA/CN victims
•  ACTH
depression/anxiety
•  CRH
Kaufman, 1991
Hart et al., 1996
De Bellis, 1994
Elevated ACTH in CA Victims
(Heim et al., 2000, JAMA)
Mean ACTH Level pmol/L
10
8
6
Child Abuse
Controls
4
2
0
-15
0
15
30
45
60
Time (Minutes)
75
90
Psychobiological Stress Response
Systems and Child Trauma
• Limbic – Hypothalamus – Pituitary – Adrenal
(CRH)
(ACTH)
(Cortisol)
– Cortisol dyregulation in CA/CN victims
• Acute response is elevation
• Chronic response is normalization or suppression (down
regulation at pituitary)
De Bellis et al., 1999
Putnam et al., 1991
Carrion et al., 2002
Elevated Cortisol in Abused Children
(Carrion et al., 2002)
Mean Cortisol Level (Mg/dl)
0.5
0.45
0.4
0.35
0.3
PTSD
Control
0.25
0.2
0.15
0.1
0.05
0
Pre
Breakfast
Pre Lunch
Pre Dinner
Pre Bed
Absence of Elevated Cortisol in Adults
(Heim et al., 2000, JAMA)
Mean Cortisol Level nmol/L
350
300
250
200
Child Abuse
Controls
150
100
50
0
-15
0
15
30
45
60
Time (minutes)
75
90
Does Stress Damage the Brain?
In the developing brain elevated catecholamines
and cortisol may lead to:
• Loss of neurons
• Delays in myelination
• Deviant pruning processes
• Inhibiting of neurogenesis
Lauder, 1988; Sapolsky, 1990; DeBellis et al., 2002; Dunlop et al., 1997;
Tanapat et al., 1998
Biological Correlates
of Trauma in Adults - Neuroimaging
PET/MRI
 Medial prefrontal (anterior cingulate) blood flow in women
abused as children (Extinction of Conditioned Fear;
Limbic Inhibition; Executive Function)
 Amygdaloid activity in child abuse victims (Anxiousness,
Hyperarousal, Social Processing) in child abuse victims
 Hippocampal volume (Learning; Concentration; Memory)
in child abuse victims
Stein et al., 1997; Shin et al., 1999; Bremmer et al., 1999
Biological Correlates
of Trauma in Children with PTSD
MRI Based Volume
 Total Brain (Early Onset, Duration)
 Corpus Callosum (Processing Emotional Stimuli/Memory)
 Prefrontal Cortex (Extinction of Conditioned Fear)
 Superior Temporal Gyrus (Language Production)
 Hippocampal Volume (Learning; Concentration; Memory)
 Cerebellum (Autonomic regulation)
Ø Pituitary (stress reaction)
Teicher et al., 1997; Carrion et al., 2001; DeBellis et al., 1999, 2002a,
2002b; 2004; 2006; Thomas & DeBellis, 2004; Tupler & DeBellis, 2006
Telehealth Based Treatments for
Traumatized Children
• SAMHSA
• National Child Traumatic Stress
Network
Telehealth Based Treatments for
Traumatized Children
Allegheny General, North Shore University Hospital,
University of Oklahoma, Medical University of South
Carolina
• UND School of
Medicine
• UND INPSYDE
• NRI
• ND Child Protection
• Cass County Family
Service
• Rape and Abuse Crisis
Center
• Red River CAC
• Dakota CAC
Telehealth Based Treatments for
Traumatized Children
Objectives
• Evidence Based Treatments (SPARCS,
TFCBT)
• Native American Adaptation
• Telehealth Delivery
• Mental Health for CPS
• Psychological Prep for Medical
Procedures
Treatment Collaborative
for Traumatized Youth
(TCTY)
Funded by Otto Bremer Foundation,
Dakota Medical Foundation,
Department of Human Services
Stern Foundation
MDU
Best Practice Treatments for Traumatized
Children in North Dakota
• 13 clinicians trained in TFCBT/SPARCS
• 2 training/supervision conferences in North
Dakota
• Data based
• Native American Adaptation?
• Telehealth?
• Sustaining Funding (SAMHSA?)
I thought this guy did
eating disorders stuff
Heterogeneity within Diagnostic Class
“Patterned within category
heterogeneity”
Westen & Harnden-Fischer, 2001
Northern Tier Research Group
S. Wonderlich
J. Mitchell
R. Crosby
S. Crow
C. Peterson
M. Klein
D. LeGrange
A. Bardone
T. Joiner
(ND)
(ND)
(ND)
(MN)
(MN)
(WI)
(Chicago)
(Missouri)
(Florida)
Mood and Eating Disorders
• Eating Disorders and Impulsivity: A
Longitudinal Study, NIMH, RO1 MH59674
• Ecological Momentary Assessment of
Anorexia Nervosa, NIMH, 5RO1 MH59674-5.
Momentary Relationship of Mood and Binge Eating
45
Negative Affect
Positive Affect
Negative Affect or Positive Affect
40
35
30
25
20
15
-6
-4
-2
0
2
Hours Relative to Binge
4
6
ICAT Collaborators
Stephen Wonderlich, Ph.D.
Carol Peterson, Ph.D.
James Mitchell, M.D.
Scott Crow, M.D.
Tracey Smith, Ph.D.
ICAT Model
Self Discrepancy
Mood Instability
Negative Coping
Self Discrepancy and BN
1.5
1
0.5
0
BN (N = 38)
Control (N = 38)
-0.5
-1
-1.5
-2
-2.5
AI
AO
AIP
AOP
Self Directed Style and BN
70
60
BN (N = 38)
Control (N = 38)
50
40
30
20
10
Spontaneous
Accept
Nourish
Protect
Monitor
Blame
Reject
Daydreaming
ICAT
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•
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20 session – manualized
Adult BN
Non Psychotic
18 cases entered
Addresses personality variation
ICT Pilot Data
Frequency Per Week
10
8
6
Binge
Purge
4
2
0
Pre
Post
Changes in EDE
4
3
Global EDE
2
1
0
Baseline
EOT
Changes in Binge Eating
20
15
# OBE Days
10
5
0
Baseline
EOT
Changes in Vomiting
50
45
40
35
30
Vomiting
Episodes
25
20
15
10
5
0
Baseline
EOT
Changes in Self Discrepancy
1
0
Pre
Post
-1
-2
-3
AI
AO
Changes in Self Directed Style
5
4
3
Blame Self
Attack Self
2
1
0
Baseline
EOT
Changes in Self Directed Style
8
6
Self Accept
Self Protect
4
2
Baseline
EOT
Abstinence at EOT
(Both Waves)
70% Binge Eat
65% Vomit
?