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

?