Childhood Trauma and Eating Disorders: From Collaboration to Intervention

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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

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Todays Talk

• Eating Disorders Comorbidity
• Traumatic Experience
• Intervention
• Collaborating

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1987 University of North Dakota

• Assistant Professor
• MeritCare Eating Disorders Program

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Personality Disorders and Eating Disorders

• 46 women treated for Eating Disorders at UWEDP
• SCID Interviews
• Paper/Pencil questionnaires

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Diagnostic Variation and PD

• Personality
• Histrionic
• Obsessive Compulsive
• Avoidant

• Comparison
• BN gt AN
• AN gt BN
• ANR gt ANBP

Wonderlich, Swift, Slotnick Goodman, 1990
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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
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72 27 0
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Personality Disorder

• Borderline Other PD No PD
• CSA () 72 27 0

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Is this real??

• Collaborations
• Village Family Service Center
• U of W ED program
• Rape and Abuse Crisis Center
• Alliance for Sexual Abuse Prevention and Treatment

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ED in Incest Victims
Incest (N 38) Control (N 27)
Binge Vomit Laxative 42 24 11 15 4 4
Wonderlich, Donaldson, Carson, Staton, Gertz,
Leach, Johnson, 1996
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Child Abuse in 712 ED Clinic Patients
Fullerton et al., 1995
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Trauma and Psychopathology
Thompson et al., 2002
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UND/NRI Child Maltreatment ProjectEating
Disorder/Purging(Ages 10 15)
KEDS
Wonderlich et al., 2001
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Prospective Study of Multi Impulsivity in
Sexually Abused Children (10 15 years)
3 or More Impulsive Behavior In Past 12 Months
Connolly et al., (2002)
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• What about Nonclinical Samples?

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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
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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

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So, how may early traumaoperate to increase risk?
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Possible 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
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Psychobiological Mediation(Animal Studies)

• Early Stress Behavioral Disturbance

Altered Biological Stress Response
Suomi, 1991 Kraemer, 1992
McEwen, 1998 Meaney et al., 1988
Sapolsky et al., 1986
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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
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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
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Psychobiological Stress Response Systems and
Child Trauma

• Limbic - Hypothalamus Pituitary Adrenal
• (CRH) (ACTH) (Cortisol)
• ACTH dysregulation in adult CA/CN victims
• ? ACTH
• ? CRH

depression/anxiety
Kaufman, 1991 Hart et al., 1996 De Bellis, 1994
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Elevated ACTH in CA Victims(Heim et al., 2000,
JAMA)
Time (Minutes)
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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
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Elevated Cortisol in Abused Children (Carrion et
al., 2002)
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Absence of Elevated Cortisol in Adults(Heim et
al., 2000, JAMA)
Time (minutes)
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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

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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

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Biological Correlatesof 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

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Telehealth Based Treatments for Traumatized
Children

• SAMHSA
• National Child Traumatic Stress Network

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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

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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

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• Treatment Collaborative
• for Traumatized Youth
• (TCTY)
• Funded by Otto Bremer Foundation,
• Dakota Medical Foundation,
• Department of Human Services
• Stern Foundation
• MDU

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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?)

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• I thought this guy did
• eating disorders stuff

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• Heterogeneity within Diagnostic Class
• Patterned within category heterogeneity
• Westen Harnden-Fischer, 2001

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Northern Tier Research Group

• S. Wonderlich (ND)
• J. Mitchell (ND)
• R. Crosby (ND)
• S. Crow (MN)
• C. Peterson (MN)
• M. Klein (WI)
• D. LeGrange (Chicago)
• A. Bardone (Missouri)
• T. Joiner (Florida)

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Mood and Eating Disorders

• Eating Disorders and Impulsivity A Longitudinal
  Study, NIMH, RO1 MH59674
• Ecological Momentary Assessment of Anorexia
  Nervosa, NIMH, 5RO1 MH59674-5.

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Momentary Relationship of Mood and Binge Eating
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ICAT Collaborators
Stephen Wonderlich, Ph.D. Carol Peterson,
Ph.D. James Mitchell, M.D. Scott Crow,
M.D. Tracey Smith, Ph.D.
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ICAT Model
Self Discrepancy
Negative Coping
Mood Instability
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Self Discrepancy and BN
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Self Directed Style and BN
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ICAT

• 20 session manualized
• Adult BN
• Non Psychotic
• 18 cases entered
• Addresses personality variation

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ICT Pilot Data
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Frequency Per Week
8
6
Binge
Purge
4
2
0
Pre
Post
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Changes in EDE
Global EDE
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Changes in Binge Eating
OBE Days
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Changes in Vomiting
Vomiting Episodes
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Changes in Self Discrepancy
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Changes in Self Directed Style
5
4
3
Blame Self
Attack Self
2
1
0
Baseline
EOT
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Changes in Self Directed Style
8
6
Self Accept
Self Protect
4
2
Baseline
EOT
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Abstinence at EOT(Both Waves)
70 Binge Eat 65 Vomit
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?