Eating Disorders and Non-Suicidal Self-Injury: The Role of Trauma

1. Eating Disorders and Non-Suicidal Self-Injury: The Role of Trauma • Stephen Wonderlich, Ph.D. • University of North Dakota School of Medicine • & Health Sciences • Neuropsychiatric Research Institute • Sanford Health • Heather Simonich, M.A. • Neuropsychiatric Research Institute • Kathryn Gordon, Ph.D. • North Dakota State University • Neuropsychiatric Research Institute

2. Topics for Today Eating Disorders Non-Suicidal Self-Injury Borderline Personality The Role of Trauma in Self-Damaging Behavior Clinical Ideas for ED, NSSI, BPD, and Trauma Trauma Informed School Systems

3. Eating Disorder Overview

4. DSM-5 Criteria for Anorexia Nervosa Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

5. DSM-5 Criteria for Bulimia Nervosa • Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: • Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. • A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) • Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, and other medications; fasting; or excessive exercise. • The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. • Self-evaluation is unduly influenced by body shape and weight. • The disturbance does not occur exclusively during episodes of anorexia nervosa.

6. DSM-5 Criteria for Binge Eating Disorder A. Recurrent episodes of binge eating. B. The binge-eating episodes are associated with three (or more) of the following: • 1. eating much more rapidly than normal • 2. eating until feeling uncomfortably full • 3. eating large amounts of food when not feeling physically hungry • 4. eating alone because of being embarrassed by how much one is eating • 5. feeling disgusted with oneself, depressed, or very guilty after overeating C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least once a week for 3 months. E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

7. Epidemiology-Anorexia Nervosa • 1% of women in community • 99% of cases are female • Middle to upper class

8. Epidemiology-Bulimia Nervosa • 2% of women in community • 4-5% of college women • 90-95% cases are female • Middle to upper class • Broadening to other strata

9. Epidemiology of BED Hudson et al., 2007  3.5% of U.S. women  2.0% of U.S. men More social and gender diversity than AN and BN 4.5% of black sample = BED

10. Psychiatric Comorbidity/ Associated Problems

11. Psychiatric Comorbidity in Bulimic PatientsN = 46

12. Eating Disorder Risk Factors Gender Age Family History/Genetics Extreme Dieting Weight/shape focused occupation/activities

13. Eating Disorder Risk Factors(cont.) Environmental stress/change Abuse Personality/self concept Depression, anxiety (particularly childhood) Sociocultural influences Stice, 2001 Jacobi et al., 2002

14. Genetic Factors

15. Biological Factors

16. Personality Factors

17. Childhood Stress

18. Weight & Performance-Related Activities

19. Socio-Cultural Factors

20. NSSI: Overview

21. Non-Suicidal Self-Injury (NSSI) Socially unaccepted behavior causing intentional and direct injury to one’s body tissue without suicidal intent (e.g., cut, burn, abrade, hit) Claes & Muehlenkamp (2014)

22. DSM 5 Handout

23. NSSI Epidemiology • Average age of onset – 12-16 years • Lifetime prevalence – 18% (teens) • Rates increasing, but recently stabilized • Females > males (slightly) • Type of self harm varies by gender Rodham & Hawtone, 2009 Muehlenkamp et al., 2012 Claes et al., 2010

24. Types of NSSI Behavior • Injury inflicted with a knife, needle, razor or sharp object, burn, abrasion • Thighs, forearm • Series of cuts – 1 or 2 cm apart • Blood and scarring

25. Overlap of ED and NSSI • > 70% of ED patients report NSSI • 25-54% of NSSI report disordered eating • NSSI more strongly associated with binge purge ED than restricting ED Claes et al., 2010 Muehlenkamp et al., 2012 Golust et al., 2008

26. Shared Risk for ED and NSSI

27. Models to Explain Similarities DISTAL FACTORS PROXIMAL FACTORS BEHAVIOR Individual Predisposing Factors TEMPERAMENT High Emotional Reactivity Negative Mood Intolerance PERSONALITY Impulsive Obsessive-Compulsive Traits Perfectionism Specific Risk Factors EMOTION DYSREGULATION Low Distress Tolerance COGNITIVE DISTORTIONS Self-Criticism/Guilt Low Self-Esteem LOW BODY REGARD Body Esteem/Body Dissatisfaction Body Competence Interceptive Awareness/Alexithymia Body Integrity DISSOCIATION PEER INFLUENCE/CONTAGION Best Friend/Peer Engagement Socialization & Selection Efforts PSYCHIATRIC Disorders Mood/Anxiety Disorders Posttraumatic Stress Disorder Substance Related Disorders Axis II Personality Disorders Stressful Life Event NSSI & Eating Disorder Social Predisposing Factors FAMILY ENVIRONMENT Low Emotional Support High Control & Criticism Low Connectedness TRAUMATIC EXPERIENCES Emotional, Physical, Sexual Abuse Peer Bullying CULTURAL PRESSURES Self-Objectification Unrealistic Body Stereotypes Individual Cultural Pressures

28. Models of NSSI • Emotional cascade • Event – emotion – rumination – behavior Selby & Joiner, 2009 • Four Function Theory Nock & Prinstein, 2008 • Escape Theory • Failure experience – negative emotion – dissociation – behavior Heatherton & Baumeister, 2001

29. Causes & Correlates: The Functional Model of NSSI (Nock) Negative Reinforcement Positive Reinforcement Get out of a situation Get a response from someone else Interpersonal Feel something even if it’s pain Stop bad feelings Intrapersonal

30. Models of NSSI (cont.) • Emotion Dysregulation • Negative body view • Depression • Emotion dysregulation Muehlenkamp et al., 2012 Gordon et al., 2014

31. You Tube - NSSI http://www.youtube.com/watch?v=dZJhJJ-h7Ek&list=PL_F7LS-9PhvsTVSOfs113c09ENQYeRIhQ

32. Is Trauma Related to ED?

33. (Miller et al., 1971)

34. Maltreatment of Children • Neglect (food, clothing, housing, medical) • Emotional abuse (degrading, demeaning) • Physical abuse (physical pain, coercion, or dominance) • Witness violence • Sexual abuse (child used for sexual stimulation)

35. Children and Abuse • 10 – 13% of America’s children have been kicked, burned, bit, punched, hit with an object, beaten or threatened with weapon by a parent • 25% of school children experience a trauma • 20% of traumatized children have a mental health diagnosis and only 10% of those receive treatment • 21 – 32% of U.S. women were sexually abused before age 18 Kilpatrick, 1996 Vogeltanz et al., 1999 NCTSN School committee, 2008

36. National Womens Study N = 714 CasesAge at time of Rape 3.0% 6.1% 29.7 7.1% 22.2% 32.2% Kilpatrick, 1996

37. ACE Study Adverse Childhood Experiences • Child physical abuse. • Child sexual abuse. • Child emotional abuse. • Emotional neglect. • Physical neglect. • Mentally ill, depressed or suicidal person in the home. • Drug addicted or alcoholic family member. • Witnessing domestic violence against the mother. • Loss of a parent to death or abandonment, including abandonment by parental divorce. • Incarceration of any family member for a crime. (Anda & Felitti, 2009)

38. Smoking Obesity Depression Suicide Gesture Alcoholism Illicit Drugs Injectable Drugs Sexual Promiscuity STD 2.2 1.6 4.6 12.2 7.4 4.7 10.3 3.2 2.5 The ACE Study(Felitti et al., 1998) 4 or More Adversities (Odds Ratio) Disease

39. Heart Disease Cancer Stroke Bronchitis/Emphysema Diabetes Hepatitis Fair/Poor Health 2.2 1.9 2.4 3.9 1.6 2.4 2.2 The ACE Study(Felitti et al., 1998) 4 or More Adversities (Odds Ratio) Disease

40. ACE STUDY

41. ACE Study ACE & SUICIDE ATTEMPTS 4+ 3 2 0 1

42. The ACE Study(Felitti et al., 1998)

44. ACE Study Summary • Adverse Childhood Experiences (ACEs) are very common • ACEs are strong predictors of adult health risks and disease • ACEs are implicated in the 10 leading causes of death in the United States

46. Is there a relationship between trauma and disordered eating in traumatized samples?

47. ED in Incest Victims Incest (N=38) Control (N=27) Binge 42% 15% Vomit 24% 4% Laxative 11% 4% (Wonderlich, Donaldson, Carson, Staton, Gertz, Leach, Johnson, 1996)

48. Trauma and Psychopathology (Thompson et al., 2002)

49. How about in traumatized children?

50. Five Year Prospective Study of CSA Children (8 - 13 years) % with Behavior (Swanston et al., 1997)