Childhood Trauma and Eating Disorders: From Collaboration to Intervention

1. 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

2. Today’s Talk • Eating Disorders – “Comorbidity” • Traumatic Experience • Intervention • Collaborating

3. 1987 – University of North Dakota Assistant Professor MeritCare Eating Disorders Program

4. Personality Disorders and Eating Disorders • 46 women treated for Eating Disorders at UWEDP • SCID Interviews • Paper/Pencil questionnaires

5. Personality Histrionic Obsessive Compulsive Avoidant Comparison BN > AN AN > BN ANR > ANBP Diagnostic Variation and PD Wonderlich, Swift, Slotnick & Goodman, 1990

6. Borderline Versus Other Personality Disorders in the Eating Disorders Wonderlich & Swift, 1990

7. 72 27 0

8. Personality Disorder Borderline Other PD No PD CSA (%) 72 27 0

10. Collaborations Village Family Service Center U of W ED program Rape and Abuse Crisis Center Alliance for Sexual Abuse Prevention and Treatment Is this real??

11. ED in Incest Victims Wonderlich, Donaldson, Carson, Staton, Gertz, Leach, Johnson, 1996

12. Child Abuse in 712 ED Clinic Patients Fullerton et al., 1995

13. Trauma and Psychopathology Thompson et al., 2002

14. UND/NRI Child Maltreatment ProjectEating Disorder/Purging(Ages 10 – 15) KEDS Wonderlich et al., 2001

15. 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)

16. What about Nonclinical Samples?

18. Wonderlich, Wilsnack, Wilsnack, & Harris, 1996

19. 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

20. So, how may early traumaoperate to increase risk?

21. 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

22. Psychobiological Mediation(Animal Studies) Altered Biological Stress Response Early Stress Behavioral Disturbance Suomi, 1991 Kraemer, 1992 McEwen, 1998 Meaney et al., 1988 Sapolsky et al., 1986

23. 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

24. 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

25. 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

26. Elevated ACTH in CA Victims(Heim et al., 2000, JAMA) Time (Minutes)

27. 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

28. Elevated Cortisol in Abused Children (Carrion et al., 2002)

29. Absence of Elevated Cortisol in Adults(Heim et al., 2000, JAMA) Time (minutes)

30. 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

31. 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

32. 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) ØPituitary (stress reaction) Teicher et al., 1997; Carrion et al., 2001; DeBellis et al., 1999, 2002a, 2002b; 2004; 2006; Thomas & DeBellis, 2004; Tupler & DeBellis, 2006

33. Telehealth Based Treatments for Traumatized Children • SAMHSA • National Child Traumatic Stress Network

34. 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 Allegheny General, North Shore University Hospital, University of Oklahoma, Medical University of South Carolina

35. 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

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

38. 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?)

39. I thought this guy did eating disorders stuff

40. Heterogeneity within Diagnostic Class “Patterned within category heterogeneity” Westen & Harnden-Fischer, 2001

41. 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)

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

44. Momentary Relationship of Mood and Binge Eating

46. ICAT Collaborators Stephen Wonderlich, Ph.D. Carol Peterson, Ph.D. James Mitchell, M.D. Scott Crow, M.D. Tracey Smith, Ph.D.

47. ICAT Model Self Discrepancy Mood Instability Negative Coping

48. Self Discrepancy and BN

49. Self Directed Style and BN

50. ICAT • 20 session – manualized • Adult BN • Non Psychotic • 18 cases entered • Addresses personality variation