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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
Today’s Talk • 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
Personality Histrionic Obsessive Compulsive Avoidant Comparison BN > AN AN > BN ANR > ANBP Diagnostic Variation and PD Wonderlich, Swift, Slotnick & Goodman, 1990
Borderline Versus Other Personality Disorders in the Eating Disorders Wonderlich & Swift, 1990
Personality Disorder Borderline Other PD No PD CSA (%) 72 27 0
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??
ED in Incest Victims Wonderlich, Donaldson, Carson, Staton, Gertz, Leach, Johnson, 1996
Child Abuse in 712 ED Clinic Patients Fullerton et al., 1995
Trauma and Psychopathology Thompson et al., 2002
UND/NRI Child Maltreatment ProjectEating Disorder/Purging(Ages 10 – 15) KEDS Wonderlich et al., 2001
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)
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
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
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
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 • CRH depression/anxiety Kaufman, 1991 Hart et al., 1996 De Bellis, 1994
Elevated ACTH in CA Victims(Heim et al., 2000, JAMA) Time (Minutes)
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
Absence of Elevated Cortisol in Adults(Heim et al., 2000, JAMA) Time (minutes)
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 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
Telehealth Based Treatments for Traumatized Children • SAMHSA • National Child Traumatic Stress Network
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
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 (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)
Mood and Eating Disorders • Eating Disorders and Impulsivity: A Longitudinal Study, NIMH, RO1 MH59674 • Ecological Momentary Assessment of Anorexia Nervosa, NIMH, 5RO1 MH59674-5.
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
ICAT • 20 session – manualized • Adult BN • Non Psychotic • 18 cases entered • Addresses personality variation