Publications of Interest

Eating Disorders, Trauma, and Dissociation

Each quarter ISSTD News endeavors to focus publications of interest (POI) on recently published articles which are timely and relevant to community discourse. This POI will focus on recent publications exploring the bearing of dissociation on eating disorders including bulimia nervosa (BN), anorexia nervosa (AN), and binge eating disorder (BED). We have also tried to ensure that at least some of the articles are open access, to assist our members who may not have access to an academic database. Those articles that are open access are noted as such next to the title.

*OPEN ACCESS* Doris Nilsson, Annika Lejonclou & Rolf Holmqvist (2020) Psychoform and somatoform dissociation among individuals with eating disorders, Nordic Journal of Psychiatry, 74:1, 1-8, DOI: 10.1080/08039488.2019.1664631

Abstract: This study analyzed the prevalence of psychoform and somatoform dissociation among individuals with the whole spectrum of eating disorder diagnoses and compared it with ratings from a non-clinical group. The relationship between dissociation and severity of eating disturbance was examined as well as differences between the eating disorder diagnosis groups in extent of dissociation. The validity of a new structural dissociation interview suitable for eating disorder patients was analyzed.

Results: Participants with eating disorders reported a higher extent of both psychoform and somatoform dissociation compared with the non-clinical individuals. Analyses also showed a correlation between degree of dissociation and severity of eating disorder symptoms. No differences in dissociation were found between the ED subgroups. Participants reporting more dissociation got higher ratings on the interview, indicating convergent validity.

Discussion: Eating disorders seem to be associated with presence and severity of dissociative symptoms. The extent of dissociation needs to be assessed for these individuals as treatment may benefit from a focus on such symptoms in order to increase its effect.

LINK 10.1080/08039488.2019.1664631

Groth, T., Hilsenroth, M., Boccio, D. et al. Relationship between Trauma History and Eating Disorders in Adolescents. Journ Child Adol Trauma 13, 443–453 (2020).


Reasons for developing an eating disorder (ED) are complex, yet one plausible risk factor gaining more relevance in adolescents with EDs is childhood trauma. The current study is the first to examine the presence of childhood trauma in relation to ED symptomatology in adolescents using DSM-5 criteria. It was hypothesized that patients with more traumatic experiences also have more severe ED symptoms. 112 therapists currently treating adolescent patients diagnosed with an ED completed an online survey consisting of a DSM-5 ED symptom checklist and a childhood trauma questionnaire on a current adolescent patient whom they have seen for at least eight sessions. Children with multiple traumatic experiences and the severity of those experiences demonstrated a relationship to overall ED (r = .179, p = .059) and bulimia symptoms (r = .183, p = .054), specifically binging (r = .188, p = .047). and purging (r = .217, p = .021). In addition, logistic regression analyses indicated that adolescents high on bulimia nervosa (B = 4.694, p = .044) were more likely to have been traumatized victims of violence. Exploratory analyses support prior literature that suggest similarities between adolescents’ lack of control of the experienced trauma(s) with lack of control of ED symptoms. These findings highlight the importance of exploring trauma history when treating an adolescent with an ED, especially bulimia.


Timothy D. Brewerton (2019) An Overview of Trauma-Informed Care and Practice for Eating Disorders, Journal of Aggression, Maltreatment & Trauma, 28:4, 445-462, DOI: 10.1080/10926771.2018.1532940


This article reviews concepts and principles of trauma-informed care and trauma-informed practice for those with eating disorders (EDs). EDs are not universally recognized to be associated with traumatic events, despite substantial research evidence indicating that individuals with EDs report very high rates of childhood maltreatment, other lifetime traumatic events, as well as adverse consequences from trauma. Using national representative samples, higher prevalence rates of PTSD and other trauma-related comorbidities have been reported in those with EDs, particularly those with bulimic symptoms (binge eating and/or purging). Evidence suggests that those prone to develop EDs appear to be especially sensitive to the effects of stress/adversity and have high rates of premorbid anxiety disorders, personality traits, and neuropsychological features that predispose them to PTSD and its symptoms. This article also reviews some of the important principles for treating individuals with EDs comorbid for PTSD and other trauma-related disorders, including the necessity of moving beyond sequential treatment to the development of integrated treatment protocols. Integration of existing evidence-based treatments, including family therapy, cognitive behavioral therapy, dialectical behavior therapy, cognitive processing therapy, prolonged exposure, and eye movement desensitization reprocessing are recommended. Recent research suggests that ED clinicians view integrated treatment for individuals with ED and PTSD as a top priority, yet they have several concerns about administering such a treatment. As trauma-informed care is embraced by all clinicians and treatment programs that assess and treat eating and related disorders, better outcomes are anticipated.

LINK 10.1080/10926771.2018.1532940

*OPEN ACCESS* Paola Longo, Antonella Bertorello, Matteo Panero, Giovanni Abbate-Daga & Enrica Marzola (2019) Traumatic events and post-traumatic symptoms in anorexia nervosa, European Journal of Psychotraumatology, 10:1, DOI: 10.1080/20008198.2019.1682930


Background: Traumatic Events (TEs) are often seen as risk factors not only for the development of eating disorders (EDs) but also for their impact on the severity of clinical presentation and psychiatric comorbidities.

Objective: This study aimed to assess the prevalence and time of occurrence of TEs in the two subtypes of anorexia nervosa (AN; restricting [RAN] and binge-purging [BPAN]) and to investigate differences in TEs (number, type, frequency) as well as clusters of post-traumatic symptoms and emotional dysregulation between the two groups.

Results: A higher occurrence of TEs was found in patients with BPAN than in those with RAN. In particular, there were significantly more women in the BPAN group than in the RAN group who had been sexually assaulted. Exposure to TEs happened before the onset of illness in most patients, regardless of the AN subtype. Finally, the BPAN group had significantly higher scores in terms of post-traumatic symptoms and emotional dysregulation than RAN patients.

Conclusions: Patients with BPAN showed a higher occurrence of TEs, post-traumatic symptom clusters, and emotional dysregulation than those with RAN. These findings are of interest as treatments could benefit from trauma-informed interventions for those affected by AN, and particularly for those with the binge-purging subtype.

LINK 10.1080/20008198.2019.1682930

Hasan Belli, Cenk Ural, Mahir Akbudak & Eser Sagaltıcı (2019) Levels of childhood traumatic experiences and dissociative symptoms in extremely obese patients with and without binge eating disorder, Nordic Journal of Psychiatry, 73:8, 527-531, DOI: 10.1080/08039488.2019.1662085


Background: It has been suggested that obese patients with binge eating disorder (BED) show higher levels of dissociation and childhood trauma.

Results: A total of 75 (31.1%) of the 241 obese patients were diagnosed with BED. The study showed that obese patients with BED had higher dissociative scores than those without BED (p < .05). The results showed higher total scores and two different types of childhood trauma (physical abuse and emotional abuse) in BED patients compared to non-BED patients (p < .05).

Conclusions: Clinicians should be fully aware of BED, dissociative symptoms and childhood traumatic experiences. These results show that, for at least a sub-group of obese patients, BED is associated with obesity and may be connected with dissociative symptoms and childhood physical abuse and emotional abuse.

LINK 10.1080/08039488.2019.1662085

Serra, R, Kiekens, G, Tarsitani, L, et al. The effect of trauma and dissociation on the outcome of cognitive behavioural therapy for binge eating disorder: A 6month prospective study. Eur Eat Disorders Rev. 2020; 28: 309– 317.


Background: Binge eating disorder (BED) is commonly associated with a history of trauma. Yet, there is little insight into the potential effect that trauma, dissociation, and depressive symptoms may have on the outcome of treatment interventions.

Results: Most BED patients (91.5%) reported a history of trauma, with two in three patients reporting three or more traumatic experiences. Whereas the number of traumatic experiences was not significantly associated with a reduction in BPW or remission, a higher traumatic impact score significantly decreased the likelihood of obtaining remission at the end of treatment (OR = 0.96; 95% CI [0.92, 0.99]). Higher levels of dissociative symptoms partially mediated this prospective association.

Conclusions: The impact of traumatic experiences, as opposed to the number of traumatic experiences experienced, negatively predicts remission after 6 months of CBT. These findings highlight the importance of addressing trauma and dissociative features in the CBT treatment of BED.


BeatoFernandez, L, MuñozMartinez, V, MataSaenz, B, et al. Attitudes towards change mediate the effect of dissociation on psychopathological outcome in the treatment of eating disorders. Eur Eat Disorders Rev. 2020; 28: 724– 738.


Objectives: The study aimed to examine whether dissociation and attitudes towards change were associated with the psychopathology in patients with eating disorders (EDs) at 1‐year follow‐up.

Results: No statistically significant differences were found between both diagnostic groups regarding dissociation scores. The ACTA at baseline, specifically for patients in the contemplation stage, mediate the effect of dissociation on the psychopathological outcome.

Discussion: These findings suggest that dissociation might be a transdiagnostic feature related to the EDs outcome. The psychotherapeutic framework must take it into account, particularly in patients in the contemplation stage.


Longo, P, Panero, M, Amodeo, L, Demarchi, M, AbbateDaga, G, Marzola, E. Psychoform and somatoform dissociation in anorexia nervosa: A systematic review. Clin Psychol Psychother. 2020; 1– 18.


Dissociation is a debilitating condition often present as comorbidity in patients with eating disorders, but to date only sparse findings are available on this topic. Additionally, very little data exist on the classification of dissociation, namely, psychoform and somatoform, in anorexia nervosa (AN). This review aimed to provide an updated view on the literature about dissociation in AN, with a focus on AN subtypes (i.e., restricter and binge‐purging) as well as dissociation type (i.e., psychoform and somatoform), when available. We screened 304 studies, and after title and abstract selection and full‐text reading, 29 of them were included in this review. Most of the studies investigated psychoform dissociation, whereas just four publications considered somatoform dissociation. Dissociation resulted to be present in AN more than in healthy controls and in individuals with other psychiatric disorders, and it was related mostly to the binge‐purging subtype of AN. Moreover, dissociation was linked to traumatic events, self‐harm and negative treatment outcomes, especially in patients affected by the binge‐purging subtype of AN. However, results on these matters are scarce and partially discordant. The methodological assessment we performed revealed an overall fair quality of the included studies, although several flaws emerged as well. The present review reported on one hand the relevance of dissociation in AN, but on the other hand the need to stimulate the scientific debate on (a) a deeper investigation of somatoform dissociation in AN and (b) the relationship between dissociation and both clinical severity and treatment response/resistance in AN.



Peer-Reviewed Chapter

*OPEN ACCESS* Reclaiming the Lost Self in the Treatment of Bulimia Nervosa: A Neurobiological Approach to Recovery That Integrates Mind, Brain, and Body

The pathology of bulimia nervosa reflects the ‘dis-integration’ of the structure of the self within the distributed nervous system, resulting in the patient’s impaired sense of self and incapacity to sense self-experience. The twenty-first century definition of self as ‘an embodied, sensory-based process grounded in kinesthetic experience’ not only refutes the long-held myth of mind-body dualism, but also sheds light on the influence of neurobiological factors in disease onset and on how people make recovery changes within psychotherapy. The capacity to create, or reinstate, self-integration is built into the nervous system through the neuroplastic brain’s ability to change its structure and function in response to thought, sensation, feeling, and motor activity. The introduction of neurophysiological (sensorimotor) and neurobiological (interpersonal, attachment-based) interventions into mainstream clinical treatment for bulimia nervosa increases exposure to embodied experience, fostering mind, brain, and body connectivity. By stimulating integrative neuronal firing and synaptic activity, top-down and bottom-up transactions enhance acuity in self-sensing, self-perception, and body image coherence, supporting the unification of the disparate self. The current focus of mainstream clinical eating disorder treatment on symptom reduction alone neglects the neurological underpinnings of the disease. This chapter describes a range of treatment options for bulimia nervosa designed to support sustainable changes at the brain level.

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