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Eating disorders are complex and multifaceted, often arising from various factors. They don’t just happen, instead they are deeply influenced by early life experiences, trauma, and even generational patterns. Behaviors such as a child refusing certain foods or fixating on body image may not just be a passing phase, it could indicate deeper emotional or psychological distress that requires careful attention and compassion.
 
Understanding these connections is key to breaking harmful cycles and helping kids heal.
 
Join us for a powerful session in which we’ll uncover the hidden link between trauma and eating disorders, bust common myths, and share simple, trauma-informed strategies for supporting children. Whether a parent, educator, or professional, you’ll walk away with practical tools to make a real impact.

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POSTTRAUMATIC STRESS DISORDER IN WOMEN WITH BINGE EATING DISORDER IN PRIMARY CARE

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To examine the frequency and significance of comorbid posttraumatic stress disorder (PTSD) in ethnically diverse obese patients with binge eating disorder (BED) seeking treatment for obesity and binge eating in primary care. Participants were a…

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The Intersection of Trauma and Eating Disorders

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We know very little about the cause of eating disorders, but one theme rings true for many: trauma. New research shows how trauma therapy helps recovery from an eating disorder.

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Intergenerational Trauma & Eating Disorders: How They’re Connected and What to Do About It - The Renfrew Center

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Understanding intergenerational trauma is critical to eating disorder prevention, treatment, and recovery. We break down the connection.

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Christy Harrison - Intuitive Eating Dietitian, Anti-Diet Author, & Health at Every Size Advocate - Food Psych Programs

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Reclaim Your Time, Money, Well-Being, and Happiness Through Intuitive Eating

About the Book

68 percent of Americans have dieted at some point in their lives. But upwards of 90% of people who intentionally lose weight gain it back within five years. And as many as 66% of people who embark on weight-loss efforts end up gaining more weight than they lost. If dieting is so clearly ineffective, why are we so obsessed with it?

The culprit is diet culture, a system of beliefs that equates thinness to health and moral virtue, promotes weight loss as a means of attaining higher status, and demonizes certain ways of eating while elevating others. It's sexist, racist, and classist, yet this way of thinking about food and bodies is so embedded in the fabric of our society that it can be hard to recognize. It masquerades as health, wellness, and fitness, and for some, it is all-consuming.

In Anti-Diet, Christy Harrison takes on diet culture and the multi-billion-dollar industries that profit from it, exposing all the ways it robs people of their time, money, health, and happiness. It will turn what you think you know about health and wellness upside down, as Harrison explores the history of diet culture, how it's infiltrated the health and wellness world, how to recognize it in all its sneaky forms, and how letting go of efforts to lose weight or eat "perfectly" actually helps to improve people's health-no matter their size.

Drawing on scientific research, personal experience, and stories from patients and colleagues, Anti-Diet provides a radical alternative to diet culture, and helps readers reclaim their bodies, minds, and lives so they can focus on the things that truly matter.

Anti-Diet was released in December 2019 by Little, Brown Spark in the U.S. and Canada, and by Yellow Kite in the UK, Australia, and New Zealand. French, Russian, and Estonian editions also coming soon.

"Anti-Diet is the 'diet' book you need to read headed into 2020. If you've been gearing up to embark on yet another diet, protocol, reset or reboot come Jan. 1, I have a different suggestion: Hit the pause button on that plan and read Christy Harrison's new book, Anti-Diet: Reclaim Your Time, Money, Well-Being and Happiness Through Intuitive Eating. Harrison, a registered dietitian and journalist, thoroughly and elegantly lays out the strange origins of modern diet culture [...] then presents a path to truly holistic health that's based on self-care, not self-control."
- Carrie Dennett, The Seattle Times

"Brilliant! Anti-Diet should be required reading for every health professional and in every health-related class. Harrison bridges the gap between intuitive eating and social-justice issues in an engaging and compassionate way. She exposes toxic diet culture-its evolution, who profits by it, and how it hurts you. Written with a friendly touch of sass, Anti-Diet is richly sourced with studies, stats, and expert interviews. I highly recommend this book to help you dismantle diet culture and to heal your own relationship with food, mind, and body."
- Evelyn Tribole, MS, RD, co-author of Intuitive Eating

"A huge burden has been lifted: I no longer have to revise my first book to reflect current understanding! Christy Harrison beat me to it. I'm blown away by how good Anti-Diet is. Using a social-justice lens, well-researched and smart science, captivating storytelling, and practical advice, this book will help you reclaim your life from the throttle of diet culture."
- Linda Bacon, Ph.D., author of Health At Every Size and co-author of Body Respect

"Please read this book! Anti-Diet is the book to end all diet books, and will be a game-changer for so many people. Christy is an expert on this subject and leaves no stone unturned in exposing how insidious and harmful diet culture is-and teaching readers how to opt-out of the madness."
- Caroline Dooner, author of The F*ck It Diet

"If you've ever wondered how we landed in this current wellness-obsessed, sugar-and-gluten-fearing moment of entrenched food anxiety, Anti-Diet is a must-read. Christy Harrison traces the history of modern diet culture, busts deeply rooted myths, and exposes the inherent biases of modern weight research. She also offers clear, practical advice for all of us trying to disentangle ourselves from diets and make peace with food."

- Virginia Sole-Smith, author of The Eating Instinct

"The most essential book to read in 2020. Christy manages to write a comprehensive history of our dieting culture which sets the stage for deepening our understanding of the fraught and highly problematic dieting landscape we find ourselves in today. With sharp insight, Christy digs through mountains of research to make a case against dieting and spells out all of the insidious ways "diet culture" lives on and in us today. While most books are either cultural critique or self-help book, Christy manages to do both. She masterfully paints a cultural narrative while also providing you with the concrete tools to create a different way of relating to food and your body. This book is essential reading." -Marci Evans, MS, RD, CEDRD

"As compassionate as it is scholarly, Christy Harrison's Anti-Diet goes deep to expose the sordid underbelly of diet culture, but it doesn't leave you there. With healing-oriented strategies that address our physical, emotional, and social selves, you will finish this book armed with ways to reclaim all that dieting has taken from you, and gain a new perspective that is empowering and sustainable."
- Jenna Hollenstein, MS, RDN, CDN, author of Eat To Love

"This must-read book just came out in January, the perfect timing to interrupt so many of the 'resolutions' and the culture that promotes weight loss in the New Year. Christy crafts very effective arguments, coupled with the science and history that shows the problematic past and present of fatphobia and diet culture. ...This book is an essential contribution to getting to the root of the issue and is so necessary to avoiding being swallowed up by the jaws of the hydra-headed beast that is diet culture, fatphobia, with its tentacles of classism, racism, and ableism." -Matt McGorry, actor ( How to Get Away with Murder, Orange Is the New Black)

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Book - Christy Harrison - Intuitive Eating Dietitian, Anti-Diet Author, & Health at Every Size Advocate - Food Psych Programs

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Reclaim Your Time, Money, Well-Being, and Happiness Through Intuitive Eating 68 percent of Americans have dieted at some point in their lives. But upwards of 90% of people who intentionally lose weight gain it back within five years. And as many as 66% of people who embark on weight-loss efforts end up gaining more weight than they lost.

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The Racial Origins of Fat Phobia

by Sabrina Strings

Published by: NYU Press

Imprint: NYU Press

304 Pages, 6.00 x 9.00 in, 0 41 black and white illustrations

Paperback

9781479886753

Published: May 2019

$28.00

BUY

Hardcover

9781479819805

Published: May 2019

$89.00

BUY

eBook

9781479831098

Published: May 2019

Request Exam or Desk Copy

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by Sabrina Strings Published by: NYU Press Imprint: NYU Press 304 Pages, 6.00 x 9.00 in, 0 41 black and white illustrations Paperback 9781479886753 Published: May 2019 $28.00 BUY Hardcover 9781479819805 Published: May 2019 $89.00 BUY eBook 9781479831098 Published: May 2019 Request Exam or Desk Copy

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Sick Enough: A Guide to the Medical Complications by Dr. Jennifer L. Gaudiani (Dr. G) offers expert medical advice for people with eating disorders, their families and loved ones, and professionals. Eating disorder help is offered in an easy-to-understand format.

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The Renfrew Center is pleased to offer our weekly Virtual SAGE (Sexuality and Gender Equality) Support Group, available across the country for all levels of care.
In this group we provide a safe, nurturing, and empowering environment to enhance the eating disorder recovery experience, tailored for patients who are members of the LGBTQIA+ community.

This setting is intended to be an affirming environment to process body image and identity concerns, in addition to relationships and other challenges, through a trauma-informed lens. We focus on strengths and resilience in this forum where patients are encouraged to discuss their eating disorder issues, and how those intersect with gender identity, sexual orientation and feelings of marginalization.

The following themes that can hinder eating disorder recovery are discussed:

Societal pressures

Fluidity in identity

Intersectionalities

Gender expression

Relationships

Exploration & questioning

For more information, please call 1-800-RENFREW (736-3739).

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The Renfrew Center's Virtual SAGE Patient Support Group - The Renfrew Center

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The Renfrew Center is pleased to offer our weekly Virtual SAGE (Sexuality and Gender Equality) Support Group, available across the country for all levels of care.

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Fasting During Ramadan Is Challenging — But 1 Thing Makes It Especially Complicated

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So many people are left to navigate this deeply personal battle alone, with little support and even less awareness.

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30+ Free Eating Disorder Support Groups - Project HEAL

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Free eating disorder support groups for everyone and anyone who is looking for support on their journey.

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Episode 2: Supporting Your Loved Ones: Signs, Challenges & Helpful Tips - The Renfrew Center

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Episode 2: Supporting Your Loved Ones: Signs, Challenges & Helpful Tips [Bouncy theme music plays.] SAM: Hey, I’m Sam! ASHLEY: Hi, I’m Ashley and you’re listening to All Bodies. All Foods. presented by The Renfrew Center for Eating Disorders. We want to create a space for all bodies to come together authentically and purposefully to…

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The BIPOC (Black, Indigenous, and Person of Color) Community has long been underserved when it comes to mental health, and especially eating disorders. There are many reasons for this-lack of resources and education in communities, underrepresentation in eating disorder research and in the development of diagnostic tools, language barriers, biased providers, and cultural attitudes that discourage seeking professional help are just a few of them. But this does not mean that BIPOC individuals are any less deserving of care and recovery.
Because of the historic inequities they've faced, the BIPOC community understands the importance of creating spaces that promote safety and healing. The discrimination they're confronted with causes harm and often ignites feelings of being "less than" others. It carries with it the message that only certain people "matter," and it often shuts down individuals' ability to speak up for themselves. This is why care that takes into consideration the unique social, cultural, and even dietary needs of BIPOC individuals is essential.

What are virtual support groups and how do they work?

Virtual eating disorder support groups are online communities where individuals who are struggling with eating disorders or in recovery can come together to share their experiences, offer support, and receive guidance. These groups are facilitated by professionals or trained moderators who ensure a safe and supportive environment.

What do you talk about in virtual BIPOC patient support groups?

In virtual BIPOC patient eating disorder support groups, discussions revolve around various topics related to eating disorders, recovery, and the specific experiences of BIPOC individuals. Here are some common themes that may be addressed during these support group sessions:

Intersectionality: The intersection of race, culture, and identity with eating disorders is often a key topic of discussion. Participants may share how their racial or ethnic background has influenced their body image and their relationship with food. Group is also a space to explore how the experience of occupying multiple marginalized identities impact eating disorder recovery , mental health, and physical wellbeing.

Cultural Factors: Support groups provide a space to discuss the that contribute to the development and maintenance of eating disorders or serve as protective factors within the BIPOC community. Discussions may focus on cultural ideals of beauty, body shape expectations, cultural food practices, and the impact of intergenerational trauma or cultural norms on body image and self-esteem.

Healing from Racial Trauma: Participants may discuss their experiences of racial trauma and its impact on their mental health, self-worth, and relationship with food. Sharing coping strategies, discussing the effects of systemic racism, and exploring ways to heal from racial trauma can be important components of these support groups.

Navigating Healthcare Systems: BIPOC individuals may face unique challenges when seeking treatment and support for eating disorders due to systemic barriers or lack of cultural competence within healthcare systems. Discussions may focus on strategies for advocating for oneself, finding culturally sensitive treatment providers, and addressing disparities in accessing care.

Family and Community Dynamics: Exploring the role of family and community in the development and recovery from eating disorders is another important topic. Participants may discuss cultural expectations, family dynamics, and the impact of community support or lack thereof on their recovery journey.

Coping Strategies and Self-Care: Sharing coping strategies, , and resilience-building practices specific to the experiences of BIPOC individuals can be a valuable part of these support groups. Participants can exchange ideas, resources, and self-care techniques that align with their cultural backgrounds and promote overall well-being.

Celebrating Resilience and Successes: Support groups provide an opportunity to celebrate individual and collective successes, no matter how small. Participants can share their milestones, victories, and positive steps taken in their recovery journey, inspiring and supporting one another.

What additional resources exist to help BIPOC individuals?

Organizations such as The Loveland Foundation, Therapy For Black Girls, and Black Emotional and Mental Health (BEAM) are great places for Black individuals to find resources such as therapist directories, podcasts, trainings, and grants.

The Indian Health Service can help connect Indigenous individuals with resources in their communities.

For Muslim American individuals, the Institute of Muslim Mental Health has resources and mentorship programs.

Melanin & Mental Health and are organizations dedicated to supporting the mental health and emotional well-being of people of color.

How Places Like Renfrew Can Help

The Renfrew Center's BIPOC weekly support group addresses the emotional and physical impacts of the current cultural climate on recovery and is ideal for BIPOC individuals with disordered eating patterns, or those questioning if they have an eating disorder and looking for additional support. In this group, we work to build trust, allowing BIPOC individuals to "show up" as their full selves while processing and discussing emotional responses surrounding race relations, complex racial issues, and discrimination.

Group members have opportunities to identify, share, and affirm connections to themselves and others, building authentic and sustainable relationships. They share their experiences and address anxiety, trauma or other related emotions that may have been recently reactivated. They also discuss access to care concerns and work with practitioners to find resources that fit their specific needs. Participants receive valuable takeaway tools to support themselves during their recovery, and after leaving treatment.

Discussion includes the following topics and their impacts on eating disorder recovery:

Lived Experiences

Marginalization

Microaggressions

Prejudices

Racism & Racial Inequality

Racial and Intergenerational Trauma

Intersectionality

Food & Nutrition

In addition to virtual help, BIPOC individuals may find it helpful to connect with others offline. This doesn't just have to be in the form of in-person treatment , but also identifying and engaging with a network of supportive people. Family and friends can also benefit from the resources found online.

Final Thoughts: What should you do next?

After receiving support from a virtual eating disorder help group, there are several important next steps that someone in the BIPOC community can consider:

Schedule an Assessment; if you're wondering if you are struggling with an eating disorder, consider scheduling an assessment or chat online with one of our Program Information Specialists

Connect with Culturally Competent Providers

Build a Support Network

Seek out BIPOC authors, educators, and content creators in the eating disorder space

Advocate for Change

Remember that recovery from an eating disorder is a journey, and it is important to be patient and kind to yourself throughout the process. By taking these next steps and continuing to prioritize your well-being, you are on a path towards healing and fostering a healthier relationship with food, body, and self.

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Virtual BIPOC Eating Disorder Support: What It Is & Why It Matters - The Renfrew Center

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Virtual BIPOC eating disorder support offers a safe space for BIPOC individuals to discuss their experiences openly and without discrimination. Here's how it works.

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A supportive online community offering resources and discussions for women in eating disorder recovery, focusing on self-empowerment and healing.

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A supportive online community offering resources and discussions for women in eating disorder recovery, focusing on self-empowerment and healing.

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Light of the Moon Cafe - Help for Recovery from Eating Disorders

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You would not be on Anita's site if you did not believe there are greater things within you. To live the extraordinary life you were meant to live is by following your joy. Anita provides a safe haven; and Light of the Moon Cafe will give you the sacred space you need to open your heart.

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This article discusses the critical role professionals play in raising awareness and providing culturally competent care for eating disorders within BIPOC communities.

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Breaking Barriers: A Professional’s Role in Eating Disorder Awareness for BIPOC Communities - The Renfrew Center

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BIPOC communities face high eating disorder rates yet struggle with diagnosis and care. Learn how professionals can drive awareness and equity.

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This guide offers practical advice for parents on supporting a child with an eating disorder, emphasizing patience, love, and open communication.

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Find out what you can do to help if your child has been diagnosed with an eating disorder.

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Recovering from an eating disorder is a challenging journey, but with family support, structured mealtimes, and professional help, healing is possible, bringing newfound strength and connection.

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Eating Disorders Meal Support: Helpful Approaches for Families (Full Video)

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Early detection of signs and symptoms is vital for accessing the help and support needed.

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In the United States, as many as 10 in 100 young women suffer from an eating disorder.

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Recognizing the signs can be challenging, but this article from Verywell Mind offers valuable insights and guidance.

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Watch for These Signs If You Think Your Teen Has an Eating Disorder

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The symptoms of an eating disorder in teens may not be what you would expect. Learn how to recognize some of the common signs of an eating disorder in a teenager.

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Feeding and eating disorders are serious, life-threatening conditions that often go unnoticed, but with early detection, empathetic support, and effective treatment, recovery is possible.

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If you're concerned about your child's eating habits, approach them gently, express concern with 'I' statements, and seek early professional help for evaluation and support.

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Eating Disorders: Talking to Your Teen - Teenology 101

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Dr. Iglesias highlights early signs of eating disorders in children, emphasizing the importance of medical attention, early intervention, and supportive, non-judgmental care.

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Five signs your child may have an eating disorder

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Watch this TED Talk on eating disorders, highlighting how these life-threatening illnesses, often mistaken as phases, are driven by societal pressures, body image struggles, and mental health challenges—teens need support and awareness to navigate and overcome them.

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No Body's Perfect: Teenage Eating Disorders | Madison Dunn | TEDxPascoCountySchools

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During the pandemic, one mother saw how social media and anxiety impacted her teen, making open talks about body image and self-esteem more important than ever.

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Mother shares advice on how to talk to teens about eating disorders

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PBS Newshour breaks down the impact of diet culture on teenage boys with food and body image.

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Eating disorders are affecting more adolescent boys. Here’s why and what signs to look for

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Read how childhood trauma can contribute to the development of disordered eating behaviors in youth.

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Cultural Issues in Eating Pathology and Body Image Among Children and Adolescents

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Abstract. Eating pathology and body image issues are now recognized as affecting all racial and ethnic groups. This article reviews eating pathology and bo

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Explore Toleda Center's findings on cultural influences that shape eating disorders in teenage girls and the importance of understanding these factors for adequate support.

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Toledo Center | Eating Disorders Treatment Center

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Our culture is part of the core of our identity. The world around us influences everything from our style to our beliefs. Eating disorders and identity are closely interrelated. Recovery from an eating disorder requires one to understand how their beliefs impact their relationship with food and body image.
Introduction to the Impact of Cultural Identity and Eating Disorders

Cultural identity reflects the cultural characteristics with which one identifies. Many people may have several influences that shape their sense of self and belonging. Some characteristics that shape one's cultural identity include [ 1]:

Cultural factors shape a young girl's sense of self. Her influences growing up create a foundation for her beliefs and values. When these values empower her to eat culturally normal foods and embrace her natural beauty, she will likely grow up with a healthy view of food and body image.

Many cultures emphasize certain beauty standards and may even have certain expectations for appearance. Some practices related to appearance, such as certain clothing, hairstyles, or jewelry, can help girls feel connected with their culture. However, beauty standards focused on certain body features may negatively impact a teen girl's sense of self.

For example, many cultures value certain body sizes and bone structures. Girls who are not genetically built with these features may develop a negative body image.

Exploring Cultural Pressures and Beauty Standards

There are unique beauty standards specific to each culture. In many cultures, teen girls feel pressured to maintain a smaller body size. There also may be certain physical features that are praised within certain groups. Some of these are related to bone structure, such as high cheekbones for girls and height for boys.

Cultural standards may also seem contradictory. For example, some cultures may emphasize thinness but also applaud when specific body parts are larger or "curvy."

Boys may feel pressure to gain larger muscles, while girls may feel pressure to maintain small but "defined" muscles.

A significant issue with these messages is that most people have minimal if any, control over their physical appearance. While teens can change their hair color, they can't change their bone structure.

Physical aspects like size, weight distribution, or muscle mass are largely influenced by genetics. However, teens are often surrounded by messages from the world around them that they can change their appearance with enough work, dedication, and sacrifice.

This misinformation can lead teens to develop unhealthy ways of coping with poor body image. They may begin engaging in disordered eating or exercise behaviors to try to change the way they look.

Strategies for Parents and Caregivers

Self-awareness and education are essential tools for understanding the intersection of identity and eating disorders. There are several practical ways that parents can help foster a healthy self-identity in teenage girls.

Examine your family's beliefs about beauty. Families that praise certain body shapes may be inadvertently sending teens the message that their body needs to look a certain way. Avoid making comments about anyone else's physical appearance in front of your teen.

Model positive self-talk and healthy body image. Parents can set the example for a healthy self-identity by not talking negatively about their bodies in front of their teens. Teach them how to care for their bodies in a manner that is empowering and sustainable.

For example, parents who exercise regularly can talk about how it helps them feel stronger, sleep better, or prevent pain from an old injury. All of these qualities can show teens how to maintain healthy behaviors without an aesthetic focus.

Teach your teen to recognize cultural influences that negatively affect their body image. Talking negatively about one's body or conversing about diet trends becomes the norm in some social circles. Help your teen recognize when these normalized conversations are harmful.

Equip your teen with tools to cope with cultural norms that may be damaging to their relationship with food. Parents can help teens by practicing how to change the subject when their peers start talking about dieting. They can also show how to set healthy boundaries if someone comments on their body. Being prepared can help teens confidently manage uncomfortable or triggering situations.

Empower your teen to participate in activities that will develop healthy self-esteem. Kids build resilience when they are immersed in experiences where they can learn for themselves that they are capable of overcoming challenges.

Sports are commonly used as a way to boost self-esteem. However, participation in sports is often not recommended during eating disorder recovery. There are plenty of other activities that can build resilience in teens, including the following:

Art, such as painting, drawing, or ceramics

Music, such as learning to play an instrument

Photography

Writing short stories or poetry

Sewing, knitting, or crocheting

Babysitting

Volunteering

Speech and debate

Creating a small business

It may take time for teens to disconnect their identity from their eating disorder. Overall, the goal is to help teens find meaning apart from their physical appearance.

The Role of Cultural Competency in Healthcare and Treatment

It is important for individuals seeking eating disorder treatment to work with practitioners who understand cultural nuances. Religious beliefs and societal influences shape one's worldview and, therefore, play a significant role in their recovery.

For example, those who prefer cultural foods that are less common to their geographical location should talk with their treatment team to create an individualized meal plan. This can help teens learn how to incorporate balanced eating patterns while continuing to honor their cultural identity.

Individual therapy can help teens differentiate between eating disorder thoughts and cultural norms to bring balance and healing. Treatment options like cognitive behavioral therapy (CBT) or dialectical behavioral therapy ( ) can help teens shift to healthier thought patterns and promote emotional regulation skills.

Our compassionate staff are sensitive to the intersection of eating disorders and cultural identity. Toledo Center provides individualized care for teens of all beliefs, cultures, and backgrounds.

References

Migration, cultural bereavement and cultural identity - PMC (nih.gov)

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How Does Culture Impact Eating Disorders Among Teens?

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The culture you live in influences everything from your personal style to your deeply held beliefs. Culture can also affect how we view and feel about our bodies.

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This resource highlights the importance of culturally sensitive care in effectively supporting individuals with eating disorders.

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Discover the truth behind common myths about eating disorders with this resource from the National Eating Disorders Collaboration.

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Research indicates that there are generally low levels of mental health literacy in the community; however, general beliefs and misunderstanding about mental health affect community responses to eating disorders. Greater understanding and awareness of mental health assists with prevention, early identification, and help-seeking.

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Learn key facts about eating disorders in teens and how to recognize the signs with insights from Johns Hopkins Medicine

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Myths and Facts About Eating Disorders in Adolescents

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Johns Hopkins All Children’s Adolescent and Young Adult Specialty Clinic treats those struggling with pediatric eating disorders.

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Get the facts and debunk common myths about eating disorders with this helpful resource from the Eating Recovery Center.

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Despite increased prevalence of eating disorders in the United States, widespread misconceptions about eating disorders remain that challenge identification, diagnosis and early intervention. To truly protect and advocate for their children, it is important that parents understand the truth behind common eating disorder myths.

Myth: Eating disorders aren't serious illnesses.
Truth: Anorexia nervosa, bulimia nervosa, binge eating disorder and eating disorder not otherwise specified (EDNOS) are very real and very serious mental illnesses. Each disorder has clear diagnostic criteria in the Diagnostic and Statistical Manual, the go-to diagnostic reference for mental healthcare professionals. Another reason to take eating disorders seriously is that they can be deadly. Anorexia nervosa has the highest mortality rate of any psychiatric disorder. In fact, women ages 15 to 24 years of age who suffer from anorexia nervosa are 12 times more likely to die from the illness than any other cause of death.**

Myth: Eating disorders are just about food.
Truth: While eating disorders generally involve obsession with calories, weight or shape, these illnesses are rooted in biological, psychological and sociocultural aspects. Restriction, bingeing, purging or over-exercise behaviors usually signify an attempt to control something of substance in the individual's life. Because friends and family mistakenly believe that eating disorders are just about food, they will often encourage their loved ones to "just eat more," "just eat less," or "just eat healthier" to be "cured" of this illness. In reality, eating disorders often require some combination of medical, psychiatric, therapeutic and dietary intervention to achieve full recovery.

Myth: Eating disorders are a women's illness.
Truth: While research shows that eating disorders affect significantly more women than men, these illnesses occur in men and boys as well. While males used to represent about 10 percent of individuals with eating disorders, a recent Harvard study found that closer to 25 percent of individuals presenting for eating disorder treatment are male. The widespread belief that eating disorders only affect women and girls can prevent accurate diagnosis of an eating disorder in a man or boy, even among healthcare experts.

Because most eating disorders (approximately 95 percent) surface between the ages of 12 and 25, parents are often a first line of defense against the development of these illnesses in their children.*

Myth: Eating disorders don't develop until the teenage years.
Truth: Consider this-research found that up to 60 percent of girls between the ages of 6 and 12 are concerned about their weight or about becoming too fat, and that this concern endures through life.*** Not surprisingly, the incidence of eating disorders in children is on the rise. Between 1999 and 2006, hospitalizations for eating disorders in children 12 and younger rose 119 percent, according to a 2010 study by the American Academy of Pediatrics.

Myth: Only very thin people have an eating disorder.
Truth: While anorexia is characterized by extreme low weight, many individuals struggling with bulimia, binge eating disorder and EDNOS are normal-weighted. The misconception that an eating disorder can only occur if someone is very thin contributes to misdiagnosis or delayed diagnosis in many cases, even among those patients seeking support from medical and mental healthcare professionals. Unfortunately, many healthcare experts lack eating disorder exposure and training, which highlights the important role of eating disorder specialists to ensure effective diagnosis and early intervention.

In addition to educating themselves about basic eating disorder information and understanding myth from fact, parents should also trust their instincts when it comes to eating disorders in their children. Eating disorders can thrive in secrecy, but parents often intuitively know if something is wrong with their children. While parents may feel terrified of saying the wrong thing, but also not want to stay silent, they are an important champion for diagnosis and effective treatment. If concern arises, consult with an eating disorder specialist sooner rather than later-early intervention is critical to lasting eating disorder recovery.

Myth: You can tell if someone has an eating disorder by looking at them.
Truth: People who suffer with eating disorders come in all shapes and sizes. The media and other public discussions about eating disorders often focus on a specific diagnoses: anorexia, wherein sufferers often display the symptom of being severely underweight. Individuals who suffer from eating disorders can be of any weight, and they can fluctuate in weight

Myth: Eating disorders are caused by the media.
Truth: Many people are exposed to the media on a daily basis but only a small percentage of them actually develop eating disorders. Eating disorders are complex and serious illnesses that have biological, genetic and psychological roots. The media can certainly impact how a person feels about their looks, and promote a great deal of pressure to look a certain way, but the media does not cause eating disorders.

Myth: Eating disorders are a result of dysfunctional families.
Truth: Historically, parents, especially mothers, have been blamed for mental illnesses, including eating disorders. However parents do not cause eating disorders. Eating disorders are complex disorders and it is known that a person's risk for developing an eating disorders is due in large part to genetic factors. Parents, or other caretakers and supports play an integral role in helping a loved one with an eating disorder to recover.

Myth: recovery from eating disorders is rare.
Truth: Recovery is absolutely possible. Due to the complexity of eating disorders, recovery can take months or years, but with treatment, many people do recover.

Eating disorder facts

Eating disorders are very serious, and even deadly, illnesses.

Eating disorders are not just about food.

Eating disorders don't just affect women.

People get eating disorders at all ages.

People can be of any weight or body type and have an eating disorder.

Families don't cause eating disorders.

You CAN recover from an eating disorder.

*Substance Abuse and Mental Health Services Administration (SAMHSA), The Center for Mental Health Services (CMHS), offices of the U.S. Department of Health and Human Services.
**American Journal of Psychiatry, Vol. 152 (7), July 1995, p. 1073-1074, Sullivan, Patrick F.
***T.F. Cash & L. Smolak (Eds.),Body Image: A Handbook of Science, Practice, and Prevention. New York: Guilford Press. 2011.

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Eating Disorder Facts & Myths | Eating Recovery Center

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Despite increased prevalence of eating disorders in the United States, widespread misconceptions about eating disorders remain that challenge identification, diagnosis and early intervention. To truly protect and advocate for their children, it is important that parents understand the truth behind common eating disorder myths. Myth: Eating disorders aren't serious illnesses.

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Stanford Center of Health dives into the link between eating disorders and mental health, offering key insights.

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Anorexia: 5 Common Myths Busted by an Eating Disorder Expert | Stanford

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Learn how to recognize the signs of eating disorders and support those struggling in this insightful and informative video by the Great Doctor Spectrum.

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MythBusted: Debunking the Myth - People with Eating Disorders Are Always Underweight 🧠❌

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Daniel Mackler from the Alliance of Eating Disorders sheds light in this video on the realities of eating disorders, breaking down myths and offering insights into their impact and recovery.

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Eating Disorders and Childhood Trauma -- An Analysis

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Did you know about 10% of people worldwide will face an eating disorder in their lifetime? Despite this, eating disorders remain deeply misunderstood, with myths about symptoms and treatment making them harder to address. Anees Bahji breaks down the facts and debunks common misconceptions.

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Why are eating disorders so hard to treat? - Anees Bahji

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This video dives into the ways trauma impacts eating disorders and how understanding this connection can lead to more effective support and healing.

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An Eating Disorder Specialist Explains How Trauma Creates Food Disorders

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The National Health Institute outlines how trauma-informed care can make a big difference in recovery.

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Abstract

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.

Keywords: Trauma, Adolescents, Eating disorders, Bulimia

Despite the extensive literature on adults with EDs (National Institute of Mental Health [NIMH], 2017), there is much less research on adolescents. The NIMH reported that the lifetime prevalence of EDs within U.S. adolescents, aged 13 to 18, was 2.7%, occurring twice as frequently in females (3.8%) than males (1.5%) (NIMH, 2017). The prevalence rates of EDs also showed an increase with age during adolescence. However, the NIMH did not conduct prevalence rates by ED type, for Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED) or Other Specific Feeding or Eating Disorder (OSFED). Previously, Swanson et al. ( 2011) sought to advance the literature by examining the prevalence and correlates of EDs in adolescents from a large sample of population-based surveys. Swanson and colleagues found the lifetime prevalence to be 0.3% AN, 0.9% BN, and 1.6% BED with the median age of onset being approximately 12 years old. In addition, BN and BED were frequently co-morbid with other psychiatric disorders, and AN was most associated with Oppositional Defiant Disorder. In regard to treatment, no treatment attendance or success rates could be located. However, Rome and colleagues concluded that recognizing and treating the disorder early are critical in decreasing morbidity and mortality rates in adolescents with EDs (Rome et al. 2003). Since both the Swanson et al. 2011 and Rome et al. 2003 studies were conducted before publication of the DSM-5, additional research should attempt to expand and confirm these findings for these new updated diagnostic criteria, in addition to a dearth of literature on risk factors for adolescents that develop EDs.

For these three most common EDs, the reasons for development are complex, yet the current literature presents various plausible risk factors. For AN, risk factors include having anxiety or displaying obsessional traits in childhood, being involved in a job (i.e., modeling) or sport where thinness is valued, or having a familial history of anorexia (genetic and social links) (APA, 2013). Previously identified risk factors of BN include low self-esteem, depression and anxiety, idealization of thin bodies, childhood obesity, and early puberty (APA, 2013). Although BED is a newly recognized disorder, a few recognized risk factors are having family members with a history of binge eating, a tendency to externalize problems (Allen et al. 2016), and a habit of eating when not hungry (Balantekin et al. 2017).

With these identified plausible risk factors for each ED, one factor that is gaining more relevance in adolescents with EDs, is childhood trauma. The literature to date highlights that a significant amount, approximately 50%, of individuals diagnosed with EDs report a history of childhood trauma and abuse (Carter et al. 2006; Rodriguez et al. 2005). Thus, it is understood that those who encounter a traumatic experience in their childhood are more vulnerable to developing an ED than children who do not. This is further supported by a meta-analysis, which identified stressful and challenging environmental factors (including traumatic events) as precursors to the development of EDs (Dalle Grave 2011).

Bruch ( 1981) states that individuals who develop EDs experience a lack of control over their body and lack of conviction for living their own life. Childhood trauma and its associated perceived loss of control is a suspected underlying mechanism of EDs, as the ED symptoms are an attempt to regain control. However, some ED symptoms, for example BN and BED, involve criterion of a loss of control with binging and purging episodes. Smolak and Murnen's ( 2002) meta-analysis identified the similarities between the lack of control present in traumatic experiences and in ED symptoms. Additionally, Waller ( 1998) found that specifically victims of abuse lack perceived personal, internal control and seek an external locus of control, which is linked to ED symptomatology.

Kong and Bernstein ( 2009) labeled three broad traumatic out of control experiences as predictors of ED: emotional abuse, physical neglect, and sexual abuse. Emotional abuse appears to be the most prevalent traumatic experience among individuals with EDs (Carretero-Garcia et al. 2012). However, emotional abuse typically accompanies other or multiple types of abuse. These traumatic experiences cause emotional distress and affective deficiencies, including depressed mood, low self-esteem and generalized anxiety (Polivy and Herman 2002), therefore the emotional trauma that is frequently experienced with additional types of traumas render these experiences important in the study of the risk factors of EDs. The intense, overwhelming, out of control, and sometimes intolerable emotions that result from the aforementioned types of trauma have been found to influence disordered eating behaviors as coping mechanisms (Polivy and Herman 2002). A focus on eating displaces the emotions from the trauma onto food and body shape. In addition, such individuals seek control over future traumatic events and associated emotions through controlling food (Polivy and Herman 2002). Thus, it is likely that trauma, including neglect, physical abuse, and sexual abuse, is a risk factor for developing an ED.

Childhood experiences of neglect (Dalle Grave 2011; Sweetingham and Waller 2008) and sexual abuse (Smolak and Murnen 2001; Wonderlich et al. 2001) are associated with emotional abuse, and also linked to disordered eating behaviors. Johnson et al. ( 2002) found that individuals who were subject to physical neglect during childhood were more vulnerable to experiencing various types of problems related to eating and weight. Specifically, parental neglect due to insecure parent-child attachments were found to predict increases in eating disordered behavior and symptoms such as dietary restraint, and eating, weight, body shape concerns, and episodes of binge eating (Goossens et al. 2012). In addition, childhood sexual abuse (CSA) is linked to the development of EDs (Smolak and Murnen 2001; Wonderlich et al. 2001), which is understood because it is believed to affect identity and body image (Kearney-Cooke and Striegel-Moore 1994). With this, such individuals have shown to develop dissociative coping styles, such as binge eating (Perry et al. 1995) or seek to regain control through limiting food intake (Schwartz and Cohn 1996). Thus, childhood neglect and sexual abuse have been identified as risk factors for EDs.

There is a longstanding history of research that associates physical abuse with increased risk of developing an ED. From a sample of women who were diagnosed with AN, BN or BED, it was concluded that women who experienced childhood physical abuse had twice the odds of developing an ED (Rayworth et al. 2004). Physical abuse particularly in forms of bullying and teasing among peers, are also traumatic interpersonal experiences that are linked to the development of any type of ED (Polivy and Herman 2002; Sweetingham and Waller 2008). Thus, childhood physical abuse is historically associated with AN, BN and BED. However, more specifically, 36% of 145 outpatients with BED reported experiences of physical abuse in their childhood (Grilo and Masheb 2001). In addition, such abuse has been identified as a specific risk factor for BN (Welch and Fairburn 1996). Therefore, specific research with various ED population, point to childhood physical abuse as risk factors for EDs.

More recent literature associates a history of multiple trauma types and trauma severity with EDs. For example, Tagay and colleagues identified a traumatic history with multiple trauma types as a risk factor for EDs (Tagay et al. 2014), specifically including physical and sexual abuse (Rayworth et al. 2004). Moreover, Smyth and colleagues found trauma severity to be related to greater ED symptomatology in general, and more explicitly binging and purging symptoms (Smyth et al. 2008). Thus, with childhood physical abuse identified as a risk factor for EDs, multiple types of trauma and trauma severity have also been linked to the development of EDs.

Aims of the Current Study

There is a limited but consistent relationship that childhood trauma may be related to ED symptoms, specifically within an adolescent population. Prior research that demonstrates this relationship is also based on DSM -IV criteria or earlier, there is no existing research that assesses this relationship using the DSM-5 ED criteria. In addition, it is unknown whether or how different types of trauma may be related to ED symptoms in adolescents. The present study is unique and distinctive, as it is the first to examine a range of childhood traumatic experiences in relation to various constellations of symptomatology in adolescents with EDs using DSM-5 criteria. The first aim of the study was to assess the relationship of a trauma history (present/absent) and the different types of trauma with EDs. It was hypothesized that the presence of a childhood trauma would be associated with EDs. The second aim was to assess the sum of the different trauma types experienced in relation to ED disorders and symptoms. It was hypothesized that adolescent patients with multiple types or poly-traumatic experiences would report more ED symptoms. The third aim of the study was to examine the relationship between the severity of traumatic experiences with ED disorders and symptoms, to which it was hypothesized that patients with greater severity of their traumatic experiences would report more ED symptoms.

Methods

Participants

Participants consisted of 112 therapists currently treating an adolescent with an ED. Participants from the United States and Canada were recruited to permit attainment of a geographically diverse sample. Table 1 presents participants' demographic data. The average age of the sample was 43.55 years (SD = 13.23), and the mean length of time practicing as a clinician was 16.17 years ( SD  = 11.62). Therapist discipline varied from a Masters or Doctoral degree in mental health (M.A., M.S., M.S.W., M.H.C., Ph.D., Psy.D.) or in medicine (M.D.), and came from various theoretical orientations.

Procedures

All participants represent those treating adolescent patients with eating disorders in private practice, and/or community clinics. Participants were recruited from several professional listservs obtained through PsychologyToday.com, National Eating Disorder Association (NEDA), International Association of Eating Disorders Professionals (IAEDP), Academy for Eating Disorders (AED), APA Division 29, Society for Psychotherapy Research (SPR), and Society for the Exploration of Psychotherapy Integration (SEPI). Participants received the invitation via their work e-mail to participate in the study on their own technological device (work computer, laptop, etc.). This invitation included a solicitation flyer, which briefly described the study and the option for participants to anonymously complete an online Qualtrics survey at a website address whenever and wherever they felt most comfortable to do so (uncompensated). Therapists were also informed that their decision to participate would have no impact on the treatment they provide and were encouraged to contact the principal investigator with any questions about the investigation. Participants who clicked on the survey link had immediate access to the questionnaire, and by clicking "I Consent," consented to participate in the study.

To complete the survey, therapists were asked to select an adolescent (13 to 18 years old, (see Swanson et al. 2011) patient diagnosed with an ED currently in their care, with whom they had worked for a minimum of eight sessions (to insure the therapist knew the patient well). To minimize selection biases, clinicians were directed to consult their calendar and select the last patient they saw during the week who met the criteria (see also: Betan et al. 2005; Tanzilli et al. 2017). Therapists were informed in writing that they should put no identifying information throughout the survey and that the ratings would be completely confidential, to ensure complete anonymity. In addition, they were informed that all data would be stored electronically on a secure server and a password-protected website accessible only to the principal investigators. However, if participants wished to not answer any question, the items would be left blank without penalty. The data was collected over a 3-month period, beginning in August 2018. To increase response rates, three waves of solicitations were posted on these various websites, including the initial in August, 1 month following in September, and again 1 month following in October. These efforts aided in achieving a sufficient response rate to obtain 112 mental health professionals. With this procedure, this study met all ethical standards and safety monitoring procedures.

Measures

Demographic Information

Participants were asked six demographic questions pertaining to gender, age, clinician discipline, years of practicing as a clinician, years licensed, and theoretical orientation.

DSM-5 ED Criteria Symptom Checklist

Participants were administered an exhaustive checklist of the 16 symptoms of Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, and Other Specified Feeding and Eating Disorder, to determine the presence or absence of these symptoms according to DSM-5 criteria.

Childhood Trauma Questionnaire - Childhood Traumatic Events Scale (Pennebaker and Susman 2013)

The Childhood Trauma Questionnaire is a 13 item, patient-rated assessment of their experience on one scale of childhood traumatic events and on another scale of recent traumatic events. For the current study, six-items from the childhood traumatic events scale were adapted to a therapist-response style, to inquire about their patients' experience with childhood trauma. The items assess whether or not a specific traumatic event occurred, and if so, at what age, and how severe the traumatic event was for their patient (where 1 = not at all and 7 = extremely traumatic). The validity and reliability of the Childhood Trauma Questionnaire has been demonstrated on a variety of populations in numerous studies, including adolescent samples (Bernstein et al. 1997; Suliman et al. 2009) and eating disorder samples (Kong and Bernstein 2009; Fischer et al. 2010).

Results

The patient sample demographic and diagnostic information is presented in Table 2. Patients averaged 16.22 years old, (SD = 2.14). Of the 112 patients reported on, 106 were female (94.6%) and 6 were male (5.4%). The majority of patients carried a diagnosis of Anorexia Nervosa ( n = 73, 65.2%), with Bulimia Nervosa ( n = 15, 13.4%) and OSFED ( n = 15, 13.4%) being the second most common, and Binge Eating Disorder being slightly less common ( n = 9, 8.0%). In addition, the trauma history of this patient sample is presented in Table 3. Over two-thirds of these ED patients reported having a trauma history (Trauma History n = 77, 68.8%; No Trauma History n = 35, 31.3%), including experiencing a major upheaval between parents ( n = 34, 30.4%), or the death of a close friend or relative ( n = 24, 21.4%), being extremely ill or injured ( n = 21, 18.8%), having a traumatic sexual experience ( n = 18, 16.1%), and being a victim of violence ( n = 5, 4.5). Additionally, 45 (40.2%) patients experienced another major upheaval that was considered traumatic and had a large impact on them. Overall, 50 patients (44.6%) reported being victim to multiple traumatic experiences, or poly-trauma.

The first aim for this study was to examine the presence or absence of any traumatic experience (CTQ-TR) and its relation to ED disorders and symptomatology (DSM-5 ED Symptom Checklist). In examining the presence or absence of any traumatic experience and the various types of traumatic experience, we utilized logistic regressions, forward entry with .05 significance level. Overall, the categorical presence ( n = 77) or absence ( n = 35) of any traumatic experience was not significantly related to any specific type or overall amount of ED symptomatology (R = .134, p = .771). Next, we examined the six specific types of traumatic experiences in relation to ED diagnostic symptoms, and one was found to reveal a significant relationship. Specifically (see Table 4) findings demonstrated that adolescents high in BN symptoms (B = 4.694, p = .044) and low in OSFED symptoms (B = −1.770, p = .031) were more likely to have been a victim of violence (R = 0.596, p = .006). Based on these results, additional exploratory logistic regressions were examined to identify which symptoms within the BN and OSFED diagnostic constellations were significant in relation to victim of violence trauma. These analyses indicated that within the BN symptom cluster those who had at least four uncontrollable binges a month were predicted to be a victim of violence (B = 2.228, p = .055). Furthermore, within the OSFED symptom cluster, having at least two compensatory behaviors (i.e. purging via laxatives, diuretics or self-induced vomiting) per month (B = .139, p = .034) was significantly related to being a victim of violence. The finding regarding this specific OSFED item is in contrast to OSFED being a negative predictor as a diagnostic category to victim of violence trauma, when assessed individually. Whereas, this specific OSFED symptom was positive in relation to victim of violence trauma.

A second aim of this study was to assess the impact of multiple types of trauma history for a given patient, in terms of no trauma ( n = 35), single trauma ( n = 27), or poly-trauma ( n = 50), with ED type and overall symptomatology (see Table 5). Pearson's r coefficient tested the strength of these associations, two-tailed, with effect sizes approximately .10, .30, and .50 respectively considered small, medium and large (Cohen 1988). Results revealed a small effect trend towards significance between the total number of different trauma types experienced (0-6) with ED total symptoms (r = .179, p = .059) and BN symptoms ( r = .183, p = .054). Thus, when patients experienced multiple types of childhood trauma, the more likely they were to be high on overall total ED symptoms and BN symptoms. With these results, we undertook an exploratory analysis of the individual ED symptoms in relation to the number of trauma experiences. We found two symptoms were significantly related to these instances of poly-trauma, including the patient having at least four compensatory behaviors (e.g., purging via laxatives, diuretics or self-induced vomiting) a month ( r = .217, p = .021) and binge eating characterized by eating an amount of food larger than what most people would eat in a discrete period of time (e.g., 2 h) and a sense of lack of control over eating during the episode ( r = .188, p = .047). In addition, marked distress about binges trended toward significance ( r = .160. p = .093).

The third aim of the study assessed the relationship between trauma sum severity (1-7), the additive value of severity ratings from all the different traumatic experiences (0-6) reported for a given patient, with ED type and overall ED symptoms (See Table 5). Results demonstrated a significant relationship between trauma sum severity and total ED symptoms (r = .194, p = .040) as well as BN symptoms (r = .236, p = .012). Given this finding, we sought to further explore the relationship between trauma sum severity and the individual ED symptoms. Results revealed that patients with greater severity of traumatic experiences across the different trauma types was related to having at least four compensatory behaviors (e.g., purging via laxatives, diuretics or self-induced vomiting) a month ( r = .266, p = .005). In addition, three symptoms trended toward significance, including binge eating characterized by rapid eating, eating until full, feeling disgusted, etc. ( r = .185, p = .051), having marked distress about binges ( r = .174, p = .067), and having at least two compensatory behaviors ( r = .174, p = .068). Therefore, with greater trauma severity, ED adolescents are more likely to have more overall ED symptoms and BN symptoms, more specifically, binge eating and compensatory behavioral symptoms (e.g., purging via laxatives, diuretics or self-induced vomiting). In total, while the results of this study are significant, these findings are largely small effects, suggesting that trauma likely has some relationship with EDs in adolescents, but it is clearly one of several factors.

Discussion

The present study is the first study to examine the relationship between childhood trauma and adolescent EDs using DSM-5 criteria. Thus, the initial aim of our research was to assess the relationship between the presence of a childhood trauma history and ED symptomatology among adolescent patients with EDs. Not only did the majority of our sample report a history of trauma, but our results also demonstrated the relationship between specifically being a victim of violence (i.e. physical abuse) with high BN symptoms and low OSFED symptoms. At the BN and OSFED symptom level, we found that among eating disordered adolescents, physical abuse was related to multiple uncontrollable binges and compensatory behaviors (e.g., purging via laxatives, diuretics or self-induced vomiting). This is consistent with the findings of Root and Fallon, who in their 1988 study found that 66% of their sample of 172 women with Bulimia had been a victim of violence (Root and Fallon 1988). Later studies that assessed this relationship also found physical abuse to be more prevalent in adults with BN compared to controls (Welch and Fairburn 1996; Rorty et al. 1995).

Even more specific and similar to our results, two studies have found childhood physical abuse to be most strongly associated with BN compared to other EDs in adolesent and young adult women (Andrews 1997) and adult women (Rayworth et al. 2004). Andrews ( 1997) specifically found associations between childhood physical abuse, bodily shame, and BN (DSM-III criteria). However, childhood physical abuse and BN were no longer related when bodily shame was considered. Given these results, they identified bodily shame as a potential mediator between childhood physical abuse and adolescent BN. Morever, Rayworth and colleagues also found a relationship between childhood physical abuse and EDs (DSM-IV criteria) in adult women (Rayworth et al. 2004). They further recognized an underlying link of control between the two phenomena, based on Smolak and Murnen's ( 2002) meta-analysis on childhood abuse and EDs. Thus, they noted that physical abuse may leave victims feeling like they lack control over their lives and develop EDs in order to regain a modicum of control over some aspect of their lives (Rayworth et al. 2004). Despite the lack of studies in this area, these findings appear to be consistent with current conceptualization of adolescent ED in the DSM-5.

The second aim of our study was to examine how the number of different traumatic experiences was related to ED type and symptomatology. The previously identified relationship between victim of violence, ED and BN appears to be even more prominent in individuals who encounter multiple categories of trauma (i.e. poly-trauma). Not only did we find childhood poly-trauma to be positively related to overall ED symptom count and BN, but at the individual level all ED patients that were victims of violence, all also had a history of poly-trauma. These findings support the relationship between patients with poly-trauma and EDs that is consistent with prior research that came to the same conclusions using previous ED criteria from earlier versions of the DSM (Brewerton 2007; Schoemaker et al. 2002). Brewerton's ( 2007) review paper on EDs and their relation to trauma and comorbidity made two important conclusions; first, the majority of women with BN report having PTSD symptoms, and second, the relationship between BN and a history of numerous instances or types of abuse. In addition, Schoemaker et al. ( 2002) assessed childhood poly-trauma in relation to BN in adults (DSM-III R criteria) and identified a history of multiple childhood traumatic experiences as a risk factor for BN, as well as other comorbid psychiatric disorders and substance use disorders. Moreover, Rayworth and colleagues concluded that individuals who experienced more than one type of trauma, specifically both physical and sexual abuse, were significantly more likely to develop an ED than individuals who did not encounter any abuse (Rayworth et al. 2004. Given these findings, a relationship between multiple types of childhood traumatic experiences and presence of ED symptoms is apparent, specifically with BN symptoms. This implies the importance of inquiring about physical abuse and poly-trauma histories in adolescent patients with BN.

The third and final aim of this study was to assess the severity of these traumatic experiences in relation to ED. Again, we found that ED patients with greater trauma severity were more likely to be high on ED symptoms and BN symptoms. This supports prior findings by Smyth and colleagues who found a relationship between overall trauma severity with EDs, as well as specific symptoms of binging and purging (e.g., compensatory behaviors) (Smyth et al. 2008). This is also consistent with our findings, that within the BN cluster, patients with greater severity of traumatic experiences were more likely to use at least four compensatory behaviors (e.g., purging via laxatives, diuretics or self- induced vomiting) per month. In addition, among all of the ED symptoms, several trended toward significance. These findings suggested that ED patients with greater severity of traumatic experiences were more likely to also use at least two compensatory behaviors per month, engage in binge eating episodes, and have marked distress about binges. Moreover, Smyth and colleagues found that trauma type and severity were related to increases in these symptoms over time (Smyth et al. 2008). Thus, individuals with a history of severe traumatic experiences may not only be at greater risk for developing an ED but also for more severe forms of ED, and especially in regard to specific BN binging and purging symptoms.

These results support previous hypotheses that a lack of control from multiple traumatic experiences may be related to the same issues of control observed in EDs. Both phenomena, trauma and ED symptoms, are intense, overwhelming, and out of control experiences, which is supported by Polivy and Herman ( 2002) who recognized that individuals with EDs may acquire and maintain ED symptoms as an attempt to cope with issues of personal control. In addition, Polivy and Herman ( 2002) specifically identified that eating disordered individuals respond to experiences that lack internal or external control (i.e. trauma) by seeking control through ED symptoms, however ultimately lose control during binge episodes and the use of compensatory behaviors (acts to undo eating or to prevent weight gain; e.g., purging via laxatives, diuretics or self-induced vomiting). The conclusions of Polivy and Herman ( 2002) are remarkably consistent with the current study's findings, depsite being replicated on a different sample with earlier DSM criteria. This demonstrates clinical utility and directs clinical attention to early childhood trauma with this constellation of bulimic symptoms and disorder.

The present study's results, specifically the lack of findings between AN and individual AN symptoms with trauma, support previous findings. Jaite and colleagues assessed the relationship between childhood trauma with AN restricting type and AN binge-eating/purging type in adults and concluded that patients with binge/purge type were more likely to report a childhood trauma history than restricting type patients (Jaite et al. ( 2012). Moreover, restricting patients and control participants showed no differences in childhood traumatization. Related, another study found the highest trauma rates to be among bulimic patients, and concluded no significant relationship between AN and trauma (Dalle Grave et al. 1996). Overall, the majority of the existing literature concludes the relationship between trauma and BN, with minimal research commenting on a trauma history and its relation to AN.

The present study had three aims to assess the relationship of ED type and ED symptomatology with the presence or absence of a childhood trauma history, the amount of different traumatic experiences in childhood, and the severity of those traumatic experiences. There were a few notable consistencies across these three aims, including the relationship of both the number and severity of traumatic experiences to the total amount of ED symptoms, and specifically BN symptoms. Related, patterns of individual symptoms were also present across these trauma variables, including binge episodes and compensatory behaviors. Specifically, the presence of violent childhood trauma was related to having at least four uncontrollable binges per month, while the amount of different traumatic experiences was similarly associated to binge episodes with a lack of control and marked distress. In addition, the amount of different trauma types and the severity of all the traumatic experiences were both related to having at least four compensatory behaviors (e.g., purging via laxatives, diuretics or self-induced vomiting) per month. Thus, clinicians should be keen to the association between trauma histories and ED symptoms so that when patients present with either a trauma history or ED symptoms, they conduct in-depth evaluations of the other corresponding phenomena. In addition, clinicians should also be aware that the relationships between specific trauma variables and ED symptomatology appear to be linked by a theme of control, desire for or lack thereof. Overall, our findings demonstrate the relationship between trauma and EDs, specifically BN with binging and purging behaviors, further supporting this link to themes of control. These findings can and should inform clinicians' conceptualization and treatment approach when working with an eating disordered adolescent patient with a trauma history.

With awareness of trauma's relation to ED, it should also be noted that not all individuals with a history of trauma develop an ED, and not all individuals with an ED report memories of trauma. In the present study of patients with ED, a relatively large percentage (31%) do not report a history of trauma. Similar to how etiology and presentation of a disorder differ across patients, the pathway of developing an ED may also differ across patients. Madowitz et al. ( 2015) discuss two etiological pathways from trauma to ED, one of body dissatisfaction, shame, and fear of trauma, and the second of failure of the typical and expected environment, need for control, and coping with psychological diagnoses and emotional regulation. The authors discuss these pathways in relation to trauma, however, it is very possible ED patients without a trauma history experience aspects of these pathways (i.e. body dissatisfaction, shame, need for control, coping with psychological diagnoses and emotional regulation difficulties) with a different underlying factor that is not trauma. Polivy and Herman ( 2002) also identified body dissatisfaction as a cause of ED, as well as sociocultural factors (e.g., peer influences), family factors (e.g., enmeshment), negative affect, and low self-esteem. It seems that in addition to trauma, there are additional identified risk factors and other pathways of developing an ED. Thus, trauma appears to be one of several risk factors and pathways to developing EDs in adolescents. Future research should examine the differences between ED individuals with and without a trauma history, comparing different etiological pathways with ED presentation and severity. Such information would be useful in informing and guiding clinicians' conceptualizations and approach to treatment of ED individuals with or without a trauma history.

In the treatment of ED patients with a trauma history, previous research found potential in treatments that emphasize self-control to reduce ED symptoms related to trauma and control. Waller ( 1998) first identified a link between an external locus of control and ED symptomatology in women who were abused and recommended that clinical work focus on cognitions of personal control. In another study, ED patients found treatment to be more satisfying when approaches focused on developing eating habits with a sense of self-control (Clinton et al. 2004), thereby reducing out of control binging and purging behaviors. In addition, a treatment that identified triggering situations that led to feeling loss of control and then worked to develop strategies to maintain control was found to decrease frequency of purging episodes and improve eating attitudes overall (Schneider and Agras 1985). Thus, treatment of ED patients should use approaches that focus on enhancing self-control.

Additionally, our findings support the previous clinical suggestions of Wonderlich and colleagues who note the complexity of treating ED patients with a trauma history and recognized that clinicians may need to focus on trauma history and associated comorbid disorders (e.g., PTSD, substance abuse) before being able to effectively treat the ED (Wonderlich et al. 1997). Further, Tasca and colleagues recognize the importance of interventions examining relational and attachment issues of ED patients (Tasca et al. 2009), which may be related to these traumatic experiences. Specifically, this study concluded that ED patients with attachment anxiety may benefit from impulse regulation and reflective functioning, whereas ED patients with avoidant attachment may benefit from exposure to affective expression and interpersonal connectedness. Thus, although self-control might be useful in treating ED symptoms, trauma seems to be an important clinical issue of focus with ED patients, and BN in particular. Therefore, it seems both timely and prudent to think about treatment for BN as being more than just focused on the symptoms, but also exploring trauma related issues on the impact of self-perception and relational functioning.

This is supported by two RCT studies that compared cognitive behavioral therapy (CBT) and psychodynamic therapy (PDT) in the treatment of BN. The CBT focus included exploring problematic behavior and psychoeducation, correcting eating disordered symptoms and dysfunctional cognitions, training in social skills, affect regulation and problem solving, and addressing relapse prevention. PDT understands BN symptoms as being a displacement from the psychological self to the physical self (i.e. body), and approaches treatment by working through personal patterns and conflicts that underpin the BN symptoms (Stefini et al., 2017). Stefini and colleagues found no differences between CBT and PDT at the end of treatment, however patients of PDT had greater improvements in eating concerns compared to patients of CBT at the 12-month follow up. Similarly, Poulsen et al. ( 2014) compared the two treatment approaches on patients with BN and concluded that psychoanalytic psychotherapy had an effect on global eating disorder psychopathology, which was attributed to working through patient's issues related to their BN symptoms. With this, they noted that treatment approaches that address such issues, as well as more directive and behavioral interventions, might be most effective in treating BN and related underpinning issues. In all, treatment of BN symptoms alone appears to not be effective, and that treatment should also focus on other underpinning issues. Related, Richards and colleagues conducted an evidence-based study to assess integrative dynamic therapy (IDT) for BN (Richards et al. 2016). The integrative treatment was comprised of 4 weeks of CBT techniques including psychoeducation, self-monitoring and regular eating, followed by psychodynamic approaches that focused on emotional expression and regulation, interpersonal relationships, and intrapsychic conflict. Through a BN case study, Richards and colleagues demonstrated the possibility and utility of the successful integration of CBT and PDT that addressed obsessional personality issues and emotional avoidance. These more recent studies support the development and application of a treatment that incorporates a CBT approach with focus on ED symptoms in conjunction with a psychodynamic approach with focus on the underpinning issues (e.g., intrapsychic and interpersonal conflicts, emotional expression and regulation) of these symptoms.

Limitations

Despite being the first study to examine the relationship between childhood trauma and adolescent EDs using DSM-5 criteria, there are a few limitations that are important to note. First, the data collection method (self-report) from one informant (clinician) perspective may affect validity. However, multiple studies have displayed that therapists make reliable and valid judgments of their patient symptoms and traumatic experiences reported in treatment when rated on well-established psychometric instruments like the ones included in this study (Bernstein et al. 2003; Paivio and Cramer 2004; Sysko et al. 2012). Second, we did not inquire about the patients' Axis I comorbid diagnoses. Individuals with EDs and additional Axis I diagnoses would understandably have more severe symptoms and be more complex to treat. Due to this lack of inquiry, we were not able to assess and compare ED individuals with and without comorbid Axis I diagnoses. Existing literature that has assessed comorbid diagnoses of EDs and Axis I disorders found that a high percentage of young adults with EDs also met criteria for an Axis I disorders (Lewinsohn et al. 2000; Zaider et al. 2000). Additionally, Keel and Brown ( 2010) concluded that greater psychiatric comorbidity in individuals with EDs are more likely to have worse prognosis. Therefore, it is common for individuals with EDs to also carry a comorbid Axis I diagnosis, as well as experience more difficulty in treatment. Overall, it is a potential limitation that we did not inquire about patient's Axis I comorbid diagnoses, but this may not have that large of an effect on found differences. Third, in any regression model the results are limited to the sample its derived from. Therefore, we would suggest additional research conduct similar and related associations between these variables with a larger sample size.

Conclusions

Despite these limitations, these results have critical implications for clinical interviewing and treatment as this is the first study to examine the relationship between childhood trauma and adolescent EDs using DSM-5 criteria. Overall, we have identified a relationship between childhood trauma, and poly-trauma with adolescents diagnosed with DSM-5 EDs. While our results are significant, they have largely small effect sizes and thus trauma likely has some relationship with EDs in adolescents, but it is clearly one of several etiological factors and is not always present in adolescents with EDs. In addition to other risk factors, given our findings, clinicians should be attuned to trauma experiences, especially physical abuse history, when working with eating-disordered adolescents, and specifically those with BN symptoms. Clinicians should also be informed that in line with these findings, trauma may have less relation to AN in adolescents. Our data also highlights the connection of two experiences bereft of control, trauma and binge eating. Thus, therapists may find these results clinically important and useful in informing their conceptualization and treatment approach. Moreover, techniques related to increasing a sense of self-control might be helpful in treating BN. In addition, it might also be helpful to think about the treatment of BN as more than only a focus on ED symptoms, as past traumatic experiences seem relevant in the treatment of BN, binge eating and compensatory behaviors. Therefore, a treatment focus that explores an ED patient's sense of self and relation to others related to both prior trauma as well as their current symptomatology seems warranted. Additionally, that clinicians become more aware of the role control, or lack thereof, plays in trauma and EDs. It will be important to gain a deeper understanding of treatment approaches that most benefit eating disordered adolescents with a history of poly-trauma experiences.

Compliance with Ethical Standards

Disclosure of Interest

All authors declare that they have no conflicts to report.

Ethical Standards and Informed Consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation [institutional and national] and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study.

Footnotes

Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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