Change processes related to long-term outcomes in eating disorders with childhood trauma: An explorative qualitative study.

Abstract

To date, eating disorder (ED) treatments are lacking for ED patients with psychiatric sequelae of childhood trauma, and successful outcomes are scarce. Therefore, the aim of this study was to explore therapeutic change processes from a patient perspective in relation to good versus poor long-term ED outcome at 1-year follow-up. Outcome categories were based on clinician assessment of ED behavior and diagnoses, body mass index, and Eating Disorder Examination Questionnaire scores. Eleven White, cisgendered female ED patients with childhood trauma were interviewed after a 3-month inpatient treatment: data was analyzed with elements from grounded theory and interpretative phenomenological analysis. The qualitative analysis rendered change-related descriptions (9 subcategories) and obstacles to change (6 subcategories), and 3 process-related domains differentiated good from poor long-term outcome: trauma exposure (4 subcategories), patient agency (6 subcategories), and patient-therapist dynamics (3 subcategories). First, sensory and emotional trauma exposure in good outcome informants was contrasted with avoiding or not addressing trauma and body in poor outcome informants. Second, promotion of patient agency while receiving support in the good outcome group was contrasted to an orientation toward others' needs, distrust in own abilities, and difficulties showing vulnerability in the poor outcome group. Third, poor outcome informants described either a distanced or immersed/idealizing relationship to their therapist, as opposed to more balanced between self-assertion and vulnerability in good outcome informants. Our findings raise new hypotheses that trauma work, fostering patient agency, and focusing on relational dynamics in patient-therapist dyad may be important in producing enduring ED outcomes for these patients. Public Significance StatementThis study uses a patient perspective on therapeutic change processes in good and poor outcome cases at 1-year follow-up. Findings are reported from a patient sample for which proper treatments and successful outcomes are scarce: eating disorder patients with childhood trauma. Findings indicate that trauma exposure, fostering patient agency, and an experience of a supportive yet agencypromoting therapist-patient relationship may be potent ED treatment elements across treatment models.

Mechanisms by which adverse childhood experiences, other traumas and PTSD influence the health and well-being of individuals with eating disorders throughout the life span

“…Such deficits may include the identification and verbalization of one’s own emotional state of mind, i.e., alexithymia, as well as that of others. Several types of socioemotional, neurocognitive, and processing difficulties have been demonstrated in EDs at all phases of the illness and may (1) impede the processing of traumatic events; (2) lead to the misidentification of potentially threatening interpersonal situations; and (3) interfere with receiving quality emotional support from others that is so crucial to healing and recovery [ 154 , 315 , 321 – 342 ]. Such deficits and related interpersonal dysfunction may play significant roles in predicting treatment outcomes and responses to treatment for both EDs and PTSD, as well as their combination [ 150 , 326 , 343 – 349 ].…”

Associations Between Trauma, Early Maladaptive Schemas, Personality Traits, and Clinical Severity in Eating Disorder Patients: A Clinical Presentation and Mediation Analysis

“…If the extended psychopathological core of ED seems to remain stable and is characterized by an overestimation of weight and shapes, depression (D), anxiety, and interpersonal ineffectiveness, patients with and without a history of trauma history seem to show different psychological phenotypes that require a different specific focus (Solmi et al, 2018b;Rodgers et al, 2019). However, more longitudinal studies are needed to evaluate the specific needs linked to patients' traumatic personal histories to achieve higher rates of effectiveness in treatments, which are now unsatisfactory (Backholm et al, 2013;Olofsson et al, 2020;Scharff et al, 2021).…”

Therapist factors related to the treatment of adolescent eating disorders.

“…This is supported by previous clinical suggestions of Wonderlich and colleagues who note the complexity of treating ED patients with a trauma history and emphasized that clinicians may need to focus on the traumatic experiences before being able to effectively treat the ED (Wonderlich et al, 1997). More recently, treatment with a greater focus on trauma correlated with higher alliance scores (Ovenstad, Ormhaug, Shirk, & Jensen, 2020), and better treatment outcomes (Olofsson et al, 2020). Therefore, it seems both timely and prudent to approach treatment of EDs as more than just focused on symptoms, but also exploring trauma related issues.…”

“…Rodríguez, Pérez, and García (2005) found that when a history of physical or sexual abuse was reported among adolescents with EDs, the risk of dropout and relapse were greater, and the likelihood of a poor treatment outcome was also greater. However, Olofsson, Oddli, Hoffart, Eielsen, and Vrabel (2020) qualitatively assessed treatment outcome in ED patients with a history of childhood trauma and concluded that interventions that focused on trauma, promoted patient agency, and created secure therapeutic relationships were associated with good outcome patients.…”