Restrictive Eating Disorders Are Increasing Among Teens

Little is known about the role of life events in adolescents and the subsequent development of restrictive eating disorders, or REDS. What is known is that the incidence is increasing among adolescents 15 to 19 years of age: the incidence is now reported as 40 to 100 cases per 100,000 population among females and 1 to 4 cases per 100,000 population among males. Among younger teens, such as those between 9 and 14 years of age, REDS have been reported among 13% of females and 7% of males (Lancet. 2010. 375:583). A recent study from Italy concluded that obtaining early information about traumatic events may help prevent new events, and improve patient outcomes among adolescents (Children. 2023. 10:376).

Health costs to teen patients

The health cost to adolescent patients can be high: REDs have the highest mortality risk rate among psychiatric diseases, and the degree of severity is associated with moderate to high levels of psychosocial and work impairment (Opin Psychiatry. 2020. 33: 521). Environmental and individual biological vulnerability are then thought to be involved in the development of eating disorders. The recent COVID lockdown also had an effect on the development and exacerbation of eating disorders, such as AN and atypical AN, among others. In one group of patients 8 to 18 years of age who were hospitalized for the first time during the pandemic, 33% reported that the only environmental factor they correlated with the onset of their AN was the experience of being “locked down.”

Several studies have shown the significance of physical, sexual, and psychological abuse, as well as emotional and physical neglect in eating disorders. Childhood sexual abuse is the most extensively studied form of traumatic experience related to eating disorders, and it may play a role in the development of AN. The difference between sexual and non-sexual early stressful life events in predisposing to a later eating disorder is still a topic of active research (BMC Psychiatry.  2021, 21, 501; Int J Eat Disord. 2022. 55, 1079-1089).

On the other side: protective life events

Protective life events could include family environmental factors and the social environment. A major review in 2017 clarified the role played by personal and protective life events in the development of REDS. Protective life events could be general, such as family support and cohesion, or more specific, such as the importance given by the family to eating meals together, avoiding negative comments about weight, or growing up in a family where thinness or physical attractiveness are not overemphasized (J Eat Disord. 2017. 5:1218).

A study of trauma

From March 2020 to May 2022, Dr. Giorgia Baradel and colleagues at the University of Pavia, Italy, studied 33 female adolescent patients 12 to 18 years old who were referred to the authors’ hospital in Pavia as inpatients, outpatients, or day-hospital patients. After completing a series of questionnaires, the authors found that nearly 88% of the teens reported having had a traumatic life event in the past year, as reported on the Coddington Life Events Scale (CLES).

All the young patients were interviewed about their family and medical histories, and 29 of the 33 teens reported having had at least one traumatic life event in the 12 months preceding enrollment. Life events could be either positive or negative, and each had a specific value: the most recent events had a greater impact than the older ones. The higher the associated scores, the more stressful the life event was, and the more psychological readjustment it required to overcome.

The authors noted that the reaction to the event could also be influenced by a patient’s perception of whether the event was positive or negative. Such life events are mainly family-related traumatic events, such as domestic violence, and physical, sexual, or emotional abuse. This is in line with the existing literature that has mainly focused on events occurring during childhood or early adolescence.

Life events and severity of RES

The second aim of the authors’ study was to assess the relationship between the presence of life events, either traumatic or protective, and the severity of REDS and patients’ psychological maladjustment. There were no statistically significant correlations between the presence of life events in the 12 months before enrollment and the patient’s clinical severity, according to the Eating Disorder Risk Composite and General Psychological Maladjustment Composite variables. Supra-threshold life events reported on the CLES during the previous 12 months did not correlate with the subsequent clinical worsening of symptoms. According to some authors, the presence of childhood traumatic events is involved in the development of biological changes in the stress response system. This leads not only to a greater susceptibility to further traumatic experiences but also to a different ability to cope with stressful events, such as REDS themselves.

The authors pointed to several limitations of their study. First, the sample size was relatively small, and they hope to replicate their current results in larger samples of patients. Second, the CLES is a new measure, and it only taps the preceding 12 months. The authors feel it would also be helpful to study earlier periods, to better clarify the role of traumatic events that occurred in childhood.

Including protective life events

Concerning the clinical practice with adolescent patients, the authors urge researchers not to limit the investigation of traumatic life events to childhood but also to explore more recent periods.

In Italy, national guidelines indicate family therapy for AN (FT-AN) as first-choice treatment of children and adolescents. But the authors note that regardless of the therapy employed–it could be useful to consider the role of trauma. On the other hand, they feel it could be interesting to investigate whether therapeutic approaches that aim at treating young patients exposed to traumatic life events also target REDS symptoms or psychological characteristics often associated with eating disorders. According to the authors, their study considers both the traumatic nature of life events but also its protective nature, which appears to play a key role in the definition of personalized treatment. Indeed, they report that protective life events could be used as strengths in therapeutic.