Eating disorders are life-threatening, debilitating illnesses. Anorexia nervosa alone has the highest mortality rate of all mental disorders, often due to suicide. Elsa is a fourteen year-old child who was diagnosed with an eating disorder. Her symptoms remain active and she has made multiple suicide attempts, with the most recent attempt approximately six months ago.

Elsa has lived with both of her parents from birth to age thirteen. During this time, several instances of documented physical abuse occurred by her biological father. Elsa’s parents divorced when she was thirteen. At this time, she was mandated to live with her father. She reports being subject to emotional abuse by her father during this time.

The role of child abuse is recognized as a key factor in elevated suicide risk, with youth abused by immediate family being the most at risk group. It is also associated with both early onset mood disorders (such anorexia nervosa and bulimia nervosa) and the trait of impulsivity. Groleau and colleagues recently found childhood emotional abuse to predict eating pathology through mediating effects of ineffectiveness and affective instability. They suggest childhood emotional abuse might influence severity of eating disordered symptoms by impacting an individual’s self-esteem and capacity for affect regulation.

Childhood adversities are associated with elevated risk for eating disorders and suicidality during adolescence and early adulthood. However, Johnson and colleagues also reported maladaptive paternal behavior to be uniquely associated with risk for eating disorders in offspring after other co-occurring childhood adversities were controlled statistically. Others have found a clear relationship between paternal abuse and severity of eating disorders symptoms (i.e. the addition of self-harm behaviors).

While these studies illuminate the clear connection between abuse (particularly paternal abuse) and development or severity of an eating disorder, they do not tell the whole story; In other words, repercussions of abuse do not result from psychosocial triggers alone. The triggers set in motion a complex gene-environment reaction.

Psychosocial stressors, such as emotional and/or physical abuse from a primary caregiver, accentuate genetic vulnerability to psychopathology, such as eating disorders and suicidal tendencies, in adolescents. Childhood stressors negatively impact adolescent and adult coping responses through psychogenetic alteration. Negative parental influence through emotional and physical abuse establishes stable phenotypic variation in one’s child through effects on intracellular signaling pathways that regulate the epigenetic state and function of specific regions of the genome.

Most contemporary etiological theories attribute bulimia nervosa to the activation, by environmental pressures, of hereditary susceptibilities. Several gene-environment interactions, involving neuroregulatory genes and childhood abuse exposures, are risk factors for development of this disorder. Most recent findings associate bulimia nervosa (when accompanied by borderline personality disorder or suicidality) with hypermethylation of certain GR exon 1C promoter sites. Several recent studies have also associated childhood abuse with increased methylation of different GR gene exon-1 promoter variants. Such processes explain associations between adverse environmental exposures, during early development, and later problems of adjustment.

The combination of low-function variants of the glucocorticoid receptor (GR) polymorphism and exposure to childhood abuse is also significantly more common in women with bulimia nervosa than in women who eat normally and, furthermore, predicts more-pronounced affective symptoms such as impulsivity and suicidality. Even in comparison to patients with anorexia nervosa, those with anorexia purging subtype show higher rates of physical abuse and emotional neglect than healthy controls or anorexia restricting-only subtypes.

Child maltreatment and other adverse childhood experiences, especially when recent and ongoing, affect adolescent, and later adult health. Efforts to intervene and prevent adverse childhood exposures are imperative for positive long-term outcomes. Given the aforementioned facts, it is recommended that Elsa receive treatment for her eating disorder and be immediately removed from all situations involving past or present physical or emotional abuse.
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