**The Impact of Retrospective Childhood Maltreatment on Eating Disorders as Mediated by Food Addiction: A Cross-Sectional Study**

**Rami Bou Khalil 1,2,\*, Ghassan Sleilaty 3, Sami Richa 1, Maude Seneque 2,4, Sylvain Iceta 5,6,7, Rachel Rodgers 4,8, Adrian Alacreu-Crespo 2, Laurent Maimoun 9,10, Patrick Lefebvre 11, Eric Renard 11,12, Philippe Courtet 2,4 and Sebastien Guillaume 2,4**


Received: 3 August 2020; Accepted: 25 September 2020; Published: 28 September 2020

**Abstract:** Background: The current study aimed to test whether food addiction (FA) might mediate the relationship between the presence of a history of childhood maltreatment and eating disorder (ED) symptom severity. Methods: Participants were 231 patients with ED presenting between May 2017 and January 2020 to a daycare treatment facility for assessment and management with mainly the Eating Disorder Inventory-2 (EDI-2), the Child Trauma Questionnaire (CTQ), and the Yale Food Addiction Scale (YFAS 2.0). Results: Participants had a median age of 24 (interquartile range (IQR) 20–33) years and manifested anorexia nervosa (61.47%), bulimia nervosa (16.88%), binge-eating disorders (9.09%), and other types of ED (12.55%). They were grouped into those likely presenting FA (*N* = 154) and those without FA (*N* = 77). The group with FA reported higher scores on all five CTQ subscales, as well as the total score of the EDI-2 (*p* < 0.001). Using mediation analysis; significant indirect pathways between all CTQ subscales and the EDI-2 total score emerged via FA, with the largest indirect effect emerging for physical neglect (standardized effect = 0.208; 95% confidence interval (CI) 0.127–0.29) followed by emotional abuse (standardized effect = 0.183; 95% CI 0.109–0.262). Conclusion: These results are compatible with a model in which certain types of childhood maltreatment, especially physical neglect, may induce, maintain, and/or exacerbate ED symptoms via FA which may guide future treatments.

**Keywords:** eating disorders; food addiction; childhood trauma; maltreatment; physical neglect

#### **1. Introduction**

According to the World Health Organization, "childhood maltreatment is the abuse and neglect that occurs to children under 18 years of age. It includes all types of physical and/or emotional ill-treatment, sexual abuse, neglect, negligence, and commercial or other exploitation, which results in actual or potential harm to the child's health, survival, development, or dignity in the context of a relationship of responsibility, trust, or power" [1]. On the other hand, eating disorders (EDs) are multifactorial mental disorders affecting young individuals and are associated with a mortality rate higher than that of the general population of the same age [2]. The relationship between a history of childhood maltreatment and the later development of an ED is well established, as supported by two major meta-analyses [3,4]. Abused and/or neglected children who have experienced any type of maltreatment (i.e., emotional, sexual, and physical) are at least threefold more likely to develop a future ED [3,4]. Furthermore, a dose–effect relationship between the number of subtypes of childhood trauma experienced and the severity of ED clinical features has been evidenced, suggesting a consistent and partly independent association between these traumatic events and more severe clinical and functional characteristics of ED [5]. While childhood maltreatment may be reported by a high proportion of patients with ED, only a minority of those previously exposed to one or more traumatic events (9–24%) may subsequently present a comorbid post-traumatic stress disorder (PTSD) [6]. Accordingly, beyond the simple comorbidity with PTSD, it is not yet understood how different types of childhood maltreatment impact the clinical presentation of ED, with emotion dysregulation being consistently considered as an important factor mediating this effect [6,7].

In addition to emotion dysregulation, PTSD, and depression as known mediators of ED development in patients who have been exposed to childhood maltreatment, food addiction (FA) may constitute a yet unexplored contributing mediator [6–9]. FA is characterized by poorly controlled intake of preferred foods, which are postulated to act via similar mechanisms as both illicit and licit drugs of abuse in the brain [10]. An increasing amount of evidence of biological and behavioral changes in response to preferred foods (such as brain reward changes, impaired control, genetic susceptibility, substance sensitization and cross-sensitization, and impulsivity) has been sufficiently convincing to conceptualize FA as an addiction disorder [11]. FA has been increasingly considered as an important psychological dimension that leads, in patients with a history of complex trauma, to ED and more specifically binge-eating disorders (BED) and bulimia nervosa (BN) [10]. Despite being a clinical manifestation of addiction to food, as much as 61.5% of patients with anorexia nervosa (AN) of the restrictive type were found to suffer from FA, which translates how much the addictive behavior related to food can be a common pathological dimension to all EDs, as well as a possible accompanying manifestation of other forms of behavioral addiction to fasting, physical exercising, etc. [12].

Although data on the relationships between childhood maltreatment and FA are lacking to date, evidence from clinical studies examining closely related dimensions suggests that such an association might exist. Although not measuring childhood maltreatment per se, in a cohort study of 49,408 female nurse participants, the prevalence of FA increased with the number of lifetime PTSD symptoms, and women with the greatest number of PTSD symptoms reported more than twice the prevalence of FA compared to women with neither PTSD symptoms nor trauma histories. Interestingly, however, in this study, the relationship between FA and PTSD did not differ by trauma type [13]. Furthermore, the co-occurrence of FA symptoms with emotional dysregulation symptoms has led to the suggestion that these might share common characteristics and, potentially, risk factors [14]. In further support of this, when compared to individuals without addictive behaviors, both women with FA and women with substance use presented higher levels of depressive and PTSD symptoms, as well as greater emotion dysregulation [15]. It has been proposed that childhood maltreatment might also be associated with decreased emotional regulation, as well as a greater propensity to and severity of addictive-like behaviors due to structural brain changes (mainly diminished hippocampus volume) [16,17]. Taken together, converging evidence, therefore, seems to exist for an indirect

relationship such that FA might constitute an intervening factor in the cross-link between childhood maltreatment and ED symptom severity.

To our knowledge, no study has yet assessed this proposed indirect pathway in patients with ED. We, therefore, hypothesized that retrospective childhood maltreatment would be indirectly related to ED symptom severity via FA among a transdiagnostic sample of ED patients. In this cross-sectional study design, we aim to establish a conceptual model to further the understanding of how different types of childhood maltreatment might impact ED in order to guide future assessment strategies and treatment development models.
