Early Maladaptive Schemas Mediate the Relationship between Severe Childhood Trauma and Eating Disorder Symptoms

Early Maladaptive Schemas Mediate the Relationship between Severe Childhood Trauma and Eating Disorder Symptoms | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Early Maladaptive Schemas Mediate the Relationship between Severe Childhood Trauma and Eating Disorder Symptoms Rachele Fasolato, Mariangela De Felice, Corrado Barbui, Mariaelena Bertani, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4492860/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Childhood trauma history has frequently been linked to eating disorders (EDs); nevertheless, the scientific literature calls for extending knowledge regarding mediators between EDs and childhood trauma. This study explored whether ED symptoms and early maladaptive schemas were more severe in ED patients with severe childhood trauma than inED patients with no/mild childhood trauma and whether early maladaptive schemas mediated the relationship between childhood trauma and ED symptom severity. Methods: Data were extracted from the Regional Centre for Eating Disorders registry at the University Hospital of Verona. The extracted data includedself-reported data, including the Eating Disorder Inventory-3 score, Young Schema Questionnaire score, Childhood Experience and Experience of Care and Abuse Questionnaire score, and sociodemographic and clinical information on the ED outpatients seeking care. Results: Forty-twooutpatients, 30.9% of whom exhibited severe childhood trauma, satisfied the criteria for registry data extraction. The severity of ED symptoms, as well as the early maladaptive schemas’ scores for emotional deprivation, defectiveness, failure, vulnerability, insufficient self-control, and negativity, were greaterin ED outpatients with severe childhood trauma. Furthermore, early maladaptive schemas related to defectiveness, failure, and negativity had a mediatingrole in the relationship between severe childhood trauma and ED symptom severity. Conclusions: These findings highlightthe importance of early maladaptive schemas in the relationship between trauma history and ED psychopathology. In addition, ED symptoms may represent a dysfunctional attempt to avoid unpleasant emotions associated with schema activation. The results support the need to consider early maladaptive schemas in the treatment of traumatized patients with ED symptoms. Research and clinical implications are discussed. Eating Disorders Childhood Trauma Early Maladaptive Schemas Outpatients Psychopathology Figures Figure 1 Figure 2 Plain English summary Eating disorder psychopathology was found to be related to a history of trauma. Nonetheless, our understanding of the mediators of the relationship between childhood trauma and eating disorders remains to be improved. The current study revealed that certain early maladaptive schemas (i.e., defectiveness, failure, and negativity) mediated the relationship between childhood trauma and eating disorder symptoms and that outpatients who experienced severe childhood trauma reported more severe eating disorder symptoms and greater severity of certain early maladaptive schemas, such as emotional deprivation, defectiveness, failure, vulnerability, insufficient self-control, and negativity. Our findings support the need to consider early maladaptive schemas in the treatment of traumatized patients with eating disorders. Background Eating disorders (EDs) are disabling, fatal, and costly mental disorders that severely affect physical health and disrupt psychosocial functioning [ 1 ]. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition, Text Revision (DSM-5-TR) categorizes eating disorders (EDs) into three broad categories: anorexia nervosa (AN), bulimia nervosa (BN), and Eating Disorders Not Otherwise Specified (EDNOS) [ 2 ]. The ED incidence has increased globally, from 3.5% in 2000–2006 to 7.8% in 2013–2018 [ 3 ]. Since the COVID-19 outbreak, ED rates have continued to rise, as indicated by the increasing incidence of ED diagnoses, primarily in young people [ 4 ]. Moreover, a considerable number of patients persist in having ED symptoms at long-term follow-up, affecting the health and quality of life of patients and their caregivers [ 1 ]. Several studies have reported an increased likelihood of trauma in ED patients [ 5 – 7 ], with a lifetime incidence ranging from 21–67% [ 8 – 9 ]. Specifically, sexual trauma remains the most well-documented symptom in this clinical population, with a lifetime prevalence ranging from 6–64% [ 10 – 12 ]. Furthermore, physical and emotional abuse [ 13 – 14 ], emotional and physical neglect [ 15 – 17 ], teasing, bullying [ 8 , 18 ], and loss [ 8 ] were also reported in ED patients, even though the findings were mixed. Caslini and colleagues (2016) conducted a systematic review and meta-analysis and revealed that emotional abuse and sexual abuse were strongly correlated with BN and binge eating disorder (BED) [ 7 ]. In contrast, physical abuse was linked to any kind of ED. These findings have also been confirmed by subsequent studies [ 15 , 19 ]. It has been observed that in both adult and adolescent populations, the likelihood of ED symptomatology increases with the number of traumatic experiences [ 20 – 22 ]. In particular, a history of multiple traumatic events [ 21 , 23 ] has also been linked to a more severe clinical presentation [ 12 , 24 ]. According to Molendijk and colleagues (2017), there was a greater incidence of childhood abuse among inpatients than among outpatients with EDs. Additionally, ED patients with a history of trauma reported suicidality, an earlier onset age of ED [ 9 ], a greater likelihood of experiencing psychiatric comorbidities [ 9 , 12 ], such as anxiety, depressive symptoms [ 24 , 25 ], and compulsion [ 12 ], and a greater likelihood of treatment dropout [ 10 ]. Furthermore, ED symptoms have been associated with dysfunctional parental bonding, characterized by low care [ 26 ], high parental overprotection [ 27 ], and attachment insecurity [ 28 ]. Within the framework of attachment theory [ 29 ], the quality of early repeated parent–child interactions has a substantial impact on how individuals interact with the world, perceive themselves and others, and regulate emotions [ 30 ], affecting psychosocial development and mental health outcomes [ 31 ]. Therefore, aversive and neglectful repeated parent–child relationships, in which the central attachment figure itself is the source of intense distress, may undermine the perception of the world as a secure place, the possibility of creating trusting relationships with others, and the ability to modulate intense affect, provoking overwhelming emotions that have a traumatic impact on the individual [ 32 ]. Consequently, the presence of multiple traumatic factors, such as childhood abuse and dysfunctional parental bonding, was associated with a greater trauma burden, which had an impact on long-term mental health [ 33 ] as well as ED symptoms [ 28 , 30 ]. As a result, it has been suggested that ED symptoms are a maladaptive mechanism for controlling trauma-related adverse emotions [ 24 , 34 ]. Early negative experiences in the context of attachment bonds are often associated with long-lasting changes in emotional and cognitive processing (i.e., expectancies and beliefs about the self, others and the world) [ 35 ]. As a consequence, during childhood or adolescence, maladaptive cognitive and emotional patterns known as Early Maladaptive Schemas (EMSs) develop as a result of these early adverse events [ 36 , 37 ]. EMSs develop as representations of the early child’s environment; they influence the elaboration of later experiences and persist throughout life, directing actions and social interactions with other people [ 38 ], as well as shaping personality development [ 39 ]. During adulthood, these schemas can be activated by life events perceived as similar to adverse experiences experienced during childhood, and the activation of these schemas is associated with an increase in emotional arousal. Young (2003) described 18 EMSs grouped into five broad domains (see Table 1 ) [ 38 ]. A number of psychiatric conditions, including eating disorders, obsessive-compulsive disorders, psychosis, anxiety, affective disorders, and posttraumatic stress disorder (PTSD), have been connected to EMSs [ 35 ]. Patients with a history of trauma frequently reported EMSs from the domain of disconnection/rejection [ 40 ], such as emotional deprivation, social isolation [ 41 ], mistrust/abuse and defectiveness/shame [ 42 ]. The disconnection/rejection domain also mediates the relationship between childhood trauma and mental disorders such as depression [ 43 ], PTSD [ 44 ] and EDs [ 45 ]. A systematic review revealed that EMS ‘unrelenting standards’ were significant across all ED diagnoses, while EMS ‘insufficient self-control’ was only associated with ED diagnoses characterized by binge eating and purging symptoms [ 46 ]. Moreover, BED severity was linked to emotional deprivation and defectiveness, which are both included in the EMS domain of rejection/disconnection [ 47 ]. Understanding the mediating role of EMSs in the relationship between childhood trauma and ED psychopathology is critical for identifying further factors that need to be clinically considered and enhancing treatments targeted for ED patients with a history of trauma. Nevertheless, this research field is still in its infancy; in fact, to the best of our knowledge, the mediating role of the 18 specific EMSs has not been extensively investigated [ 45 , 48 ]. Moreover, a recent systematic review conducted by Rabito-Alcon and colleagues (2021) highlighted the need to extend knowledge regarding mediators between ED and childhood trauma [ 49 ]. Considering that multiple traumatic experiences have shown a cumulative effect on the severity of the clinical presentation [ 21 , 23 ], the objectives of the current study were to (1) compare the Eating Disorder (ED) symptom severity (assessed during the first admission to the Regional Centre for Eating Disorders) and early maladaptive schema (EMS) scores of patients with severe childhood trauma to those with no/mild childhood trauma. As mentioned above, trauma burden increases when a person experiences multiple traumatic factors; as a consequence, in the present study, severe childhood trauma was defined as having experienced both childhood abuse and dysfunctional parental bonding, whereas no/mild childhood trauma was characterized by having experienced childhood abuse or dysfunctional parental bonding or neither of them; and (2) the mediating role of 18 EMSs on the relationship between childhood trauma and ED symptom severity (measured during the first admission to the Regional Centre for Eating Disorders) was investigated. According to the literature [ 21 , 41 , 45 , 50 ], we hypothesized that severe childhood trauma is linked to more severe ED symptomatology and higher EMS scores. Additionally, we hypothesized that the burden of childhood trauma may indirectly influence the severity of ED symptoms through EMSs, particularly those associated with the disconnection/rejection domain. Table 1 Description of Early Maladaptive Schemas and Schema Domains Schema Domain Description of the domain Early Maladaptive Schema (EMS) Disconnection/Rejection The belief that one's needs for security, nurturance and empathy will not be satisfied Abandonment Mistrust/Abuse Emotional Deprivation Defectiveness/Shame Social Isolation Impaired autonomy/performance The belief that one's ability to survive and cope autonomously or perform successfully is impaired Dependence Vulnerability Enmeshment Failure Impaired limits Difficulties in controlling impulses, obeying rules, and practicing goal-directed behaviors Entitlement Insufficient Self-Control Other-directedness The needs, desires and responses of other people are overvalued and considered instead of their own needs Subjugation Self-Sacrifice Approval-Seeking Overvigilance and inhibition The spontaneous emotions and drives are repressed and displaced by inflexible internalized norms about performance and conduct Negativity Emotional Inhibition Unrelenting Standards Punitiveness Methods Study design and participants The current research is an observational retrospective study. The data were extracted from the Regional Centre for Eating Disorders (ED) registry at the University Hospital of Verona, which has stored sociodemographic and clinical information on all outpatients seeking care since 2014 and was routinely gathered during the first admission to the Regional Centre. For the current study, we extracted data on outpatients who were admitted to the Regional Centre between 2014 and 2016 using the following criteria: 1) clinical diagnosis of anorexia nervosa (AN), bulimia nervosa (BN) or eating disorders not otherwise specified (EDNOS) according to the DSM-5 criteria; 2) absence of significant psychiatric comorbidity, based on clinical assessment; and 3) completion of self-report questionnaires described in section ‘Measures’. The following types of information were also extracted from the registry: sociodemographic data, including sex, age, education level, and marital status, and clinical data, such as height, weight, and body mass index. The study was conducted in compliance with the Declaration of Helsinki and was approved by the local Ethics Committee (CESC Protocol number 48455 of 8 August 2022). Measures The Eating Disorder Inventory (EDI-3) [ 51 – 52 ] is a standardized questionnaire that evaluates current symptoms and psychological characteristics associated with EDs. It consists of 91 items categorized into three subscales of eating disorder symptoms and nine general psychological subscales, which are relevant but not specific to EDs. The Eating Disorder Risk Composite (EDRC) is obtained by combining the scores from three subscales of ED symptoms (i.e., Drive for Thinness, Bulimia, and Body Dissatisfaction). Regarding psychometric properties, Clausen and colleagues (2011) reported satisfactory internal consistency of the questionnaire (Cronbach’s alpha values ranging from 0.75 to 0.92 for ED patients and from 0.59 to 0.93 for normal controls) [ 53 ]. The Young Schema Questionnaire (YSQ) [ 54 – 55 ] is a standardized self-report questionnaire consisting of 232 items. These items are organized into 18 clusters, each representing an early maladaptive schema (EMS). These schemas are further categorized into 5 areas: (1) disconnection/rejection; (2) impaired autonomy/performance; (3) impaired limits; (4) other-directedness; and (5) overvigilance/inhibition (see Table 1 ). Saggino and colleagues (2018) discovered that the Italian version of the instrument demonstrated strong internal consistency. Specifically, Cronbach's alpha values ranged from 0.80 to 0.92 for clinical samples and from 0.83 to 0.94 for nonclinical samples [ 55 ]. The Childhood Experience of Care and Abuse Questionnaire (CECA-Q) [ 56 – 57 ] is a self-administered questionnaire designed to retrospectively assess whether individuals experienced severe adversity during the first 17 years of life. The instrument is composed of two sections. The first section consists of two sets of 16 items that evaluate individuals’ perceptions of aversion and neglect from both mothers and fathers. A score higher than 25 indicates a severe level of perceived aversion, whereas a score higher than 22 (for the mother) or 24 (for the father) indicates a severe level of perceived neglect [ 56 ]. The second part is composed of screening questions pertaining to physical and sexual abuse. The presence of physical and sexual abuse was evaluated with dichotomic responses (yes/no). By combining the results obtained from both sections, the following variables are generated: 1) abuse: the individual has experienced at least one kind of abuse (i.e., either sexual or physical abuse); 2) problematic parental bonding: the individual has experienced neglect or aversion from at least one parent. The Italian version of the instrument demonstrated interrater reliability (Cohen's k) ranging from 0.66 to 1.00 and had high construct validity [ 57 ]. Statistical analysis Participants were categorized into two groups based on their burden of childhood trauma, according to the CECA-Q criteria outlined by Bifulco and colleagues (2005) (see section ‘Measures’): the first group, referred to as 'High Trauma' (HT), comprised outpatients with severe childhood trauma (i.e., both abuse and problematic parental bonding). In contrast, the second group, named 'Low Trauma' (LT), consisted of outpatients with no/mild childhood trauma (i.e., either no abuse or no problematic parental bonding, or only one of these factors). To examine differences between the HT and LT groups in terms of sociodemographic and clinical continuous variables, a t test was utilized. A chi-square test was conducted to assess the relationships between categorical variables. A bivariate correlation using Pearson's coefficient was computed to investigate the relationships between continuous variables. The tests were two-tailed, with a significance threshold set at 0.05. No adjustment for multiple testing was implemented due to the exploratory nature of the study. SPSS 27 was utilized to perform descriptive statistics and statistical tests. A mediation analysis was conducted using the structural equation modeling procedure with bootstrapping sampling (5,000 replications) in Stata 17. The dependent variable was the EDI-3-EDRC (i.e., the severity of ED symptoms, measured during the first admission to the Regional Centre for Eating Disorders), the independent variable was childhood trauma experienced before the age of 17, and each of the 18 YSQ EMSs (i.e., long-lasting maladaptive cognitive and emotional patterns that emerge following negative childhood events) was considered a mediator. The threshold for statistical significance in the mediation models was established at 0.05. Results Forty-two outpatients satisfied the abovementioned criteria (see section ‘Study design and participants’) for the registry data extraction, providing data suitable for the present analysis. Within the sample analysed, the percentage of females was 95.2%. The mean age was 25 years. Fifteen patients had a diagnosis of AN, 10 patients satisfied the criteria for a diagnosis of BN, and 17 patients were diagnosed with EDNOS. The mean body mass index (BMI) was 20 kg/m2, with a range from 16 to 33 kg/m2. Considering the severity of childhood traumatic experiences, 13 individuals (30.9%) exhibited severe childhood trauma and were classified as part of the HT group, while the remaining 29 participants were classified into the LT group. HT patients were older than LT patients were (32.7 (SD = 11.4) vs 21.5 (SD = 7.3), respectively). The HT group had a significantly greater severity of ED symptoms, as shown by the Eating Disorder Risk Composite (EDRC) mean score (p = 0.017). With respect to YSQ scores, the HT group had a general upwards trend in comparison to the LT group, with scores for emotional deprivation (p = 0.045), defectiveness (p = 0.005), failure (p = 0.020), vulnerability (p = 0.049), insufficient self-control (p = 0.026), and negativity (p = 0.027) attaining statistical significance. Tables 2 and 3 present sociodemographic and clinical data according to the burden of childhood trauma. Table 2 Sociodemographic data according to the burden of childhood trauma Sociodemographic variables LT – Low Trauma N = 29 HT – High Trauma N = 13 p Value Gender Female 27 (67.5%) 13 (100.0%) 0.332 Male 2 (6.9%) 0 (0.0%) Age mean (SD) 21.5 (7.3) 32.7 (11.4) < 0.001** Educational level High 13 (46.4%) 8 (66.7%) 0.204 Low 15 (53.6%) 4 (33.3%) Marital status Single 27 (93.1%) 9 (69.2%) Married 2 (6.9%) 2 (15.4%) 0.057 Separated 0 (0.0%) 2 (15.4%) SD = standard deviation; p value (significance associated with t test); * α ≤ 0.05; ** α ≤ 0.01 Table 3 Clinical data according to the burden of childhood trauma Clinical variables LT – Low Trauma N = 29 HT – High Trauma N = 13 p Value ED diagnosis AN 11 (37.9%) 4 (30.8%) 0.868 BN 7 (24.1%) 3 (23.1%) EDNOS 11 (37.9%) 6 (46.2%) BMI mean (SD) 19.3 (3.1) 21.7(5.7) 0.086 YSQ mean (SD) Emotional deprivation 1.31 (1.85) 3.00 (3.43) 0.045* Abandonment 5.06 (3.84) 7.53 (4.41) 0.073 Abuse 3.13 (2.91) 3.76 (3.26) 0.535 Social isolation 3.20 (2.69) 4.76 (3.51) 0.122 Defectiveness 3.34 (3.93) 7.38 (4.27) 0.005** Failure 2.21 (2.69) 4.46 (3.01) 0.020* Dependence 2.17 (2.92) 4.31 (3.83) 0.054 Vulnerability 1.51 (2.36) 3.38 (3.47) 0.049* Enmeshment 1.58 (1.88) 0.76 (1.16) 0.157 Subjugation 2.64 (3.43) 3.76 (3.58) 0.341 Self-sacrifice 6.17 (5.19) 6.23 (5.62) 0.974 Emotional inhibition 2.48 (2.13) 3.38 (2.78) 0.256 Unrelenting Standard 4.60 (3.42) 4.15 (2.82) 0.680 Entitlement 1.41 (1.88) 2.00 (2.51) 0.406 Insufficient Self-control 2.89 (3.07) 5.46 (3.86) 0.026* Approval-seeking 3.62 (4.02) 4.23 (3.44) 0.638 Negativity 3.13 (3.18) 5.61 (3.33) 0.027* Punitiveness 3.31 (3.29) 4.92 (3.54) 0.160 EDI-3 EDRC mean score (SD) 57.2 (20.2) 73.1 (16.5) 0.017* ED = Eating Disorder; AN = Anorexia Nervosa; BN = Bulimia Nervosa; EDNOS = Eating Disorders Not Otherwise Specified; BMI = Body Mass Index; YSQ = Young Schema Questionnaire; EDI-3 = Eating Disorder Inventory-3; EDRC = Eating Disorder Risk Composite; SD = Standard Deviation; p Value (significance associated with t test for continuous variable and with chi-square for categorical variable); * α ≤ 0.05; ** α ≤ 0.01 Mediation analyses Mediation analyses were performed to explore whether EMS played a mediating role in the relationship between childhood trauma and symptoms of ED, as assessed during the first admission to the Regional Centre for Eating Disorders. A statistically significant relationship was found between severe childhood trauma and ED symptoms, as indicated by the estimated overall effect of severe childhood trauma on ED symptoms in terms of EDRC scores (c = 15.90, p = 0.007). When considering each EMS as a mediator, only schemas related to defectiveness, failure, and negativity exhibited a significant effect. Since there was no significant relationship between age and the EDRC score (r = 0.218, p = 0.165), defectiveness (r = 0.004, p = 0.979), failure (r = 0.038, p = 0.809), or negativity (r=-0.022, p = 0.891), no adjustment for age was made. Severe childhood trauma had a significant effect on defectiveness (a = 4.04, 95% CI: [1.32, 6.75], p = 0.004). Additionally, defectiveness had a significant effect on symptoms of eating disorders (b = 1.49, 95% CI: [0.28, 2.70], p = 0.016). After adjusting for defectiveness, the direct effect of severe childhood trauma on symptoms of eating disorders was lower but not statistically significant compared to the overall effect (c1 = 9.88; 95% CI: [-2.09, 21.86], p = 0.106). Severe childhood trauma had a significant indirect effect on eating disorder symptoms through defectiveness, with a coefficient of 6.02 (95% CI: [-0.17, 12.21], p = 0.057). The defectiveness accounted for 37.9% of the total effect. The effect of severe childhood trauma on failure had a coefficient of 2.25 (95% CI: [0.40, 4.11], p = 0.017), whereas the coefficient for the effect of failure on symptoms related to eating disorders was 2.59 (95% CI: [0.86, 4.33], p = 0.003). After adjusting for failure, the direct effect of severe childhood trauma on ED symptoms decreased, but the difference was not statistically significant (c1 = 10.05; 95% CI: [-1.98, 22.09], p = 0.101). The indirect effect of severe childhood trauma on ED symptoms through failure was 5.85 (95% CI: [-0.02, 11.72], p = 0.051), and the percentage of the total effect mediated by failure was 36.8%. The coefficient for the effect of severe childhood trauma on negativity was 2.48 (95% CI: [0.36, 4.60], p = 0.022), while that for the effect of negativity on symptoms of eating disorders was 1.83 (95% CI: [0.33, 3.32], p = 0.017). Severe childhood trauma had a direct effect on symptoms of EDs, even after adjusting for negativity. The estimated coefficient for this direct effect was 11.38 (95% CI: [-0.13, 22.89], p = 0.053). Additionally, an indirect effect of severe childhood trauma on eating disorder symptoms was found through negativity. The estimated coefficient for this indirect effect was 4.52 (95% CI: [-1.05, 10.10], p = 0.112). The percentage of the total effect that was mediated by negativity was 28.4%. Figures 1 represents the three mediation models. Figure 1 . Childhood Trauma measured as a categorical variable (High Trauma vs Low Trauma) = independent variable; EDI-3 EDRC score = dependent variable; YSQ defectiveness score, YSQ failure score, and YSQ negativity score = mediators; YSQ = Young Schema Questionnaire; EDI-3 = Eating Disorder Inventory-3; EDRC = Eating Disorder Risk Composite; a = coefficient relating the independent variable to the mediator; b = coefficient relating the mediator to the dependent variable adjusted for the independent variable; c = coefficient relating the independent variable to the dependent variable; c 1 = coefficient relating the independent variable to the dependent variable adjusted for the mediator. Mediation analysis with multiple mediators The inclusion of defectiveness, failure, and negativity as multiple mediators resulted in a decrease in the direct effect of severe childhood trauma on symptoms of eating disorders. However, this decrease was not statistically significant (c1 = 8.64; 95% CI: [-3.83, 21.11], p = 0.174). Through all three mediators, the indirect impact of severe childhood trauma on ED symptoms was 7.26 (95% CI: [-0.47, 14.06], p = 0.036); through defectiveness, failure, and negativity, it was 1.94, 4.23, and 1.07, respectively. Overall, 45.7% of the effect was mediated by all three mediators combined. When examining each mediator individually, the percentages of the overall effect that was mediated by defectiveness, failure, and negativity were 12.2%, 26.6%, and 6.72%, respectively. Figure 2 graphically represents a mediation model with multiple mediators, as shown below (Fig. 2 ). Discussion The main objective of the present work was to investigate the mediating role of EMSs in the association between childhood trauma and ED symptom severity. EMSs have been shown to play a mediating role in the association between psychopathology and trauma history [ 43 , 44 ]. These results in the field of ED are still preliminary. The current research partially corroborated the findings of Meneguzzo and colleagues (2021), who discovered a mediating effect of the disconnection/rejection domain [ 45 ]. Our findings showed that the degree of defectiveness (i.e., belief about oneself as defective and unlovable), failure (i.e., belief about oneself as incapable of achieving goals), and negativity (i.e., negative beliefs about life, minimizing positive aspects) mediated the relationship between childhood trauma and the severity of ED symptoms. Furthermore, our results showed that patients with severe childhood trauma reported greater severity of ED symptoms during the first admission to the Regional Centre. This finding is in line with previous literature, which has already highlighted a positive association between a more severe clinical presentation of ED psychopathology and a history of multiple traumatic experiences [ 21 , 23 ]. According to several authors [ 24 , 34 ], in traumatized individuals, ED symptoms are considered a maladaptive coping mechanism for managing PTSD symptoms. Therefore, patients who experienced childhood abuse against the backdrop of dysfunctional parental bonding may be more engaged in ED behaviors such as dietary restriction, binge eating, and purging to manage adverse emotions and intrusive memories related to trauma. This could explain the greater severity of ED symptoms in these patients. Additionally, compared to ED patients with no/mild childhood trauma, ED patients with severe childhood trauma generally exhibited significantly greater EMS scores for emotional deprivation, defectiveness, failure, vulnerability, insufficient self-control, and negativity. According to Young's (2003) definition of EMSs—persistent cognitive and emotional patterns derived from early adverse life experiences—these findings supported the link between EMSs and trauma history [ 35 , 38 ]. Emotional deprivation and defectiveness refer to the domain of disconnection/rejection, whereas vulnerability and failure refer to the domain of impaired autonomy/performance. These two domains were found to be prevalent in our data, which is consistent with the findings of a recent systematic review conducted by Lian and colleagues (2023) [ 40 ]. Insufficient self-control and negativity refer to the domains of impaired limits (i.e., difficulty in controlling impulses, engaging in goal-directed behaviour, and following rules) and overvigilance/inhibition (i.e., tendency to suppress feelings, impulses, and choices), respectively. Although these two EMSs have been reported less frequently in trauma patients, our data suggest that they are associated with severe childhood trauma. This link may be explained by the fact that the whole study sample was characterized by an ED diagnosis. In fact, a range of temperaments and self-regulation profiles, such as the overcontrolled/inhibited subtype and the undercontrolled/dysregulated subtype, have been observed in the ED field [ 58 ]. We hypothesized that severe childhood trauma could maximize engagement in these dysfunctional self-regulation patterns. According to Pugh (2015), EMSs may influence several aspects of ED pathology, including risk behaviors, comorbidities, emotion dysregulation, and the severity of the ED [ 59 ]. Furthermore, prior research has shown that ED behaviors, such as purging, dietary restriction, and overexercise, play a role in the avoidance of negative emotions linked to schema activation [ 59 – 60 ]. Within this framework, severe childhood trauma fosters the development of dysfunctional cognitive and emotional patterns - Early Maladaptive Schemas - that lead individuals to perceive life as negative and themselves as unlovable, defective, and failed. As a consequence, a greater severity of ED symptoms, which is indicative of greater cognitive and behavioural engagement in restrictive and/or binge-eating patterns, may represent a more dysfunctional attempt to avoid unpleasant emotions associated with this schema activation. A strength of this study concerns the systematic collection of data regarding all outpatients who were admitted to the Regional Centre for Eating Disorders. Moreover, internationally well-validated tools were used to assess clinical variables (i.e., ED symptomatology, trauma history, and EMSs). Nevertheless, the current study also has several limitations. First, the sample size was small. This aspect allows only an explorative approach to the data analysis, and it was not possible to conduct subgroup analyses. Moreover, no information about trauma in adulthood was collected; thus, it was not possible to account for these events. Finally, all the data were collected through self-reported instruments, which may have introduced recall and social desirability bias. Hence, prospective longitudinal studies and multimethod assessments could be considered for further research in the field of ED and trauma. Conclusion The current study explores a relatively new field of research and provides preliminary evidence for the potential relevance of EMSs in the relationship between trauma history and ED psychopathology. Furthermore, the association between childhood trauma and ED severity reinforces the need to evaluate the trauma burden in ED patients and treat the trauma component. As a result, some authors have already begun to assess add-on trauma-focused therapy, such as eye movement desensitization and reprocessing (EMDR), to evidence-based treatments for ED (e.g., cognitive‒behavioral therapy) [ 61 – 63 ]. In addition, our findings emphasize the importance of taking EMSs into account when treating ED patients who have a history of childhood trauma. EMSs represent a transdiagnostic concept that is relevant for the comprehension of dysfunctional and pervasive changes in cognitive and emotional processing that sustain the symptoms of mental disorders. To modify and reduce these EMSs, schema therapy was introduced. It has been shown that schema therapy is an effective treatment for conditions other than personality disorders [ 35 ]. Therefore, few recent studies have applied schema therapy for the treatment of ED symptomatology, and promising results have been reported [ 59 , 64 – 65 ]. Further research on the application of schema therapy in the ED field is needed to better understand the role of EMSs in ED pathology and to improve the treatment response in ED patients who do not receive any advantage from first-line treatments. Future longitudinal studies with larger sample sizes will be necessary to confirm these data. Abbreviations EDs Eating Disorders EMSs Early Maladaptive Schemas DSM-5-TR Diagnostic and Statistical Manual of Mental Disorders, fifth edition, Text Revision AN Anorexia Nervosa BN Bulimia Nervosa EDNOS Eating Disorders Not Otherwise Specified BED Binge Eating Disorder PTSD posttraumatic stress disorder EDI-3 Eating Disorder Inventory-3 YSQ Young Schema Questionnaire EDRC Eating Disorder Risk Composite CECA-Q Childhood Experience of Care and Abuse Questionnaire HT-High Trauma LT low-trauma BMI Body mass index EMDR Eye Movement Desensitization and Reprocessing Declarations Ethics approval and consent to participate The study involving human participants was conducted in accordance with the ethical standards of the institutional and national research committee, as well as the Declaration of Helsinki (1964) and its later amendments, or equivalent ethical standards. The data were extracted from the Regional Centre for Eating Disorders (ED) registry (University Hospital of Verona), which was approved by by the Verona University Hospital Ethics Committee (CESC Protocol number 48455 of 8 August 2022). All participants provided their written consent to have their data recorded in the Regional Centre for Eating Disorders (ED) registry. Consent for publication Not Applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding No funding was received for this study. Author contributions RBD, MDF, MR and C Bonetto conceptualized the study. MB, FB, MC, SC, and BS supervised the data collection. DC contributed to the data extraction. C Bonetto analysed the data. RF drafted the manuscript. RF, C Bonetto and C Barbui contributed to the revision and editing of the final manuscript. All authors critically reviewed and approved the final draft of the manuscript. Acknowledgements Not applicable. Author details 1 Section of Psychiatry, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy 2 UOC Psichiatria, Azienda Ospedaliera Universitaria Integrata (AOUI) di Verona, Verona, Italy References van Hoeken D, Hoek HW. Review of the burden of eating disorders: mortality, disability, costs, quality of life, and family burden. Curr Opin Psychiatry. 2020;33(6):521-27; doi: 10.1097/YCO.0000000000000641 American Psychiatric Association. Diagnostic and statistical manual of mental disorder, fifth edition, Text Revision (DSM-5 TR). 2022 Galmiche M, Déchelotte P, Lambert G, Tavolacci MP. Prevalence of eating disorders over the 2000–2018 period: a systematic literature review. Am J Clin Nutr. 2019;109(5):1402-13; doi: 10.1093/ajcn/nqy342 Taquet M, Geddes JR, Luciano S, Harrison PJ. Incidence and outcomes of eating disorders during the COVID-19 pandemic. Br J Psychiatry. 2022; 220(5):262-64; doi: 10.1192/bjp.2021.105 Rienecke RD, Johnson C, Le Grange D, Manwaring J, Mehler PS, Duffy A, et al. Adverse childhood experiences among adults with eating disorders: Comparison to a nationally representative sample and identification of trauma profiles. J Eat Disord. 2022;10(1):72; doi: 10.1186/s40337-022-00594-x Trottier K, MacDonald DE. Update on psychological trauma, other severe adverse experiences and eating disorders: state of the research and future research directions. Curr Psychiatry Rep. 2017;19:1-9; doi: 10.1007/s11920-017-0806-6 Caslini M, Bartoli F, Crocamo C, Dakanalis A, Clerici M, Carrà G. Disentangling the association between child abuse and eating disorders: a systematic review and meta-analysis. Psychosom Med. 2016;78(1):79-90; doi: 10.1097/PSY.0000000000000233 Kjaersdam Telléus G, Lauritsen MB, Rodrigo-Domingo M. Prevalence of various traumatic events including sexual trauma in a clinical sample of patients with an eating disorder. Front psychol. 2021;12:687452; doi: 10.3389/fpsyg.2021.687452 Molendijk ML, Hoek HW, Brewerton TD, Elzinga BM. Childhood maltreatment and eating disorder pathology: a systematic review and dose‒response meta-analysis. Psychol Med. 2017;47(8):1402-16; doi: 10.1017/S0033291716003561 Convertino AD, Morland LA, Blashill AJ. Trauma exposure and eating disorders: Results from a United States nationally representative sample. Int J Eat Disord. 2022;55(8):1079-89; doi: 10.1002/eat.23757 Madowitz J, Matheson BE, Liang J. The relationship between eating disorders and sexual trauma. Eat Weight Disord. 2015;20:281-93; doi: 10.1007/s40519-015-0195-y Backholm K, Isomaa R, Birgegård A. The prevalence and impact of trauma history in eating disorder patients. Eur J Psychotraumatol. 2013;4(1):22482; doi: 10.3402/ejpt.v4i0.22482 Afifi TO, Sareen J, Fortier J, Taillieu T, Turner S, Cheung K, et al. Child maltreatment and eating disorders among men and women in adulthood: Results from a nationally representative United States sample. Int J Eat Disord. 2017;50(11):1281-96; doi: 10.1002/eat.22783 Fischer S, Stojek M, Hartzell E. Effects of multiple forms of childhood abuse and adult sexual assault on current eating disorder symptoms. Eat Behav. 2010;11(3):190-92; doi: 10.1016/j.eatbeh.2010.01.001 Kimber M, McTavish JR, Couturier J, Boven A, Gill S, Dimitropoulos et al. Consequences of child emotional abuse, emotional neglect and exposure to intimate partner violence for eating disorders: a systematic critical review. BMC Psychol. 2017;5:1-18; doi: 10.1186/s40359-017-0202-3 Piacentino D, Loriedo C, Biondi M, Girardi P, Vanderlinden J, Pignatelli AM. Emotional neglect as the colossus among traumas in patients with eating disorders. A case‒control study. Eur Psychiatry. 2016;33(S1):S165-S165; doi: 10.1016/j.eurpsy.2016.01.331 Pignatelli AM, Wampers M, Loriedo C, Biondi M, Vanderlinden J. Childhood neglect in eating disorders: A systematic review and meta-analysis. J Trauma Dissociatio. 2017;18(1):100-15; doi: 10.1080/15299732.2016.1198951 Lie SØ, Rø Ø, Bang L. Is bullying and teasing associated with eating disorders? A systematic review and meta‐analysis. Int J Eat Disord. 2019;52(5):497-514; doi: 10.1002/eat.23035 Friedman JK, Yoon CY, Tavernier RE, Mason SM, Neumark-Sztainer D. Associations of childhood maltreatment with binge eating and binge drinking in emerging adult women. Prev Med Rep. 2023;33:102217; doi: 10.1016/j.pmedr.2023.102217 Vidaña AG, Forbush KT, Barnhart EL, Chana SM, Chapa DA, Richson B, Thomeczek ML. Impact of trauma in childhood and adulthood on eating-disorder symptoms. Eat Behav. 2020;39:101426; doi: 10.1016/j.eatbeh.2020.101426 Groth T, Hilsenroth M, Boccio D, Gold J. Relationship between trauma history and eating disorders in adolescents. J Child Adolesc Trauma. 2020;13:443-53; doi: 10.1007/s40653-019-00275-z Guillaume S, Jaussent I, Maïmoun L, Ryst A, Seneque M, Villain L, et al. Associations between adverse childhood experiences and clinical characteristics of eating disorders. Sci Rep, 2016;6(1):35761; doi: 10.1038/srep35761 Messman-Moore TL, Garrigus AS. The association of child abuse and eating disorder symptomatology: The importance of multiple forms of abuse and revictimization. J Aggression Maltreat Trauma. 2007;14(3):51-72; doi: 10.1300/J146v14n03_04 Hambleton A, Pepin G, Le A, Maloney D, Touyz S, Maguire S. Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. J Eat Disord. 2022;10(1):132; doi: 10.1186/s40337-022-00654-2 Scharff A, Ortiz SN, Forrest LN, Smith AR. Comparing the clinical presentation of eating disorder patients with and without trauma history and/or comorbid PTSD. Eat Disord. 2021;29(1):88-102; doi: 10.1080/10640266.2019.1642035 Grenon R, Tasca GA, Maxwell H, Balfour L, Proulx G, Bissada H. Parental bonds and body dissatisfaction in a clinical sample: The mediating roles of attachment anxiety and media internalization. Body Image. 2016;19:49-56; doi: 10.1016/j.bodyim.2016.08.005 Tetley A, Moghaddam NG, Dawson DL, Rennoldson M. Parental bonding and eating disorders: A systematic review. Eat Behav. 2014;15(1):49-59; doi: 10.1016/j.eatbeh.2013.10.008 Tasca GA. Attachment and eating disorders: a research update. Curr Opin Psychol. 2019;25: 59-64; doi: 10.1016/j.copsyc.2018.03.003 Bowlby J. Attachment and Loss, Vol. 1: Attachment. New York: Basic Books; 1969 Tasca GA, Balfour L. Attachment and eating disorders: A review of current research. Int J Eat Disord. 2014;47(7):710-17; doi: 10.1002/eat.22302 Wolfe DA, McIsaac C. Distinguishing between poor/dysfunctional parenting and child emotional maltreatment. Child Abuse Negl, 2011;35(10):802-13; doi: 10.1016/j.chiabu.2010.12.009 Lahousen T, Unterrainer HF, Kapfhammer HP. Psychobiology of attachment and trauma—some general remarks from a clinical perspective. Front Psychiatry. 2019;10:914; doi: 10.3389/fpsyt.2019.00914 Chartier MJ, Walker JR, Naimark B. Separate and cumulative effects of adverse childhood experiences in predicting adult health and health care utilization. Child Abuse Negl. 2010;34(6):454-64; doi: 10.1016/j.chiabu.2009.09.020 Mitchell KS, Scioli ER, Galovski T, Belfer PL, Cooper Z. Posttraumatic stress disorder and eating disorders: maintaining mechanisms and treatment targets. Eat Disord. 2021;29(3):292-306; doi: 10.1080/10640266.2020.1869369 Bär A, Bär HE, Rijkeboer MM, Lobbestael J. Early Maladaptive Schemas and Schema Modes in clinical disorders: A systematic review. Psychol Psychother. 2023;96(3):716-47; doi: 10.1111/papt.12465 Nicol A, Mak AS, Murray K, Walker I, Buckmaster D. The relationships between early maladaptive schemas and youth mental health: A systematic review. Cogn Behav Ther. 2020;44:715-51; doi: 10.1007/s10608-020-10092-6 Costa IF, Tomaz MP, Pessoa GDN, Miranda HDS, Galdino MK. Early maladaptive schemas and harm avoidance as mediating factors between early life stress and psychiatric symptoms in adults. Braz J Psychiatry. 2020;42:489-95; doi: 10.1590/1516-4446-2019-0593 Young JE, Klosko JS, Weishaar ME. Schema therapy. A practitioner’s guide. New York: Guilford; 2003 Basso LA, Fortes AB, Steinhorst E, Wainer R. The effects of parental rearing styles and early maladaptive schemas in the development of personality: a systematic review. Trends Psychiatry Psychother. 2019;41:301-13; doi: 10.1590/2237-6089-2017-0118 Lian AEZ, Chooi WT, Bono SA. A systematic review investigating the early maladaptive schemas (EMS) in Individuals with trauma experiences and PTSD. Eur J Trauma Dissoc. 2023;7(1):100315; doi: 10.1016/j.ejtd.2023.100315 Pilkington PD, Bishop A, Younan R. Adverse childhood experiences and early maladaptive schemas in adulthood: A systematic review and meta‐analysis. Clin Psychol Psychother. 2021;28(3):569-84; doi: 10.1002/cpp.2533 Simpson ESS, Smith E. Schema Therapy for Eating Disorders. London: Routledge; 2019 Rezaei M, Ghazanfari F. The role of childhood trauma, early maladaptive schemas, emotional schemas and experimental avoidance on depression: A structural equation modeling. Psychiatry Res. 2016;246:407-14; doi: 10.1016/j.psychres.2016.10.037 Vasilopoulou E, Karatzias T, Hyland P, Wallace H, Guzman A. The mediating role of early maladaptive schemas in the relationship between childhood traumatic events and complex posttraumatic stress disorder symptoms in older adults (> 64 years). J Loss Trauma. 2020;25(2):141-58; doi: 10.1080/15325024.2019.1661598 Meneguzzo P, Cazzola C, Castegnaro R, Buscaglia F, Bucci E, Pillan A, et al. Associations between trauma, early maladaptive schemas, personality traits, and clinical severity in eating disorder patients: a clinical presentation and mediation analysis. Front Psychol. 2021;12:661924; doi: 10.3389/fpsyg.2021.661924 Maher A, Cason L, Huckstepp T, Stallman H, Kannis‐Dymand L, Millear P, et al. Early maladaptive schemas in eating disorders: A systematic review. Eur Eat Disord Rev. 2022;30(1):3-22; doi: 10.1002/erv.2866 Aloi M, Rania M, Caroleo M, Carbone EA, Fazia G, Calabrò G, et al. How are early maladaptive schemas and DSM‐5 personality traits associated with the severity of binge eating?. J Clin Psychol. 2020;76(3):539-48; doi: 10.1002/jclp.22900 Jenkins PE, Meyer C, Blissett JM. Childhood abuse and eating psychopathology: The mediating role of core beliefs. J Aggression Maltreat Trauma. 2013;22(3):248-61; doi: 10.1080/10926771.2013.741665 Rabito-Alcon MF, Baile JI, Vanderlinden J. Mediating factors between childhood traumatic experiences and eating disorders development: a systematic review. Children. 2021;8(2):114; doi: 10.3390/children8020114 Brewerton TD, Perlman MM, Gavidia I, Suro G, Genet J, Bunnell DW. The association of traumatic events and posttraumatic stress disorder with greater eating disorder and comorbid symptom severity in residential eating disorder treatment centers. Int J Eat Disord. 2020;53(12):2061-66; doi: 10.1002/eat.23401 Garner DM. Eating disorder inventory-3 (EDI-3). Professional manual. Odessa, FL: Psychological Assessment Resources, 1; 2004. Giannini M, Pannocchia L, Dalle Grave R, Muratori F, Viglione V. EDI-3 Eating Disorder Inventory-3: Manuale. Firenze: OS Organizzazioni Speciali; 2008. Clausen L, Rosenvinge JH, Friborg O, Rokkedal K. Validating the Eating Disorder Inventory-3 (EDI-3): A comparison between 561 female eating disorders patients and 878 females from the general population. J Psychopathol Behav Assess. 2011;33:101-110; doi: 10.1007/s10862-010-9207-4 Young JE. Young Schema Questionnaire - Long Form 3 (YSQ-L3). New York: Schema Therapy Institute; 2005 Saggino A, Balsamo M, Carlucci L, Cavalletti V, Sergi MR, Da Fermo G, et al. Psychometric properties of the Italian version of the young schema questionnaire l-3: Preliminary results. Front psychol. 2018;9: 312; doi: 10.3389/fpsyg.2018.00312 Bifulco A, Bernazzani O, Moran PM, Jacobs C. The childhood experience of care and abuse questionnaire (CECA. Q): validation in a community series. Br J Clin Psychol. 2005;44(4):563-81; doi: 10.1348/014466505X35344 Giannone F, Schimmenti A, Caretti V, Chiarenza A, Ferraro A, Guarino S, et al. Validità, attendibilità e proprietà psicometriche della versione italiana dell’intervista CECA (Childhood Experience of Care and Abuse). Psichiatria e Psicoterapia. 2011;30(1):3-21. Turner BJ, Claes L, Wilderjans TF, Pauwels E, Dierckx E, Chapman AL, et al. Personality profiles in eating disorders: Further evidence of the clinical utility of examining subtypes based on temperament. Psychiatry Res. 2014;219(1):157-65; doi: 10.1016/j.psychres.2014.04.036 Pugh M. A narrative review of schemas and schema therapy outcomes in the eating disorders. Clin Psychol Rev. 2015;39:30-41; doi: 10.1016/j.cpr.2015.04.003 Brown JM, Selth S, Stretton A, Simpson S. Do dysfunctional coping modes mediate the relationship between perceived parenting style and disordered eating behaviours?. J Eat Disord. 2016;4:1-10; doi: 10.1186/s40337-016-0123-1 Rossi E, Cassioli E, Cecci L, Arganini F, Martelli M, Redaelli CA, et al. Eye movement desensitization and reprocessing as add‐on treatment to enhanced cognitive behaviour therapy for patients with anorexia nervosa reporting childhood maltreatment: A quasi‐experimental multicenter study. Eur Eat Disord Rev. 2024;32(2):322-37; doi: 10.1002/erv.3044 Ergüney-Okumuş FE. Integrating EMDR with enhanced cognitive behavioral therapy in the treatment of bulimia nervosa: A single case study. J EMDR pract res. 2021;15(4):231-43; doi: 10.1891/EMDR-D-21-00012 Yaşar AB, Abamor AE, Usta FD, Taycan SE, Kaya B. Two cases with avoidant/restrictive food intake disorder (ARFID): Effectiveness of EMDR and CBT combination on eating disorders (ED). Klin Psikiyatri Derg. 2019;22(4); doi: 10.5505/kpd.2019.04127 Joshua PR, Lewis V, Kelty SF, Boer DP. Is schema therapy effective for adults with eating disorders? A systematic review into the evidence. Cogn Behav Ther. 2023;52(3):213-231; doi: 10.1080/16506073.2022.2158926 McIntosh VV, Jordan J, Carter JD, Frampton CM, McKenzie JM, Latner JD, et al. Psychotherapy for transdiagnostic binge eating: A randomized controlled trial of cognitive-behavioural therapy, appetite-focused cognitive-behavioural therapy, and schema therapy. Psychiatry Res. 2016;240:412-20; doi: 10.1016/j.psychres.2016.04.080 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 09 Jun, 2024 Editor assigned by journal 02 Jun, 2024 Submission checks completed at journal 02 Jun, 2024 First submitted to journal 28 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4492860","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":312243545,"identity":"a18946ca-69ef-425c-a269-2f0df4313f17","order_by":0,"name":"Rachele Fasolato","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIie2RsWrDMBCGb3KWK1ovJPgZrgicJcSvIhFIF7V07NAhU7KUzn6MQKFTBwVDu+QBPDqLunjwVDqEtnLI1Nbq2kEfHBziPvSfBBCJ/E8SgGuAwdK3tS/hy/rCsMJ+ohtTvhsuT0rA+aawPZ33KZN16eqWp4CDl32tbg+prC635dkTjPMeZbxbTM4LXvgcRrJ6ZplVV6pE1x+MwCQj5BJy35BKWD9WhreFDSiiSUYH/gQUr47UB+uH4i+F/C3dykgqI71ivSHDtg0qLhve8RyRGsn6XkraNZ1CeHzDX4PNHb3fzFIUF/u6fUtTsTayVXaaHz83wI8UFJ6PRCKRSJAvXapQfyOINcoAAAAASUVORK5CYII=","orcid":"","institution":"University of Verona","correspondingAuthor":true,"prefix":"","firstName":"Rachele","middleName":"","lastName":"Fasolato","suffix":""},{"id":312243546,"identity":"35ae21c6-f71a-4c40-89a4-08ba7a4d711f","order_by":1,"name":"Mariangela De Felice","email":"","orcid":"","institution":"University of Verona","correspondingAuthor":false,"prefix":"","firstName":"Mariangela","middleName":"","lastName":"De Felice","suffix":""},{"id":312243548,"identity":"ec74c4e1-f5ce-4a86-a1ce-255cc4468ebf","order_by":2,"name":"Corrado Barbui","email":"","orcid":"","institution":"University of Verona","correspondingAuthor":false,"prefix":"","firstName":"Corrado","middleName":"","lastName":"Barbui","suffix":""},{"id":312243549,"identity":"5d413f96-45bf-456c-8b27-63a0448768f2","order_by":3,"name":"Mariaelena Bertani","email":"","orcid":"","institution":"UOC Psichiatria, Azienda Ospedaliera Universitaria Integrata (AOUI) di Verona","correspondingAuthor":false,"prefix":"","firstName":"Mariaelena","middleName":"","lastName":"Bertani","suffix":""},{"id":312243550,"identity":"9429e168-a203-4b78-9b6e-abaf4a2b164a","order_by":4,"name":"Federica Bonora","email":"","orcid":"","institution":"University of Verona","correspondingAuthor":false,"prefix":"","firstName":"Federica","middleName":"","lastName":"Bonora","suffix":""},{"id":312243552,"identity":"7429189e-ba36-4ea4-8bd9-2d83d79e67bb","order_by":5,"name":"Mariasole Castellazzi","email":"","orcid":"","institution":"UOC Psichiatria, Azienda Ospedaliera Universitaria Integrata (AOUI) di Verona","correspondingAuthor":false,"prefix":"","firstName":"Mariasole","middleName":"","lastName":"Castellazzi","suffix":""},{"id":312243553,"identity":"77de30c6-5a41-4cc8-b928-34f0f429959f","order_by":6,"name":"Silvia Castelli","email":"","orcid":"","institution":"UOC Psichiatria, Azienda Ospedaliera Universitaria Integrata (AOUI) di Verona","correspondingAuthor":false,"prefix":"","firstName":"Silvia","middleName":"","lastName":"Castelli","suffix":""},{"id":312243554,"identity":"9050c017-50c5-4160-99e2-c3fbc1718e72","order_by":7,"name":"Doriana Cristofalo","email":"","orcid":"","institution":"University of Verona","correspondingAuthor":false,"prefix":"","firstName":"Doriana","middleName":"","lastName":"Cristofalo","suffix":""},{"id":312243555,"identity":"c72fed4c-e9fa-454a-8204-c8b480371231","order_by":8,"name":"Rosa Bruna Dall’Agnola","email":"","orcid":"","institution":"UOC Psichiatria, Azienda Ospedaliera Universitaria Integrata (AOUI) di Verona","correspondingAuthor":false,"prefix":"","firstName":"Rosa","middleName":"Bruna","lastName":"Dall’Agnola","suffix":""},{"id":312243556,"identity":"f3f4e208-36d9-4e8e-b2ae-a0eceb359e6c","order_by":9,"name":"Mirella Ruggeri","email":"","orcid":"","institution":"University of Verona","correspondingAuthor":false,"prefix":"","firstName":"Mirella","middleName":"","lastName":"Ruggeri","suffix":""},{"id":312243557,"identity":"e7ffcbc9-b54e-45e4-b2b0-dbe685106028","order_by":10,"name":"Benedetta Signoretto","email":"","orcid":"","institution":"UOC Psichiatria, Azienda Ospedaliera Universitaria Integrata (AOUI) di Verona","correspondingAuthor":false,"prefix":"","firstName":"Benedetta","middleName":"","lastName":"Signoretto","suffix":""},{"id":312243558,"identity":"b6943a66-c032-4b50-b173-7a529b3c754e","order_by":11,"name":"Chiara Bonetto","email":"","orcid":"","institution":"University of Verona","correspondingAuthor":false,"prefix":"","firstName":"Chiara","middleName":"","lastName":"Bonetto","suffix":""}],"badges":[],"createdAt":"2024-05-28 19:26:41","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4492860/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4492860/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58516193,"identity":"e7d219ca-bcfb-4ee0-bdaf-23e3a824be67","added_by":"auto","created_at":"2024-06-17 16:45:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":39166,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eGraphic representation of mediation analyses\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eChildhood Trauma measured as a categorical variable (High Trauma vs Low Trauma) = independent variable; EDI-3 EDRC score= dependent variable; YSQ defectiveness score, YSQ failure score, and YSQ negativity score= mediators; YSQ= Young Schema Questionnaire; EDI-3= Eating Disorder Inventory-3; EDRC= Eating Disorder Risk Composite; \u003cem\u003ea\u003c/em\u003e= coefficient relating the independent variable to the mediator; \u003cem\u003eb\u003c/em\u003e= coefficient relating the mediator to the dependent variable adjusted for the independent variable; \u003cem\u003ec\u003c/em\u003e=coefficient relating the independent variable to the dependent variable; \u003cem\u003ec\u003c/em\u003e\u003csup\u003e1\u003c/sup\u003e= coefficient relating the independent variable to the dependent variable adjusted for the mediator.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4492860/v1/362f7488b631f5bc5d0854c5.png"},{"id":58517028,"identity":"c1805a91-7968-45bf-b992-6357a44cbf6d","added_by":"auto","created_at":"2024-06-17 16:53:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":29745,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eGraphic representation of mediation analysis with defectiveness, failure and negativity as multiple mediators\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eChildhood Trauma measured as a categorical variable (High Trauma vs Low Trauma) = independent variable; EDI-3 EDRC score= dependent variable; YSQ defectiveness score, YSQ failure score, YSQ negativity score= mediators; YSQ= Young Schema Questionnaire; EDI-3= Eating Disorder Inventory-3; EDRC= Eating Disorder Risk Composite; \u003cem\u003ea\u003c/em\u003e= coefficient relating the independent variable to the mediator; \u003cem\u003eb\u003c/em\u003e= coefficient relating the mediator to the dependent variable adjusted for the independent variable; \u003cem\u003ec\u003c/em\u003e=coefficient relating the independent variable to the dependent variable; \u003cem\u003ec\u003c/em\u003e\u003csup\u003e1\u003c/sup\u003e= coefficient relating the independent variable to the dependent variable adjusted for the three mediators combined.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4492860/v1/26d568baccb3028f24395e08.png"},{"id":58517793,"identity":"cb7404d7-3476-4f49-80bb-00dc95ec7adf","added_by":"auto","created_at":"2024-06-17 17:01:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":727273,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4492860/v1/87985678-17e2-4aaf-8020-62503708d7b3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Early Maladaptive Schemas Mediate the Relationship between Severe Childhood Trauma and Eating Disorder Symptoms","fulltext":[{"header":"Plain English summary","content":"\u003cp\u003eEating disorder psychopathology was found to be related to a history of trauma. Nonetheless, our understanding of the mediators of the relationship between childhood trauma and eating disorders remains to be improved. The current study revealed that certain early maladaptive schemas (i.e., defectiveness, failure, and negativity) mediated the relationship between childhood trauma and eating disorder symptoms and that outpatients who experienced severe childhood trauma reported more severe eating disorder symptoms and greater severity of certain early maladaptive schemas, such as emotional deprivation, defectiveness, failure, vulnerability, insufficient self-control, and negativity. Our findings support the need to consider early maladaptive schemas in the treatment of traumatized patients with eating disorders.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eEating disorders (EDs) are disabling, fatal, and costly mental disorders that severely affect physical health and disrupt psychosocial functioning [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition, Text Revision (DSM-5-TR) categorizes eating disorders (EDs) into three broad categories: anorexia nervosa (AN), bulimia nervosa (BN), and Eating Disorders Not Otherwise Specified (EDNOS) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The ED incidence has increased globally, from 3.5% in 2000\u0026ndash;2006 to 7.8% in 2013\u0026ndash;2018 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Since the COVID-19 outbreak, ED rates have continued to rise, as indicated by the increasing incidence of ED diagnoses, primarily in young people [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Moreover, a considerable number of patients persist in having ED symptoms at long-term follow-up, affecting the health and quality of life of patients and their caregivers [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral studies have reported an increased likelihood of trauma in ED patients [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], with a lifetime incidence ranging from 21\u0026ndash;67% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Specifically, sexual trauma remains the most well-documented symptom in this clinical population, with a lifetime prevalence ranging from 6\u0026ndash;64% [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Furthermore, physical and emotional abuse [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], emotional and physical neglect [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], teasing, bullying [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], and loss [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] were also reported in ED patients, even though the findings were mixed. Caslini and colleagues (2016) conducted a systematic review and meta-analysis and revealed that emotional abuse and sexual abuse were strongly correlated with BN and binge eating disorder (BED) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In contrast, physical abuse was linked to any kind of ED. These findings have also been confirmed by subsequent studies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt has been observed that in both adult and adolescent populations, the likelihood of ED symptomatology increases with the number of traumatic experiences [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In particular, a history of multiple traumatic events [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] has also been linked to a more severe clinical presentation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. According to Molendijk and colleagues (2017), there was a greater incidence of childhood abuse among inpatients than among outpatients with EDs. Additionally, ED patients with a history of trauma reported suicidality, an earlier onset age of ED [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], a greater likelihood of experiencing psychiatric comorbidities [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], such as anxiety, depressive symptoms [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and compulsion [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and a greater likelihood of treatment dropout [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, ED symptoms have been associated with dysfunctional parental bonding, characterized by low care [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], high parental overprotection [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], and attachment insecurity [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Within the framework of attachment theory [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], the quality of early repeated parent\u0026ndash;child interactions has a substantial impact on how individuals interact with the world, perceive themselves and others, and regulate emotions [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], affecting psychosocial development and mental health outcomes [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Therefore, aversive and neglectful repeated parent\u0026ndash;child relationships, in which the central attachment figure itself is the source of intense distress, may undermine the perception of the world as a secure place, the possibility of creating trusting relationships with others, and the ability to modulate intense affect, provoking overwhelming emotions that have a traumatic impact on the individual [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Consequently, the presence of multiple traumatic factors, such as childhood abuse and dysfunctional parental bonding, was associated with a greater trauma burden, which had an impact on long-term mental health [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] as well as ED symptoms [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. As a result, it has been suggested that ED symptoms are a maladaptive mechanism for controlling trauma-related adverse emotions [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEarly negative experiences in the context of attachment bonds are often associated with long-lasting changes in emotional and cognitive processing (i.e., expectancies and beliefs about the self, others and the world) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. As a consequence, during childhood or adolescence, maladaptive cognitive and emotional patterns known as Early Maladaptive Schemas (EMSs) develop as a result of these early adverse events [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. EMSs develop as representations of the early child\u0026rsquo;s environment; they influence the elaboration of later experiences and persist throughout life, directing actions and social interactions with other people [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], as well as shaping personality development [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. During adulthood, these schemas can be activated by life events perceived as similar to adverse experiences experienced during childhood, and the activation of these schemas is associated with an increase in emotional arousal. Young (2003) described 18 EMSs grouped into five broad domains (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. A number of psychiatric conditions, including eating disorders, obsessive-compulsive disorders, psychosis, anxiety, affective disorders, and posttraumatic stress disorder (PTSD), have been connected to EMSs [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Patients with a history of trauma frequently reported EMSs from the domain of disconnection/rejection [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], such as emotional deprivation, social isolation [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], mistrust/abuse and defectiveness/shame [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. The disconnection/rejection domain also mediates the relationship between childhood trauma and mental disorders such as depression [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], PTSD [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] and EDs [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. A systematic review revealed that EMS \u0026lsquo;unrelenting standards\u0026rsquo; were significant across all ED diagnoses, while EMS \u0026lsquo;insufficient self-control\u0026rsquo; was only associated with ED diagnoses characterized by binge eating and purging symptoms [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Moreover, BED severity was linked to emotional deprivation and defectiveness, which are both included in the EMS domain of rejection/disconnection [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Understanding the mediating role of EMSs in the relationship between childhood trauma and ED psychopathology is critical for identifying further factors that need to be clinically considered and enhancing treatments targeted for ED patients with a history of trauma. Nevertheless, this research field is still in its infancy; in fact, to the best of our knowledge, the mediating role of the 18 specific EMSs has not been extensively investigated [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Moreover, a recent systematic review conducted by Rabito-Alcon and colleagues (2021) highlighted the need to extend knowledge regarding mediators between ED and childhood trauma [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConsidering that multiple traumatic experiences have shown a cumulative effect on the severity of the clinical presentation [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], the objectives of the current study were to (1) compare the Eating Disorder (ED) symptom severity (assessed during the first admission to the Regional Centre for Eating Disorders) and early maladaptive schema (EMS) scores of patients with severe childhood trauma to those with no/mild childhood trauma. As mentioned above, trauma burden increases when a person experiences multiple traumatic factors; as a consequence, in the present study, severe childhood trauma was defined as having experienced both childhood abuse and dysfunctional parental bonding, whereas no/mild childhood trauma was characterized by having experienced childhood abuse or dysfunctional parental bonding or neither of them; and (2) the mediating role of 18 EMSs on the relationship between childhood trauma and ED symptom severity (measured during the first admission to the Regional Centre for Eating Disorders) was investigated. According to the literature [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], we hypothesized that severe childhood trauma is linked to more severe ED symptomatology and higher EMS scores. Additionally, we hypothesized that the burden of childhood trauma may indirectly influence the severity of ED symptoms through EMSs, particularly those associated with the disconnection/rejection domain.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDescription of Early Maladaptive Schemas and Schema Domains\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchema Domain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription of the domain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEarly Maladaptive Schema (EMS)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisconnection/Rejection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe belief that one's needs for security, nurturance and empathy will not be satisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbandonment\u003c/p\u003e \u003cp\u003eMistrust/Abuse\u003c/p\u003e \u003cp\u003eEmotional Deprivation\u003c/p\u003e \u003cp\u003eDefectiveness/Shame\u003c/p\u003e \u003cp\u003eSocial Isolation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpaired autonomy/performance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe belief that one's ability to survive and cope autonomously or perform successfully is impaired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDependence\u003c/p\u003e \u003cp\u003eVulnerability\u003c/p\u003e \u003cp\u003eEnmeshment\u003c/p\u003e \u003cp\u003eFailure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpaired limits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDifficulties in controlling impulses, obeying rules, and practicing goal-directed behaviors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEntitlement\u003c/p\u003e \u003cp\u003eInsufficient Self-Control\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther-directedness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe needs, desires and responses of other people are overvalued and considered instead of their own needs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubjugation\u003c/p\u003e \u003cp\u003eSelf-Sacrifice\u003c/p\u003e \u003cp\u003eApproval-Seeking\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOvervigilance and inhibition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe spontaneous emotions and drives are repressed and displaced by inflexible internalized norms about performance and conduct\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegativity\u003c/p\u003e \u003cp\u003eEmotional Inhibition\u003c/p\u003e \u003cp\u003eUnrelenting Standards\u003c/p\u003e \u003cp\u003ePunitiveness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and participants\u003c/h2\u003e \u003cp\u003eThe current research is an observational retrospective study. The data were extracted from the Regional Centre for Eating Disorders (ED) registry at the University Hospital of Verona, which has stored sociodemographic and clinical information on all outpatients seeking care since 2014 and was routinely gathered during the first admission to the Regional Centre. For the current study, we extracted data on outpatients who were admitted to the Regional Centre between 2014 and 2016 using the following criteria: 1) clinical diagnosis of anorexia nervosa (AN), bulimia nervosa (BN) or eating disorders not otherwise specified (EDNOS) according to the DSM-5 criteria; 2) absence of significant psychiatric comorbidity, based on clinical assessment; and 3) completion of self-report questionnaires described in section \u0026lsquo;Measures\u0026rsquo;. The following types of information were also extracted from the registry: sociodemographic data, including sex, age, education level, and marital status, and clinical data, such as height, weight, and body mass index. The study was conducted in compliance with the Declaration of Helsinki and was approved by the local Ethics Committee (CESC Protocol number 48455 of 8 August 2022).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cp\u003eThe \u003cem\u003eEating Disorder Inventory\u003c/em\u003e (EDI-3) [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] is a standardized questionnaire that evaluates current symptoms and psychological characteristics associated with EDs. It consists of 91 items categorized into three subscales of eating disorder symptoms and nine general psychological subscales, which are relevant but not specific to EDs. The Eating Disorder Risk Composite (EDRC) is obtained by combining the scores from three subscales of ED symptoms (i.e., Drive for Thinness, Bulimia, and Body Dissatisfaction). Regarding psychometric properties, Clausen and colleagues (2011) reported satisfactory internal consistency of the questionnaire (Cronbach\u0026rsquo;s alpha values ranging from 0.75 to 0.92 for ED patients and from 0.59 to 0.93 for normal controls) [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe \u003cem\u003eYoung Schema Questionnaire\u003c/em\u003e (YSQ) [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e] is a standardized self-report questionnaire consisting of 232 items. These items are organized into 18 clusters, each representing an early maladaptive schema (EMS). These schemas are further categorized into 5 areas: (1) disconnection/rejection; (2) impaired autonomy/performance; (3) impaired limits; (4) other-directedness; and (5) overvigilance/inhibition (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Saggino and colleagues (2018) discovered that the Italian version of the instrument demonstrated strong internal consistency. Specifically, Cronbach's alpha values ranged from 0.80 to 0.92 for clinical samples and from 0.83 to 0.94 for nonclinical samples [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe \u003cem\u003eChildhood Experience of Care and Abuse Questionnaire\u003c/em\u003e (CECA-Q) [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] is a self-administered questionnaire designed to retrospectively assess whether individuals experienced severe adversity during the first 17 years of life. The instrument is composed of two sections. The first section consists of two sets of 16 items that evaluate individuals\u0026rsquo; perceptions of aversion and neglect from both mothers and fathers. A score higher than 25 indicates a severe level of perceived aversion, whereas a score higher than 22 (for the mother) or 24 (for the father) indicates a severe level of perceived neglect [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. The second part is composed of screening questions pertaining to physical and sexual abuse. The presence of physical and sexual abuse was evaluated with dichotomic responses (yes/no). By combining the results obtained from both sections, the following variables are generated: 1) abuse: the individual has experienced at least one kind of abuse (i.e., either sexual or physical abuse); 2) problematic parental bonding: the individual has experienced neglect or aversion from at least one parent. The Italian version of the instrument demonstrated interrater reliability (Cohen's k) ranging from 0.66 to 1.00 and had high construct validity [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eParticipants were categorized into two groups based on their burden of childhood trauma, according to the CECA-Q criteria outlined by Bifulco and colleagues (2005) (see section \u0026lsquo;Measures\u0026rsquo;): the first group, referred to as 'High Trauma' (HT), comprised outpatients with severe childhood trauma (i.e., both abuse and problematic parental bonding). In contrast, the second group, named 'Low Trauma' (LT), consisted of outpatients with no/mild childhood trauma (i.e., either no abuse or no problematic parental bonding, or only one of these factors). To examine differences between the HT and LT groups in terms of sociodemographic and clinical continuous variables, a t test was utilized. A chi-square test was conducted to assess the relationships between categorical variables. A bivariate correlation using Pearson's coefficient was computed to investigate the relationships between continuous variables. The tests were two-tailed, with a significance threshold set at 0.05. No adjustment for multiple testing was implemented due to the exploratory nature of the study. SPSS 27 was utilized to perform descriptive statistics and statistical tests.\u003c/p\u003e \u003cp\u003eA mediation analysis was conducted using the structural equation modeling procedure with bootstrapping sampling (5,000 replications) in Stata 17. The dependent variable was the EDI-3-EDRC (i.e., the severity of ED symptoms, measured during the first admission to the Regional Centre for Eating Disorders), the independent variable was childhood trauma experienced before the age of 17, and each of the 18 YSQ EMSs (i.e., long-lasting maladaptive cognitive and emotional patterns that emerge following negative childhood events) was considered a mediator. The threshold for statistical significance in the mediation models was established at 0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eForty-two outpatients satisfied the abovementioned criteria (see section \u0026lsquo;Study design and participants\u0026rsquo;) for the registry data extraction, providing data suitable for the present analysis. Within the sample analysed, the percentage of females was 95.2%. The mean age was 25 years. Fifteen patients had a diagnosis of AN, 10 patients satisfied the criteria for a diagnosis of BN, and 17 patients were diagnosed with EDNOS. The mean body mass index (BMI) was 20 kg/m2, with a range from 16 to 33 kg/m2. Considering the severity of childhood traumatic experiences, 13 individuals (30.9%) exhibited severe childhood trauma and were classified as part of the HT group, while the remaining 29 participants were classified into the LT group. HT patients were older than LT patients were (32.7 (SD\u0026thinsp;=\u0026thinsp;11.4) vs 21.5 (SD\u0026thinsp;=\u0026thinsp;7.3), respectively). The HT group had a significantly greater severity of ED symptoms, as shown by the Eating Disorder Risk Composite (EDRC) mean score (p\u0026thinsp;=\u0026thinsp;0.017). With respect to YSQ scores, the HT group had a general upwards trend in comparison to the LT group, with scores for emotional deprivation (p\u0026thinsp;=\u0026thinsp;0.045), defectiveness (p\u0026thinsp;=\u0026thinsp;0.005), failure (p\u0026thinsp;=\u0026thinsp;0.020), vulnerability (p\u0026thinsp;=\u0026thinsp;0.049), insufficient self-control (p\u0026thinsp;=\u0026thinsp;0.026), and negativity (p\u0026thinsp;=\u0026thinsp;0.027) attaining statistical significance. Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e present sociodemographic and clinical data according to the burden of childhood trauma.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eSociodemographic data according to the burden of childhood trauma\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSociodemographic variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLT \u0026ndash; Low Trauma\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;29\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHT \u0026ndash; High Trauma\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;13\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27 (67.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.332\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (6.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21.5 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.7 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13 (46.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.204\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (53.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27 (93.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (69.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (6.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeparated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eSD\u0026thinsp;=\u0026thinsp;standard deviation; p value (significance associated with t test); * α\u0026thinsp;\u0026le;\u0026thinsp;0.05; ** α\u0026thinsp;\u0026le;\u0026thinsp;0.01\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eClinical data according to the burden of childhood trauma\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLT \u0026ndash; Low Trauma\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;29\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHT \u0026ndash; High Trauma\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;13\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eED diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (37.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (30.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.868\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (24.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (23.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEDNOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (37.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (46.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19.3 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.7(5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.086\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYSQ mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional deprivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.31 (1.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.00 (3.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.045*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbandonment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.06 (3.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.53 (4.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbuse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.13 (2.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.76 (3.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.535\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial isolation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.20 (2.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.76 (3.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.122\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDefectiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.34 (3.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.38 (4.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.005**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFailure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.21 (2.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.46 (3.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.020*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDependence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.17 (2.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.31 (3.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVulnerability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.51 (2.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.38 (3.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.049*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnmeshment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.58 (1.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.76 (1.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.157\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubjugation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.64 (3.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.76 (3.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.341\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-sacrifice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.17 (5.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.23 (5.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.974\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional inhibition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.48 (2.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.38 (2.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.256\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnrelenting Standard\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.60 (3.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.15 (2.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.680\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEntitlement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.41 (1.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.00 (2.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.406\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsufficient Self-control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.89 (3.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.46 (3.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.026*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApproval-seeking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.62 (4.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.23 (3.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.638\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegativity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.13 (3.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.61 (3.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.027*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePunitiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.31 (3.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.92 (3.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.160\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEDI-3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEDRC mean score (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57.2 (20.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73.1 (16.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.017*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eED\u0026thinsp;=\u0026thinsp;Eating Disorder; AN\u0026thinsp;=\u0026thinsp;Anorexia Nervosa; BN\u0026thinsp;=\u0026thinsp;Bulimia Nervosa; EDNOS\u0026thinsp;=\u0026thinsp;Eating Disorders Not Otherwise Specified; BMI\u0026thinsp;=\u0026thinsp;Body Mass Index; YSQ\u0026thinsp;=\u0026thinsp;Young Schema Questionnaire; EDI-3\u0026thinsp;=\u0026thinsp;Eating Disorder Inventory-3; EDRC\u0026thinsp;=\u0026thinsp;Eating Disorder Risk Composite; SD\u0026thinsp;=\u0026thinsp;Standard Deviation; \u003cem\u003ep\u003c/em\u003e Value (significance associated with t test for continuous variable and with chi-square for categorical variable); * α\u0026thinsp;\u0026le;\u0026thinsp;0.05; ** α\u0026thinsp;\u0026le;\u0026thinsp;0.01\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eMediation analyses\u003c/h2\u003e \u003cp\u003eMediation analyses were performed to explore whether EMS played a mediating role in the relationship between childhood trauma and symptoms of ED, as assessed during the first admission to the Regional Centre for Eating Disorders. A statistically significant relationship was found between severe childhood trauma and ED symptoms, as indicated by the estimated overall effect of severe childhood trauma on ED symptoms in terms of EDRC scores (c\u0026thinsp;=\u0026thinsp;15.90, p\u0026thinsp;=\u0026thinsp;0.007). When considering each EMS as a mediator, only schemas related to defectiveness, failure, and negativity exhibited a significant effect. Since there was no significant relationship between age and the EDRC score (r\u0026thinsp;=\u0026thinsp;0.218, p\u0026thinsp;=\u0026thinsp;0.165), defectiveness (r\u0026thinsp;=\u0026thinsp;0.004, p\u0026thinsp;=\u0026thinsp;0.979), failure (r\u0026thinsp;=\u0026thinsp;0.038, p\u0026thinsp;=\u0026thinsp;0.809), or negativity (r=-0.022, p\u0026thinsp;=\u0026thinsp;0.891), no adjustment for age was made. Severe childhood trauma had a significant effect on defectiveness (a\u0026thinsp;=\u0026thinsp;4.04, 95% CI: [1.32, 6.75], p\u0026thinsp;=\u0026thinsp;0.004). Additionally, defectiveness had a significant effect on symptoms of eating disorders (b\u0026thinsp;=\u0026thinsp;1.49, 95% CI: [0.28, 2.70], p\u0026thinsp;=\u0026thinsp;0.016). After adjusting for defectiveness, the direct effect of severe childhood trauma on symptoms of eating disorders was lower but not statistically significant compared to the overall effect (c1\u0026thinsp;=\u0026thinsp;9.88; 95% CI: [-2.09, 21.86], p\u0026thinsp;=\u0026thinsp;0.106). Severe childhood trauma had a significant indirect effect on eating disorder symptoms through defectiveness, with a coefficient of 6.02 (95% CI: [-0.17, 12.21], p\u0026thinsp;=\u0026thinsp;0.057). The defectiveness accounted for 37.9% of the total effect.\u003c/p\u003e \u003cp\u003eThe effect of severe childhood trauma on failure had a coefficient of 2.25 (95% CI: [0.40, 4.11], p\u0026thinsp;=\u0026thinsp;0.017), whereas the coefficient for the effect of failure on symptoms related to eating disorders was 2.59 (95% CI: [0.86, 4.33], p\u0026thinsp;=\u0026thinsp;0.003). After adjusting for failure, the direct effect of severe childhood trauma on ED symptoms decreased, but the difference was not statistically significant (c1\u0026thinsp;=\u0026thinsp;10.05; 95% CI: [-1.98, 22.09], p\u0026thinsp;=\u0026thinsp;0.101). The indirect effect of severe childhood trauma on ED symptoms through failure was 5.85 (95% CI: [-0.02, 11.72], p\u0026thinsp;=\u0026thinsp;0.051), and the percentage of the total effect mediated by failure was 36.8%.\u003c/p\u003e \u003cp\u003eThe coefficient for the effect of severe childhood trauma on negativity was 2.48 (95% CI: [0.36, 4.60], p\u0026thinsp;=\u0026thinsp;0.022), while that for the effect of negativity on symptoms of eating disorders was 1.83 (95% CI: [0.33, 3.32], p\u0026thinsp;=\u0026thinsp;0.017). Severe childhood trauma had a direct effect on symptoms of EDs, even after adjusting for negativity. The estimated coefficient for this direct effect was 11.38 (95% CI: [-0.13, 22.89], p\u0026thinsp;=\u0026thinsp;0.053). Additionally, an indirect effect of severe childhood trauma on eating disorder symptoms was found through negativity. The estimated coefficient for this indirect effect was 4.52 (95% CI: [-1.05, 10.10], p\u0026thinsp;=\u0026thinsp;0.112). The percentage of the total effect that was mediated by negativity was 28.4%. Figures\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e represents the three mediation models.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Childhood Trauma measured as a categorical variable (High Trauma vs Low Trauma)\u0026thinsp;=\u0026thinsp;independent variable; EDI-3 EDRC score\u0026thinsp;=\u0026thinsp;dependent variable; YSQ defectiveness score, YSQ failure score, and YSQ negativity score\u0026thinsp;=\u0026thinsp;mediators; YSQ\u0026thinsp;=\u0026thinsp;Young Schema Questionnaire; EDI-3\u0026thinsp;=\u0026thinsp;Eating Disorder Inventory-3; EDRC\u0026thinsp;=\u0026thinsp;Eating Disorder Risk Composite; \u003cem\u003ea\u003c/em\u003e\u0026thinsp;=\u0026thinsp;coefficient relating the independent variable to the mediator; \u003cem\u003eb\u003c/em\u003e\u0026thinsp;=\u0026thinsp;coefficient relating the mediator to the dependent variable adjusted for the independent variable; \u003cem\u003ec\u003c/em\u003e\u0026thinsp;=\u0026thinsp;coefficient relating the independent variable to the dependent variable; \u003cem\u003ec\u003c/em\u003e\u003csup\u003e1\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;coefficient relating the independent variable to the dependent variable adjusted for the mediator.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMediation analysis with multiple mediators\u003c/h2\u003e \u003cp\u003eThe inclusion of defectiveness, failure, and negativity as multiple mediators resulted in a decrease in the direct effect of severe childhood trauma on symptoms of eating disorders. However, this decrease was not statistically significant (c1\u0026thinsp;=\u0026thinsp;8.64; 95% CI: [-3.83, 21.11], p\u0026thinsp;=\u0026thinsp;0.174). Through all three mediators, the indirect impact of severe childhood trauma on ED symptoms was 7.26 (95% CI: [-0.47, 14.06], p\u0026thinsp;=\u0026thinsp;0.036); through defectiveness, failure, and negativity, it was 1.94, 4.23, and 1.07, respectively.\u003c/p\u003e \u003cp\u003eOverall, 45.7% of the effect was mediated by all three mediators combined. When examining each mediator individually, the percentages of the overall effect that was mediated by defectiveness, failure, and negativity were 12.2%, 26.6%, and 6.72%, respectively. Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e graphically represents a mediation model with multiple mediators, as shown below (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe main objective of the present work was to investigate the mediating role of EMSs in the association between childhood trauma and ED symptom severity. EMSs have been shown to play a mediating role in the association between psychopathology and trauma history [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. These results in the field of ED are still preliminary. The current research partially corroborated the findings of Meneguzzo and colleagues (2021), who discovered a mediating effect of the disconnection/rejection domain [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Our findings showed that the degree of defectiveness (i.e., belief about oneself as defective and unlovable), failure (i.e., belief about oneself as incapable of achieving goals), and negativity (i.e., negative beliefs about life, minimizing positive aspects) mediated the relationship between childhood trauma and the severity of ED symptoms.\u003c/p\u003e \u003cp\u003eFurthermore, our results showed that patients with severe childhood trauma reported greater severity of ED symptoms during the first admission to the Regional Centre. This finding is in line with previous literature, which has already highlighted a positive association between a more severe clinical presentation of ED psychopathology and a history of multiple traumatic experiences [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. According to several authors [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], in traumatized individuals, ED symptoms are considered a maladaptive coping mechanism for managing PTSD symptoms. Therefore, patients who experienced childhood abuse against the backdrop of dysfunctional parental bonding may be more engaged in ED behaviors such as dietary restriction, binge eating, and purging to manage adverse emotions and intrusive memories related to trauma. This could explain the greater severity of ED symptoms in these patients. Additionally, compared to ED patients with no/mild childhood trauma, ED patients with severe childhood trauma generally exhibited significantly greater EMS scores for emotional deprivation, defectiveness, failure, vulnerability, insufficient self-control, and negativity. According to Young's (2003) definition of EMSs\u0026mdash;persistent cognitive and emotional patterns derived from early adverse life experiences\u0026mdash;these findings supported the link between EMSs and trauma history [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Emotional deprivation and defectiveness refer to the domain of disconnection/rejection, whereas vulnerability and failure refer to the domain of impaired autonomy/performance. These two domains were found to be prevalent in our data, which is consistent with the findings of a recent systematic review conducted by Lian and colleagues (2023) [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Insufficient self-control and negativity refer to the domains of impaired limits (i.e., difficulty in controlling impulses, engaging in goal-directed behaviour, and following rules) and overvigilance/inhibition (i.e., tendency to suppress feelings, impulses, and choices), respectively. Although these two EMSs have been reported less frequently in trauma patients, our data suggest that they are associated with severe childhood trauma. This link may be explained by the fact that the whole study sample was characterized by an ED diagnosis. In fact, a range of temperaments and self-regulation profiles, such as the overcontrolled/inhibited subtype and the undercontrolled/dysregulated subtype, have been observed in the ED field [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. We hypothesized that severe childhood trauma could maximize engagement in these dysfunctional self-regulation patterns.\u003c/p\u003e \u003cp\u003eAccording to Pugh (2015), EMSs may influence several aspects of ED pathology, including risk behaviors, comorbidities, emotion dysregulation, and the severity of the ED [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Furthermore, prior research has shown that ED behaviors, such as purging, dietary restriction, and overexercise, play a role in the avoidance of negative emotions linked to schema activation [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Within this framework, severe childhood trauma fosters the development of dysfunctional cognitive and emotional patterns - Early Maladaptive Schemas - that lead individuals to perceive life as negative and themselves as unlovable, defective, and failed. As a consequence, a greater severity of ED symptoms, which is indicative of greater cognitive and behavioural engagement in restrictive and/or binge-eating patterns, may represent a more dysfunctional attempt to avoid unpleasant emotions associated with this schema activation.\u003c/p\u003e \u003cp\u003eA strength of this study concerns the systematic collection of data regarding all outpatients who were admitted to the Regional Centre for Eating Disorders. Moreover, internationally well-validated tools were used to assess clinical variables (i.e., ED symptomatology, trauma history, and EMSs). Nevertheless, the current study also has several limitations. First, the sample size was small. This aspect allows only an explorative approach to the data analysis, and it was not possible to conduct subgroup analyses. Moreover, no information about trauma in adulthood was collected; thus, it was not possible to account for these events. Finally, all the data were collected through self-reported instruments, which may have introduced recall and social desirability bias. Hence, prospective longitudinal studies and multimethod assessments could be considered for further research in the field of ED and trauma.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe current study explores a relatively new field of research and provides preliminary evidence for the potential relevance of EMSs in the relationship between trauma history and ED psychopathology. Furthermore, the association between childhood trauma and ED severity reinforces the need to evaluate the trauma burden in ED patients and treat the trauma component. As a result, some authors have already begun to assess add-on trauma-focused therapy, such as eye movement desensitization and reprocessing (EMDR), to evidence-based treatments for ED (e.g., cognitive‒behavioral therapy) [\u003cspan additionalcitationids=\"CR62\" citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. In addition, our findings emphasize the importance of taking EMSs into account when treating ED patients who have a history of childhood trauma. EMSs represent a transdiagnostic concept that is relevant for the comprehension of dysfunctional and pervasive changes in cognitive and emotional processing that sustain the symptoms of mental disorders. To modify and reduce these EMSs, schema therapy was introduced. It has been shown that schema therapy is an effective treatment for conditions other than personality disorders [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Therefore, few recent studies have applied schema therapy for the treatment of ED symptomatology, and promising results have been reported [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurther research on the application of schema therapy in the ED field is needed to better understand the role of EMSs in ED pathology and to improve the treatment response in ED patients who do not receive any advantage from first-line treatments. Future longitudinal studies with larger sample sizes will be necessary to confirm these data.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEDs Eating Disorders\u003c/p\u003e\n\u003cp\u003eEMSs Early Maladaptive Schemas\u003c/p\u003e\n\u003cp\u003eDSM-5-TR Diagnostic and Statistical Manual of Mental Disorders, fifth edition, Text Revision\u003c/p\u003e\n\u003cp\u003eAN Anorexia Nervosa\u003c/p\u003e\n\u003cp\u003eBN Bulimia Nervosa\u003c/p\u003e\n\u003cp\u003eEDNOS Eating Disorders Not Otherwise Specified\u003c/p\u003e\n\u003cp\u003eBED Binge Eating Disorder\u003c/p\u003e\n\u003cp\u003ePTSD posttraumatic stress disorder\u003c/p\u003e\n\u003cp\u003eEDI-3 Eating Disorder Inventory-3\u003c/p\u003e\n\u003cp\u003eYSQ Young Schema Questionnaire\u003c/p\u003e\n\u003cp\u003eEDRC Eating Disorder Risk Composite\u003c/p\u003e\n\u003cp\u003eCECA-Q Childhood Experience of Care and Abuse Questionnaire\u003c/p\u003e\n\u003cp\u003eHT-High Trauma\u003c/p\u003e\n\u003cp\u003eLT low-trauma\u003c/p\u003e\n\u003cp\u003eBMI Body mass index\u003c/p\u003e\n\u003cp\u003eEMDR Eye Movement Desensitization and Reprocessing\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study involving human participants was conducted in accordance with the ethical standards of the institutional and national research committee, as well as the Declaration of Helsinki (1964) and its later amendments, or equivalent ethical standards. The data were extracted from\u0026nbsp;the Regional Centre for Eating Disorders (ED) registry (University Hospital of Verona), which was approved by\u003c/p\u003e\n\u003cp\u003eby the Verona University Hospital Ethics Committee (CESC\u0026nbsp;Protocol number 48455 of 8 August 2022). All participants provided their written consent to have their data recorded in the Regional Centre for Eating Disorders (ED) registry.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author\u0026nbsp;upon\u0026nbsp;reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRBD, MDF, MR and C Bonetto conceptualized the study. MB, FB, MC, SC,\u0026nbsp;and\u0026nbsp;BS supervised\u0026nbsp;the\u0026nbsp;data collection. DC contributed to\u0026nbsp;the\u0026nbsp;data extraction. C Bonetto analysed the data. RF drafted the manuscript. RF, C Bonetto and C Barbui contributed to\u0026nbsp;the revision\u0026nbsp;and\u0026nbsp;editing of\u0026nbsp;the final manuscript. All authors critically reviewed and approved the final draft of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eSection of Psychiatry, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003eUOC Psichiatria, Azienda Ospedaliera Universitaria Integrata (AOUI) di Verona, Verona, Italy\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003evan Hoeken D, Hoek HW. Review of the burden of eating disorders: mortality, disability, costs, quality of life, and family burden. Curr Opin Psychiatry. 2020;33(6):521-27; doi: 10.1097/YCO.0000000000000641\u003c/li\u003e\n \u003cli\u003eAmerican Psychiatric Association. Diagnostic and statistical manual of mental disorder, fifth edition, Text Revision (DSM-5 TR). 2022\u003c/li\u003e\n \u003cli\u003eGalmiche M, D\u0026eacute;chelotte P, Lambert G, Tavolacci MP. Prevalence of eating disorders over the 2000\u0026ndash;2018 period: a systematic literature review. Am J Clin Nutr. 2019;109(5):1402-13; doi: 10.1093/ajcn/nqy342\u003c/li\u003e\n \u003cli\u003eTaquet M, Geddes JR, Luciano S, Harrison PJ. Incidence and outcomes of eating disorders during the COVID-19 pandemic. Br J Psychiatry. 2022; 220(5):262-64; doi: 10.1192/bjp.2021.105\u003c/li\u003e\n \u003cli\u003eRienecke RD, Johnson C, Le Grange D, Manwaring J, Mehler PS, Duffy A, et al. Adverse childhood experiences among adults with eating disorders: Comparison to a nationally representative sample and identification of trauma profiles. J Eat Disord. 2022;10(1):72; doi: 10.1186/s40337-022-00594-x\u003c/li\u003e\n \u003cli\u003eTrottier K, MacDonald DE. Update on psychological trauma, other severe adverse experiences and eating disorders: state of the research and future research directions. Curr Psychiatry Rep. 2017;19:1-9; doi: 10.1007/s11920-017-0806-6\u003c/li\u003e\n \u003cli\u003eCaslini M, Bartoli F, Crocamo C, Dakanalis A, Clerici M, Carr\u0026agrave; G. Disentangling the association between child abuse and eating disorders: a systematic review and meta-analysis. Psychosom Med. 2016;78(1):79-90; doi: 10.1097/PSY.0000000000000233\u003c/li\u003e\n \u003cli\u003eKjaersdam Tell\u0026eacute;us G, Lauritsen MB, Rodrigo-Domingo M. Prevalence of various traumatic events including sexual trauma in a clinical sample of patients with an eating disorder. Front psychol. 2021;12:687452; doi: 10.3389/fpsyg.2021.687452\u003c/li\u003e\n \u003cli\u003eMolendijk ML, Hoek HW, Brewerton TD, Elzinga BM. Childhood maltreatment and eating disorder pathology: a systematic review and dose‒response meta-analysis. Psychol Med. 2017;47(8):1402-16; doi: 10.1017/S0033291716003561\u003c/li\u003e\n \u003cli\u003eConvertino AD, Morland LA, Blashill AJ. Trauma exposure and eating disorders: Results from a United States nationally representative sample. Int J Eat Disord. 2022;55(8):1079-89; doi: 10.1002/eat.23757\u003c/li\u003e\n \u003cli\u003eMadowitz J, Matheson BE, Liang J. The relationship between eating disorders and sexual trauma. Eat Weight Disord. 2015;20:281-93; doi: 10.1007/s40519-015-0195-y\u003c/li\u003e\n \u003cli\u003eBackholm K, Isomaa R, Birgeg\u0026aring;rd A. The prevalence and impact of trauma history in eating disorder patients. Eur J Psychotraumatol. 2013;4(1):22482; doi: 10.3402/ejpt.v4i0.22482\u003c/li\u003e\n \u003cli\u003eAfifi TO, Sareen J, Fortier J, Taillieu T, Turner S, Cheung K, et al. Child maltreatment and eating disorders among men and women in adulthood: Results from a nationally representative United States sample. Int J Eat Disord. 2017;50(11):1281-96; doi: 10.1002/eat.22783\u003c/li\u003e\n \u003cli\u003eFischer S, Stojek M, Hartzell E. Effects of multiple forms of childhood abuse and adult sexual assault on current eating disorder symptoms. Eat Behav. 2010;11(3):190-92; doi: 10.1016/j.eatbeh.2010.01.001\u003c/li\u003e\n \u003cli\u003eKimber M, McTavish JR, Couturier J, Boven A, Gill S, Dimitropoulos et al. Consequences of child emotional abuse, emotional neglect and exposure to intimate partner violence for eating disorders: a systematic critical review. BMC Psychol. 2017;5:1-18; doi: 10.1186/s40359-017-0202-3\u003c/li\u003e\n \u003cli\u003ePiacentino D, Loriedo C, Biondi M, Girardi P, Vanderlinden J, Pignatelli AM. Emotional neglect as the colossus among traumas in patients with eating disorders. A case‒control study. Eur Psychiatry. 2016;33(S1):S165-S165; doi: 10.1016/j.eurpsy.2016.01.331\u003c/li\u003e\n \u003cli\u003ePignatelli AM, Wampers M, Loriedo C, Biondi M, Vanderlinden J. Childhood neglect in eating disorders: A systematic review and meta-analysis. J Trauma Dissociatio. 2017;18(1):100-15; doi: 10.1080/15299732.2016.1198951\u003c/li\u003e\n \u003cli\u003eLie S\u0026Oslash;, R\u0026oslash; \u0026Oslash;, Bang L. Is bullying and teasing associated with eating disorders? A systematic review and meta‐analysis. Int J Eat Disord. 2019;52(5):497-514; doi: 10.1002/eat.23035\u003c/li\u003e\n \u003cli\u003eFriedman JK, Yoon CY, Tavernier RE, Mason SM, Neumark-Sztainer D. Associations of childhood maltreatment with binge eating and binge drinking in emerging adult women. Prev Med Rep. 2023;33:102217; doi: 10.1016/j.pmedr.2023.102217\u003c/li\u003e\n \u003cli\u003eVida\u0026ntilde;a AG, Forbush KT, Barnhart EL, Chana SM, Chapa DA, Richson B, Thomeczek ML. Impact of trauma in childhood and adulthood on eating-disorder symptoms. Eat Behav. 2020;39:101426; doi: 10.1016/j.eatbeh.2020.101426\u003c/li\u003e\n \u003cli\u003eGroth T, Hilsenroth M, Boccio D, Gold J. Relationship between trauma history and eating disorders in adolescents. J Child Adolesc Trauma. 2020;13:443-53; doi: 10.1007/s40653-019-00275-z\u003c/li\u003e\n \u003cli\u003eGuillaume S, Jaussent I, Ma\u0026iuml;moun L, Ryst A, Seneque M, Villain L, et al. Associations between adverse childhood experiences and clinical characteristics of eating disorders. Sci Rep, 2016;6(1):35761; doi: 10.1038/srep35761\u003c/li\u003e\n \u003cli\u003eMessman-Moore TL, Garrigus AS. The association of child abuse and eating disorder symptomatology: The importance of multiple forms of abuse and revictimization. J Aggression Maltreat Trauma. 2007;14(3):51-72; doi: 10.1300/J146v14n03_04\u003c/li\u003e\n \u003cli\u003eHambleton A, Pepin G, Le A, Maloney D, Touyz S, Maguire S. Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. J Eat Disord. 2022;10(1):132; doi: 10.1186/s40337-022-00654-2\u003c/li\u003e\n \u003cli\u003eScharff A, Ortiz SN, Forrest LN, Smith AR. Comparing the clinical presentation of eating disorder patients with and without trauma history and/or comorbid PTSD. Eat Disord. 2021;29(1):88-102; doi: 10.1080/10640266.2019.1642035\u003c/li\u003e\n \u003cli\u003eGrenon R, Tasca GA, Maxwell H, Balfour L, Proulx G, Bissada H. Parental bonds and body dissatisfaction in a clinical sample: The mediating roles of attachment anxiety and media internalization. Body Image. 2016;19:49-56; doi: 10.1016/j.bodyim.2016.08.005\u003c/li\u003e\n \u003cli\u003eTetley A, Moghaddam NG, Dawson DL, Rennoldson M. Parental bonding and eating disorders: A systematic review. Eat Behav. 2014;15(1):49-59; doi: 10.1016/j.eatbeh.2013.10.008\u003c/li\u003e\n \u003cli\u003eTasca GA. Attachment and eating disorders: a research update. Curr Opin Psychol. 2019;25: 59-64; doi: 10.1016/j.copsyc.2018.03.003\u003c/li\u003e\n \u003cli\u003eBowlby J. Attachment and Loss, Vol. 1: Attachment. New York: Basic Books; 1969\u003c/li\u003e\n \u003cli\u003eTasca GA, Balfour L. Attachment and eating disorders: A review of current research. Int J Eat Disord. 2014;47(7):710-17; doi: 10.1002/eat.22302\u003c/li\u003e\n \u003cli\u003eWolfe DA, McIsaac C. Distinguishing between poor/dysfunctional parenting and child emotional maltreatment. Child Abuse Negl, 2011;35(10):802-13; doi: 10.1016/j.chiabu.2010.12.009\u003c/li\u003e\n \u003cli\u003eLahousen T, Unterrainer HF, Kapfhammer HP. Psychobiology of attachment and trauma\u0026mdash;some general remarks from a clinical perspective. Front Psychiatry. 2019;10:914; doi: 10.3389/fpsyt.2019.00914\u003c/li\u003e\n \u003cli\u003eChartier MJ, Walker JR, Naimark B. Separate and cumulative effects of adverse childhood experiences in predicting adult health and health care utilization. Child Abuse Negl. 2010;34(6):454-64; doi: 10.1016/j.chiabu.2009.09.020\u003c/li\u003e\n \u003cli\u003eMitchell KS, Scioli ER, Galovski T, Belfer PL, Cooper Z. Posttraumatic stress disorder and eating disorders: maintaining mechanisms and treatment targets. Eat Disord. 2021;29(3):292-306; doi: 10.1080/10640266.2020.1869369\u003c/li\u003e\n \u003cli\u003eB\u0026auml;r A, B\u0026auml;r HE, Rijkeboer MM, Lobbestael J. Early Maladaptive Schemas and Schema Modes in clinical disorders: A systematic review. Psychol Psychother. 2023;96(3):716-47; doi: 10.1111/papt.12465\u003c/li\u003e\n \u003cli\u003eNicol A, Mak AS, Murray K, Walker I, Buckmaster D. The relationships between early maladaptive schemas and youth mental health: A systematic review. Cogn Behav Ther. 2020;44:715-51; doi: 10.1007/s10608-020-10092-6\u003c/li\u003e\n \u003cli\u003eCosta IF, Tomaz MP, Pessoa GDN, Miranda HDS, Galdino MK. Early maladaptive schemas and harm avoidance as mediating factors between early life stress and psychiatric symptoms in adults. Braz J Psychiatry. 2020;42:489-95; doi: 10.1590/1516-4446-2019-0593\u003c/li\u003e\n \u003cli\u003eYoung JE, Klosko JS, Weishaar ME. Schema therapy. A practitioner\u0026rsquo;s guide. New York: Guilford; 2003\u003c/li\u003e\n \u003cli\u003eBasso LA, Fortes AB, Steinhorst E, Wainer R. The effects of parental rearing styles and early maladaptive schemas in the development of personality: a systematic review. Trends Psychiatry Psychother. 2019;41:301-13; doi: 10.1590/2237-6089-2017-0118\u003c/li\u003e\n \u003cli\u003eLian AEZ, Chooi WT, Bono SA. A systematic review investigating the early maladaptive schemas (EMS) in Individuals with trauma experiences and PTSD. Eur J Trauma Dissoc. 2023;7(1):100315; doi: 10.1016/j.ejtd.2023.100315\u003c/li\u003e\n \u003cli\u003ePilkington PD, Bishop A, Younan R. Adverse childhood experiences and early maladaptive schemas in adulthood: A systematic review and meta‐analysis. Clin Psychol Psychother. 2021;28(3):569-84; doi: 10.1002/cpp.2533\u003c/li\u003e\n \u003cli\u003eSimpson ESS, Smith E. Schema Therapy for Eating Disorders. London: Routledge; 2019\u003c/li\u003e\n \u003cli\u003eRezaei M, Ghazanfari F. The role of childhood trauma, early maladaptive schemas, emotional schemas and experimental avoidance on depression: A structural equation modeling. Psychiatry Res. 2016;246:407-14; doi: 10.1016/j.psychres.2016.10.037\u003c/li\u003e\n \u003cli\u003eVasilopoulou E, Karatzias T, Hyland P, Wallace H, Guzman A. The mediating role of early maladaptive schemas in the relationship between childhood traumatic events and complex posttraumatic stress disorder symptoms in older adults (\u0026gt; 64 years). J Loss Trauma. 2020;25(2):141-58; doi: 10.1080/15325024.2019.1661598\u003c/li\u003e\n \u003cli\u003eMeneguzzo P, Cazzola C, Castegnaro R, Buscaglia F, Bucci E, Pillan A, et al. Associations between trauma, early maladaptive schemas, personality traits, and clinical severity in eating disorder patients: a clinical presentation and mediation analysis. Front Psychol. 2021;12:661924; doi: 10.3389/fpsyg.2021.661924\u003c/li\u003e\n \u003cli\u003eMaher A, Cason L, Huckstepp T, Stallman H, Kannis‐Dymand L, Millear P, et al. Early maladaptive schemas in eating disorders: A systematic review. Eur Eat Disord Rev. 2022;30(1):3-22; doi: 10.1002/erv.2866\u003c/li\u003e\n \u003cli\u003eAloi M, Rania M, Caroleo M, Carbone EA, Fazia G, Calabr\u0026ograve; G, et al. How are early maladaptive schemas and DSM‐5 personality traits associated with the severity of binge eating?. J Clin Psychol. 2020;76(3):539-48; doi: 10.1002/jclp.22900\u003c/li\u003e\n \u003cli\u003eJenkins PE, Meyer C, Blissett JM. Childhood abuse and eating psychopathology: The mediating role of core beliefs. J Aggression Maltreat Trauma. 2013;22(3):248-61; doi: 10.1080/10926771.2013.741665\u003c/li\u003e\n \u003cli\u003eRabito-Alcon MF, Baile JI, Vanderlinden J. Mediating factors between childhood traumatic experiences and eating disorders development: a systematic review. Children. 2021;8(2):114; doi: 10.3390/children8020114\u003c/li\u003e\n \u003cli\u003eBrewerton TD, Perlman MM, Gavidia I, Suro G, Genet J, Bunnell DW. The association of traumatic events and posttraumatic stress disorder with greater eating disorder and comorbid symptom severity in residential eating disorder treatment centers. Int J Eat Disord. 2020;53(12):2061-66; doi: 10.1002/eat.23401\u003c/li\u003e\n \u003cli\u003eGarner DM. Eating disorder inventory-3 (EDI-3). Professional manual. Odessa, FL: Psychological Assessment Resources, 1; 2004.\u003c/li\u003e\n \u003cli\u003eGiannini M, Pannocchia L, Dalle Grave R, Muratori F, Viglione V. EDI-3 Eating Disorder Inventory-3: Manuale. Firenze: OS Organizzazioni Speciali; 2008.\u003c/li\u003e\n \u003cli\u003eClausen L, Rosenvinge JH, Friborg O, Rokkedal K. Validating the Eating Disorder Inventory-3 (EDI-3): A comparison between 561 female eating disorders patients and 878 females from the general population. J Psychopathol Behav Assess. 2011;33:101-110; doi: 10.1007/s10862-010-9207-4\u003c/li\u003e\n \u003cli\u003eYoung JE. Young Schema Questionnaire - Long Form 3 (YSQ-L3). New York: Schema Therapy Institute; 2005\u003c/li\u003e\n \u003cli\u003eSaggino A, Balsamo M, Carlucci L, Cavalletti V, Sergi MR, Da Fermo G, et al. Psychometric properties of the Italian version of the young schema questionnaire l-3: Preliminary results. Front psychol. 2018;9: 312; doi: 10.3389/fpsyg.2018.00312\u003c/li\u003e\n \u003cli\u003eBifulco A, Bernazzani O, Moran PM, Jacobs C. The childhood experience of care and abuse questionnaire (CECA. Q): validation in a community series. Br J Clin Psychol. 2005;44(4):563-81; doi: 10.1348/014466505X35344\u003c/li\u003e\n \u003cli\u003eGiannone F, Schimmenti A, Caretti V, Chiarenza A, Ferraro A, Guarino S, et al. Validit\u0026agrave;, attendibilit\u0026agrave; e propriet\u0026agrave; psicometriche della versione italiana dell\u0026rsquo;intervista CECA (Childhood Experience of Care and Abuse). Psichiatria e Psicoterapia. 2011;30(1):3-21.\u003c/li\u003e\n \u003cli\u003eTurner BJ, Claes L, Wilderjans TF, Pauwels E, Dierckx E, Chapman AL, et al. Personality profiles in eating disorders: Further evidence of the clinical utility of examining subtypes based on temperament. Psychiatry Res. 2014;219(1):157-65; doi: 10.1016/j.psychres.2014.04.036\u003c/li\u003e\n \u003cli\u003ePugh M. A narrative review of schemas and schema therapy outcomes in the eating disorders. Clin Psychol Rev. 2015;39:30-41; doi: 10.1016/j.cpr.2015.04.003\u003c/li\u003e\n \u003cli\u003eBrown JM, Selth S, Stretton A, Simpson S. Do dysfunctional coping modes mediate the relationship between perceived parenting style and disordered eating behaviours?. J Eat Disord. 2016;4:1-10; doi: 10.1186/s40337-016-0123-1\u003c/li\u003e\n \u003cli\u003eRossi E, Cassioli E, Cecci L, Arganini F, Martelli M, Redaelli CA, et al. Eye movement desensitization and reprocessing as add‐on treatment to enhanced cognitive behaviour therapy for patients with anorexia nervosa reporting childhood maltreatment: A quasi‐experimental multicenter study. Eur Eat Disord Rev. 2024;32(2):322-37; doi: 10.1002/erv.3044\u003c/li\u003e\n \u003cli\u003eErg\u0026uuml;ney-Okumuş FE. Integrating EMDR with enhanced cognitive behavioral therapy in the treatment of bulimia nervosa: A single case study. J EMDR pract res. 2021;15(4):231-43; doi: 10.1891/EMDR-D-21-00012\u003c/li\u003e\n \u003cli\u003eYaşar AB, Abamor AE, Usta FD, Taycan SE, Kaya B. Two cases with avoidant/restrictive food intake disorder (ARFID): Effectiveness of EMDR and CBT combination on eating disorders (ED). Klin Psikiyatri Derg. 2019;22(4); doi: 10.5505/kpd.2019.04127\u003c/li\u003e\n \u003cli\u003eJoshua PR, Lewis V, Kelty SF, Boer DP. Is schema therapy effective for adults with eating disorders? A systematic review into the evidence. Cogn Behav Ther. 2023;52(3):213-231; doi: 10.1080/16506073.2022.2158926\u003c/li\u003e\n \u003cli\u003eMcIntosh VV, Jordan J, Carter JD, Frampton CM, McKenzie JM, Latner JD, et al. Psychotherapy for transdiagnostic binge eating: A randomized controlled trial of cognitive-behavioural therapy, appetite-focused cognitive-behavioural therapy, and schema therapy. Psychiatry Res. 2016;240:412-20; doi: 10.1016/j.psychres.2016.04.080\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-eating-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joed","sideBox":"Learn more about [Journal of Eating Disorders](http://jeatdisord.biomedcentral.com)","snPcode":"40337","submissionUrl":"https://submission.nature.com/new-submission/40337/3","title":"Journal of Eating Disorders","twitterHandle":"@JEatDisord","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Eating Disorders, Childhood Trauma, Early Maladaptive Schemas, Outpatients, Psychopathology","lastPublishedDoi":"10.21203/rs.3.rs-4492860/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4492860/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eChildhood trauma history has frequently been linked to eating disorders (EDs); nevertheless, the scientific literature calls for extending knowledge regarding mediators between EDs and childhood trauma. This study explored whether ED symptoms and early maladaptive schemas were more severe in ED patients with severe childhood trauma than inED patients with no/mild childhood trauma and whether early maladaptive schemas mediated the relationship between childhood trauma and ED symptom severity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eData were extracted from the Regional Centre for Eating Disorders registry at the University Hospital of Verona. The extracted data includedself-reported data, including the Eating Disorder Inventory-3 score, Young Schema Questionnaire score, Childhood Experience and Experience of Care and Abuse Questionnaire score, and sociodemographic and clinical information on the ED outpatients seeking care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Forty-twooutpatients, 30.9% of whom exhibited severe childhood trauma, satisfied the criteria for registry data extraction. The severity of ED symptoms, as well as the early maladaptive schemas’ scores for emotional deprivation, defectiveness, failure, vulnerability, insufficient self-control, and negativity, were greaterin ED outpatients with severe childhood trauma. Furthermore, early maladaptive schemas related to defectiveness, failure, and negativity had a mediatingrole in the relationship between severe childhood trauma and ED symptom severity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThese findings\u003cstrong\u003e \u003c/strong\u003ehighlightthe importance of early maladaptive schemas in the relationship between trauma history and ED psychopathology. In addition, ED symptoms may represent a dysfunctional attempt to avoid unpleasant emotions associated with schema activation. The results support the need to consider early maladaptive schemas in the treatment of traumatized patients with ED symptoms. Research and clinical implications are discussed.\u003c/p\u003e","manuscriptTitle":"Early Maladaptive Schemas Mediate the Relationship between Severe Childhood Trauma and Eating Disorder Symptoms","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-17 16:45:23","doi":"10.21203/rs.3.rs-4492860/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-09T09:13:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-02T21:11:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-02T21:11:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Eating Disorders","date":"2024-05-28T19:25:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-eating-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joed","sideBox":"Learn more about [Journal of Eating Disorders](http://jeatdisord.biomedcentral.com)","snPcode":"40337","submissionUrl":"https://submission.nature.com/new-submission/40337/3","title":"Journal of Eating Disorders","twitterHandle":"@JEatDisord","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9ae28c60-d461-4f43-a7bb-909267d9a1e6","owner":[],"postedDate":"June 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-06-24T01:44:58+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-17 16:45:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4492860","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4492860","identity":"rs-4492860","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}