The Correlation Between Anorexia Nervosa and Childhood Traumatic Experience: the Mediating Role of Impulsivity

The Correlation Between Anorexia Nervosa and Childhood Traumatic Experience: the Mediating Role of Impulsivity | 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 The Correlation Between Anorexia Nervosa and Childhood Traumatic Experience: the Mediating Role of Impulsivity Jing Zhang, Yanran Hu, Qing Kang, Mengting Wu, Yunling Zou, Sufang Peng, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7445886/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Feb, 2026 Read the published version in Journal of Eating Disorders → Version 1 posted 9 You are reading this latest preprint version Abstract Background The pathogenesis of anorexia nervosa (AN) involves multiple factors, among which childhood traumatic experience has attracted attention. It may affect AN by influencing emotional regulation and impulsivity. However, relevant research has rarely been conducted in China. The purpose of this study is to compare differences in childhood traumatic experience of patients with different subtypes of AN, and explore the correlation between AN and childhood traumatic experience, as well as elucidating the mediating role of impulsivity between emotional abuse in childhood traumatic experience and disease severity. Methods This study included 164 patients with AN, including 76 with the restricting type (AN-R) and 81 with the binge-eating/purging type (AN-BP), as well as 124 matched healthy controls (HC). Childhood traumatic experience was evaluated using Early Trauma Inventory-short form (ETI-SF), impulsivity assessed by Barratt Impulsiveness Scale 11th Version (BIS-11), and clinical symptoms via Eating Disorder Examination-questionnaire (EDE-Q 6.0), Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI). Furthermore, inter-group differences in childhood traumatic experience were determined by one-way analysis of variance, the correlation between childhood traumatic experience and AN by Pearson correlation analysis, and the mediating role of impulsivity between emotional abuse and disease severity was clarified by the Bootstrap method. Results Cases in the AN-BP group had significantly higher exposure to childhood traumatic experience compared with the AN-R and HC groups (both p < 0.05). Childhood traumatic experience was positively correlated with AN impulsivity and disease severity (both p < 0.05), and emotional abuse in childhood traumatic experience was obviously positively correlated with AN impulsivity and disease severity (both p < 0.05). In addition, the mediation effect of impulsivity between emotional abuse and disease severity was 0.073 (95% CI 0.013 ~ 0.153), with an effect proportion of 19.363%. Conclusion AN-BP patients have more significant childhood traumatic experience than AN-R patients. Childhood traumatic experience, especially emotional abuse, has established correlation with impulsivity and disease severity in AN, with impulsivity playing a mediating role between emotional abuse and disease severity. Anorexia nervosa Childhood traumatic experience Emotional abuse Impulsivity Mediating role Figures Figure 1 Plain English summary In recent years, the incidence rate of anorexia nervosa (AN) in China has been rising, drawing significant attention. The causes of AN have long been a challenging and prominent research topic. In this study, we explored the childhood traumatic experience and personality traits of patients with AN. We found that different subtypes of AN are associated with varying childhood traumatic experience. AN patients with symptoms of binge eating and purging often suffered more emotional abuse in their childhood, such as being scolded, neglected, or belittled for a long time. We also found that impulsivity plays an important role in the development of AN. Through this study, we aim to elucidate the pathogenic mechanisms of AN and generate novel insights for its clinical intervention. Background Anorexia nervosa (AN) is an eating disorder featured predominantly by extreme dieting and significant weight loss, accompanied frequently by excessive concern about body weight and shape, as well as an intense fear of obesity in the affected individuals ( 1 ). AN is highly prevalent among adolescents and young women, which not only causes damage to the patient's mental health, but also leads to bradycardia, electrolyte disorders, osteoporosis, endocrine disorders and various other complications, even posing a threat to life in severe cases ( 2 ). Given the development of media and the impact of novel coronavirus pandemic recently, the incidence of AN is on the rise, triggering significantly adverse impact on Chinese adolescents( 1 ). According to the diagnostic criteria of the Diagnostic and Statistical Manual 5th Edition (DSM-5), it consists of the restricting-type (AN-R) and binge-eating/purging-type (AN-BP) based on the presence or absence of recurrent binge-eating or purging behaviors in the last 3 months. Patients with AN-BP has been found to have a heightened impulsivity trait, attributable intimately to their binge eating and purging behaviors ( 3 , 4 ). Our prior research has documented more pronounced impulsivity in AN-BP patients than that in AN-R cases, which was evidenced by lack of planning, pursuit of sensation-seeking behaviors, and difficulty in adhering to tasks, yet with poor understanding on the early factors contributing to the heterogeneity currently ( 5 ). It should be acknowledged that AN has a complex pathogenesis involving multiple biological, psychological, and sociocultural factors ( 6 ). In recent decades, great concern has been attached to the potential role of childhood traumatic experience in the pathogenesis of AN. Childhood traumatic experience, including emotional abuse, physical abuse, and sexual trauma, has been confirmed to be associated with the development of several mental disorders ( 7 , 8 ). As evidenced by the results of neuroimaging ( 9 ), childhood traumatic experience can cause emotional disturbance, presenting with emotional instability, behavioral impulsivity, and interpersonal difficulties, with influence in prefrontal-limbic system functions. The childhood traumatic experience of AN patients may affect disease development by affecting the emotion regulation and impulsivity of individuals. So far, there are still relatively few studies in China on the differences of childhood traumatic experience in different subtypes of AN and their correlation with AN. Accordingly, the present study was conducted to compare childhood traumatic experience in patients with different subtypes of AN, to explore the correlation of childhood traumatic experience with impulsivity and disease severity, and to unveil the mediating role of impulsivity, so as to provide a scientific basis for early intervention and individualized treatment of AN patients. Methods Participants From September 2019 to August 2024, this study included 164 patients who were admitted to the Psychosomatic Medicine Ward and Psychological Counseling Clinic of Shanghai Mental Health Center as the AN group. Subsequently, patients in the AN group were further divided into the AN-R group (n = 76) and the AN-BP group (n = 81), with 7 cases of atypical AN not included in the subgroups. The healthy control (HC) group included 124 cases from the recruited population and students of Shanghai Jiao Tong University. Inclusion and exclusion criteria The inclusion criteria for AN group were as follows: female; Han Chinese; 13–30 years old; confirmed diagnosis of AN by clinical psychologists or psychiatrists at deputy director-level and above based on the criteria of the DSM-5; body mass index (BMI) ranged between 13-18.5 kg/m 2 . The exclusion criteria for AN group were as follows: met the diagnostic criteria of other mental disorders except AN; serious passive suicidal ideation or behaviors; serious somatic diseases or physical complications; pregnant or breastfeeding. The inclusion criteria for HC group were as follows: females; Han Chinese; 13–30 years old; BMI ranged between 18.5–23.9 kg/m 2 . The exclusion criteria for HC group were as follows: met any of the diagnostic criteria of DSM-5; serious somatic diseases or physical complications; pregnant or breastfeeding. Assessment scales General information questionnaire General information of all the enrolled participants was acquired by using a self-designed general information questionnaire, including study number, name, gender, age, occupation, marriage, education level, height, weight, BMI, contact information, history of major illnesses, history of suicide attempts, and history of pregnancy. For AN patients, additional data should also be included, such as the age at onset, total course of disease, precipitating factors, current diagnosis (including subtype), outpatient number, or hospitalization number. Eating Disorder Examination-questionnaire (EDE-Q 6.0) EDE-Q 6.0 is a self-rating scale with 28 entries, which is divided into four subscales, including dietary restriction, eating concerns, body image concerns, and weight concerns. The Chinese version of this questionnaire has good reliability and validity ( 10 ). In this study, EDE-Q 6.0 was employed to assess the clinical behavioral and psychological characteristics of AN, and to evaluate the disease severity of AN by rating the frequency and intensity of symptoms. Barratt Impulsiveness Scale 11th Version (BIS-11) BIS-11 is a self-assessment questionnaire with 30 entries. It is the most common self-report scale for measuring impulsivity from attentional impulsivity, motor impulsivity, and unplanned impulsivity, with good reliability and validity ( 11 ). The assessed with higher scores would have higher impulsivity. Early Trauma Inventory-short form (ETI-SF) In order to investigate the traumatic experience of participants before the age of 18, this study employed the self-assessment questionnaire ETI-SF for assessing environmental factors. The questionnaire has 27 items from four dimensions of general trauma, physical trauma, emotional abuse, and sexual trauma. The Chinese version of this questionnaire has been validated to possess good reliability and validity ( 12 ). Each entry has two options of “yes” and “no”, with “yes” scoring 1 point and “no” scoring 0 point. Emotional-Related Assessment Scales To assess the participants' emotional states, this study used Beck Depression Inventory (BDI) to evaluate depressive symptoms and Beck Anxiety Inventory (BAI) to assess anxiety symptoms, respectively. Both of these scales are self-report scales, and their Chinese versions have demonstrated good reliability and validity. Statistical analyses Database establishment and data analysis were completed in SPSS 26.0. Measurement data were evaluated for normality by Kolmogorov-Smirnov normality test and stem-and-leaf plot, with normally distributed data expressed as x ± s. Inter-group and multi-group comparisons employed independent samples t-test, and one-way analysis of variance, respectively, and pairwise comparison adopted the LSD method. Pearson correlation analysis was utilized to profile the correlations of continuous variables. Finally, the percentile Bootstrap method (PROCESS plug-in) was used to perform mediation effect test ( 13 ), with the random sampling set as 5,000 times and reported 95% confidence interval (CI). The presence of statistically significant difference was determined when p < 0.05. Results Comparison of childhood traumatic experience Inter-group statistical comparison revealed no statistically significant differences in the distribution of age, height and years of education between AN and HC groups (all p > 0.05), with BMI of the AN group significantly lower than that of the HC group ( p < 0.05). Meanwhile, the age, years of education, weight, and BMI of the AN-R group were significantly lower than those of the AN-BP group (all p < 0.05), without any significant differences in height between groups ( p = 0.972). According to the comparison of childhood traumatic experience among groups, the AN-BP group had significantly higher ETI-SF total score and emotional abuse scores than those of the AN-R and HC groups (all p 0.05). In addition, the general trauma score in the AN-R group was obviously lower than that in the AN-BP and HC groups (both p < 0.05). Table 1 Comparison of childhood traumatic experience between AN-R group, AN-BP group, and HC groups AN-R (n = 76) AN-BP (n = 81) HC (n = 124) F p Pairwise comparison p -values AN-R Vs AN-BP AN-R Vs HC AN-BP Vs HC ETI-SF Total score 3.27± 3.01 5.64± 4.29 4.20± 3.52 6.203 0.002 0.000 0.082 0.017 General trauma 0.59± 1.16 1.09± 1.67 1.21± 1.56 3.643 0.028 0.071 0.008 0.613 Physical trauma 1.37± 1.52 1.89± 1.79 1.56± 1.42 1.780 0.171 0.063 0.424 0.182 Emotional abuse 1.11± 1.47 2.29± 1.89 1.24± 1.45 10.574 0.000 0.000 0.593 0.000 Sexual trauma 0.15± 0.44 0.38± 0.98 0.19± 0.57 1.922 0.149 0.069 0.689 0.096 Correlation analysis between AN and childhood traumatic experience According to the correlation analysis, the ETI-SF total score revealed significantly positive correlations with EDE-Q 6.0 total score, BDI score and BAI score (r = 0.249–0.350, p = 0.000-0.006). Furthermore, emotional abuse in the ETI-SF scale also yielded significantly positive correlations with EDE-Q 6.0 total score, BDI score and BAI score (r = 0.401–0.471, p = 0.000). Physical trauma was significantly positively correlated with BDI score and BAI score (r = 0.282, p = 0.002; r = 0.257, p = 0.005). However, general trauma and sexual trauma in the ETI-SF scale had none obvious correlations with clinical characteristics of AN (all p > 0.01). Our correlation analysis also showed that the ETI-SF total score exhibited significantly positive correlations with the BIS-11 score (r = 0.240, p = 0.014). Meanwhile, emotional abuse in the ETI-SF scale was significantly and positively correlated with the BIS-11 score (r = 0.285, p = 0.003). However, no significant correlation was observed in general trauma, physical trauma, and sexual trauma with BIS-11 score ( p > 0.05). Table 2 Correlation between AN and childhood traumatic experience ETI-SF total score General trauma Physical trauma Emotional abuse Sexual trauma EDE-Q 6.0 total score Pearson correlation 0.249** 0.058 0.140 0.409 ** -0.002 Significance (bilateral) 0.006 0.530 0.127 0.000 0.987 BDI score Pearson correlation 0.290** -0.012 0.282** 0.401** 0.053 Significance (bilateral) 0.002 0.898 0.002 0.000 0.569 BAI score Pearson correlation 0.350** 0.018 0.257** 0.471** 0.194 Significance (bilateral) 0.000 0.845 0.005 0.000 0.034 BIS-11 score Pearson correlation 0.240 * 0.103 0.149 0.285 ** 0.091 Significance (bilateral) 0.014 0.295 0.127 0.003 0.351 Mediation effect test of impulsivity Given the strong correlations of emotional abuse in childhood traumatic experience with impulsivity and disease severity, Model 4 of the PROCESS plug-in was used for modeling, with emotional abuse as the independent variable, disease severity as the dependent variable, and impulsivity as the mediator variable. Based on the results of regression analysis, emotional abuse indicated a significant positive predictive effect on impulsivity ( β = 1.551, t = 2.995, p = 0.003) and disease severity ( β = 0.304, t = 4.123, p = 0.000), suggesting 0.304-unit increase in disease severity per one-unit increase in emotional abuse. Moreover, after the control of emotional abuse, there was still a significant direct effect of impulsivity on disease severity ( β = 0.047, t = 3.492, p = 0.001). Our study continued to investigate the mediation effect on impulsivity between emotional abuse and disease severity in AN patients by employing a Bootstrap method. The results showed that the total effect of emotional abuse on disease severity was 0.377, with a CI not containing 0 (95% CI: 0.229 ~ 0.524). The direct effect of emotional abuse on disease severity was 0.304, with the CI not containing 0 (95% CI 0.158 ~ 0.450). The mediation effect of impulsivity between emotional abuse and disease severity was 0.073, with the CI of Bootstrap not containing 0 (95% CI 0.013 ~ 0.153) and an effect proportion of 19.363%. As a result, impulsivity might exert a partial mediation effect between emotional abuse and disease severity. Table 3 Regression analysis of the mediation model Variable Dependent variable Disease severity Disease severity Impulsivity t value p t value p t value p Emotional abuse 4.123 0.000 5.066 0.000 2.995 0.003 Impulsivity 3.492 0.001 R ² value 0.287 0.201 0.081 F value 20.336 25.660 8.971 Table 4 Mediation effect analysis of impulsivity Effect type Effect value SE 95%CI Relative effect ratio/% Total effect 0.377 0.074 0.229 ~ 0.524 100.000 Direct effect 0.304 0.073 0.158 ~ 0.450 80.637 Indirect effect 0.073 0.036 0.013 ~ 0.153 19.363 Discussion It has been well-established with regard to the pathogenesis of AN, a complex, multifactorial disease, generally involving the combined effects of genetic, environmental, and personality factors. Previous research has been dedicated to discovering the potential risk factors that may exist in the growth environment of AN. As early as 1989, a survey in the United States found the experience of sexual abuse in 38% of women with eating disorders ( 14 ). In 2001, a twin study in the United Kingdom revealed that AN patients had suffered from more physical and sexual trauma than their healthy sisters through the interview of 45 pairs of sisters using the Eating Disorder Risk Factor Questionnaire from Oxford University ( 15 ). Similar to the results of a cross-sectional study ( 16 ), the present study found that AN-BP patients had more significant childhood traumatic experience than AN-R patients according to the evaluation and comparison of childhood traumatic experience between two subtypes of AN. Moreover, differences between the two subtypes were mainly manifested in the emotional abuse. Consistently, a study in the United States supported childhood abuse as an inducing factor of emotional disturbance in AN patients, with the strongest relationship between emotional abuse and the severity of AN symptoms ( 17 ). Therefore, childhood traumatic experience, especially emotional abuse, may be an essential contributor to the pathogenesis of AN. Emotional abuse may stem from parental or caregiver misunderstanding, indifference, criticism, belittlement, or neglect. As documented by a Chinese study, AN patients often experienced an uncomfortable family environment characterized by low intimacy, low emotional expression, low entertainment value, and high ambivalence ( 18 ). Beyond that, emotional abuse may also originate from school, social, and other environments, such as humiliation or ridicule of classmates, cyberbullying, or verbal aggression. Accumulated evidence has revealed more traumatic experiences (e.g., sexual and physical trauma) in AN patients than the general population ( 14 , 15 , 19 , 20 ). However, this study failed to uncover significant difference in sexual and physical trauma between the two subtypes of AN and HC. It may be explained by the relatively low incidence of sexual and physical trauma with social progress and the continuous improvement of the rule of law. In addition, some participants of study may choose to conceal some experience owing to privacy-exposing factors, leading to potential reporting bias. On the basis of previous study, it can be understood that AN-BP patients exhibited more significant impulsivity than AN-R patients, evidenced by increased attentional impulsivity, motor impulsivity, and unplanned impulsivity, which was in line with the recurrent binge eating and purging behaviors ( 5 ). Furthermore, individuals with serious childhood traumatic experience might also develop maladaptive personality traits. It has been reported that childhood abuse can increase the risk of developing impulsive, antisocial, obsessive-compulsive, and anxious personalities in adulthood ( 21 – 23 ). In 2016, Spinhoven et al. found that childhood traumatic experience mediated by maladaptive traits can predict higher psychological stress levels, which might increase the risk of mental illness ( 24 ). Similarly, Chinese researchers have also found significantly increase the risk of multiple mental problems in adolescents in subjects experiencing emotional and physical abuse in childhood ( 25 ). This study also showed a similar conclusion that childhood traumatic experience was significantly and positively correlated with impulsivity in AN, highlighting more significant correlation between emotional abuse and impulsivity. Prior research has also revealed the relationship of emotional abuse during childhood in AN patients with impulsive behavior under negative emotions ( 17 ). Furthermore, our study also get into the bottom of the mediating role of impulsivity between emotional abuse and disease severity in childhood traumatic experience. Beyond direct exacerbation of the clinical manifestations of AN, emotional abuse would also indirectly exacerbate the disease severity by shaping high impulsivity traits. It was highly consistent with the theory of the emotion dysregulation-impulsivity model in dialectical behavioral therapy. In other words, emotional abuse in childhood traumatic experience can compromise the regulatory role of individuals on negative emotions to induce impulsive coping strategies (e.g., binge eating, vomiting, autolesion, and substance abuse), behaviors that are core features of AN-BP ( 26 ). Accordingly, it may provide use with some insights into clinical psychotherapy, where different psychological treatment methods can be used for targeted interventions on childhood traumatic experience of patients ( 27 ). For example, family therapy can be employed to adjust family interaction mode, repair family relationships, and reduce family environment-induced emotional neglect or emotional abuse ( 18 , 28 ). Dialectical behavior therapy targeting impulsivity may facilitating patients’ understanding and grasp of emotional regulation skills and mindfulness skills, thus dealing with emotional dysregulation and impulsive behaviors caused by childhood traumatic experience ( 29 ). Additionally, cognitive behavioral therapy can be used to deal with traumatic memory; while gradual exposure and cognitive reconstruction can be utilized to reduce negative emotions and impulsive behaviors caused by traumatic experience ( 30 ). Conclusion In conclusion, AN-BP patients have more significant childhood traumatic experience than AN-R patients, which is particularly prominent in emotional abuse. Emotional abuse in childhood traumatic experience can affect the disease severity either through direct effects or through mediation effects of impulsivity. Therefore, clinical interventions should focus on both the relief of clinical symptoms of AN, and the management of trauma and emotional disturbance taking into consideration of the family environment, personality traits, and other factors of patients. However, this study still has some limitations. For example, as a cross-sectional study, this study established correlations between all factors, but their causal relationship necessitate further exploration and validation. In addition, this study only included impulsivity as a single mediating variable in the mediation effect model. Therefore, future in-depth studies can be conducted by establishing a more complete mechanism model based on the inclusion of more personality traits, as well as integration of neuroimaging, biochemical indicators, and other variables. Abbreviations AN Anorexia nervosa AN-R restricting-type of Anorexia nervosa AN-BP binge-eating/purging type of Anorexia nervosa HC Healthy controls ETI-SF Early Trauma Inventory-short form BIS-11 Barratt Impulsiveness Scale 11th Version EDE-Q 6.0 Eating Disorder Examination-questionnaire 6.0 BDI Beck Depression Inventory BAI Beck Anxiety Inventory DSM-5 the Diagnostic and Statistical Manual 5th Edition BMI Body mass index CI Confidence Interval P P-Valu F F-Value β Beta-Value SE Standard Error Declarations Ethics approval and consent to participate The official ethical approval was granted by the Ethics Committee of our Health Center (Approval No. 2018-28), with written informed consent provided by adult patients themselves, or by pediatric patients themselves and their guardians. Consent for publication This manuscript is original and has never been published or presented elsewhere. All the authors have approved the manuscript and agree with submission to your esteemed journal. Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The Integrated Innovation Team of Shanghai Mental Health Center; National Natural Science Foundation of China (grant number: 82471573); Clinical Science and Technology Innovation Project of Shanghai Hospital Development Center (grant number: SHDC12023122); and Chinese Medicine Education Association (grant number: 2022KTM033) supported this work. Authors' contributions JZ is responsible for study design, data analysis and writing of the initial manuscript. YRH contributed to the recruitment of participants in the healthy control group, data acquisition and critical input. QK contributed to revisions. MTW contributed to appraisal of data. YLZ and SFP contributed to the recruitment of participants in the case group and data acquisition. JC contributed to study design, project supervision and revisions. All authors read and approved the final manuscript. Acknowledgements The authors are grateful to all participants in this study. Author details ¹Department of Psychological Medicine, Shanghai Xuhui District Dahua Hospital, Shanghai, China. ²Department of Clinical Psychology, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China. ³Shanghai Changning Mental Health Center, Shanghai, China. Correspondence: Jue Chen, Department of Clinical Psychology, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, 600 Wan Ping Nan Road, Shanghai, 200030. Email: [email protected] References Zhang L, Wu MT, Guo L, Zhu ZY, Chen J. Psychological distress and associated factors of the primary caregivers of offspring with eating disorder during the coronavirus disease 2019 pandemic. Journal of Eating Disorders. 2021;9(1).http://doi.org/10.1186/s40337-021-00405-9. 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Cite Share Download PDF Status: Published Journal Publication published 26 Feb, 2026 Read the published version in Journal of Eating Disorders → Version 1 posted Editorial decision: Revision requested 08 Sep, 2025 Reviews received at journal 06 Sep, 2025 Reviews received at journal 28 Aug, 2025 Reviewers agreed at journal 28 Aug, 2025 Reviewers agreed at journal 27 Aug, 2025 Reviewers invited by journal 27 Aug, 2025 Editor assigned by journal 25 Aug, 2025 Submission checks completed at journal 25 Aug, 2025 First submitted to journal 24 Aug, 2025 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. 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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-7445886","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":508938154,"identity":"7dae32c2-c3cc-4e5b-8040-288d75be3011","order_by":0,"name":"Jing Zhang","email":"","orcid":"","institution":"Shanghai Xuhui District Dahua Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Zhang","suffix":""},{"id":508938155,"identity":"acfc232e-e76b-4c14-82a2-d4034e8a5829","order_by":1,"name":"Yanran Hu","email":"","orcid":"","institution":"Shanghai Mental Health Center","correspondingAuthor":false,"prefix":"","firstName":"Yanran","middleName":"","lastName":"Hu","suffix":""},{"id":508938156,"identity":"d3e44eee-b6ba-468a-9963-88ad9c9f2f40","order_by":2,"name":"Qing Kang","email":"","orcid":"","institution":"Shanghai Mental Health Center","correspondingAuthor":false,"prefix":"","firstName":"Qing","middleName":"","lastName":"Kang","suffix":""},{"id":508938158,"identity":"6c93e4f3-e195-4b55-a46b-661ece91635f","order_by":3,"name":"Mengting Wu","email":"","orcid":"","institution":"Shanghai Mental Health Center","correspondingAuthor":false,"prefix":"","firstName":"Mengting","middleName":"","lastName":"Wu","suffix":""},{"id":508938159,"identity":"a600cd8e-66b6-4e64-959f-a6ef534f8769","order_by":4,"name":"Yunling Zou","email":"","orcid":"","institution":"Shanghai Changning Mental Health Center","correspondingAuthor":false,"prefix":"","firstName":"Yunling","middleName":"","lastName":"Zou","suffix":""},{"id":508938160,"identity":"a80c411c-4618-4505-9c9d-e17a4bad3962","order_by":5,"name":"Sufang Peng","email":"","orcid":"","institution":"Shanghai Mental Health Center","correspondingAuthor":false,"prefix":"","firstName":"Sufang","middleName":"","lastName":"Peng","suffix":""},{"id":508938161,"identity":"5594a2ff-0092-48e5-9ec1-b944601c279d","order_by":6,"name":"Jue Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYDACCQiWY2NvPvggoaKGeC3G/DzHkg0enDlGpBYgSJw5I8dM8mELM2Ed/LObjz2wbLNh3HDmWFpFYgMbA397dwJ+S+4cSzeQbEtjNjjefOxG4g4ZBokzZzfg1WIgkWMmIdl2mM0AaMuNxDNsQJFcQlryvwG1/OcxuJFjVpDYxkyMlhw2oJYDEpJA7zMQpUXiRpqZhMS5ZANQIEsknDnGQ9Av/DOSn0lLlNnVtwGj8uOPiho5/vZe/FpAgFkCicNDUDkIMH4gStkoGAWjYBSMWAAAN2lI8k+k0QIAAAAASUVORK5CYII=","orcid":"","institution":"Shanghai Mental Health Center","correspondingAuthor":true,"prefix":"","firstName":"Jue","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2025-08-24 11:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7445886/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7445886/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40337-026-01557-2","type":"published","date":"2026-02-26T15:57:40+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90792596,"identity":"d7637ea6-3eca-42ba-a7b0-f3bdd935365b","added_by":"auto","created_at":"2025-09-08 08:29:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":20769,"visible":true,"origin":"","legend":"\u003cp\u003eMediation effect model of emotional abuse and disease severity\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003e\u003cem\u003eP \u003c/em\u003e\u0026lt; 0.05\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7445886/v1/84ba5abd434214e8c8cf52b1.png"},{"id":103765451,"identity":"a986adbb-da88-425b-892c-651b11742e1b","added_by":"auto","created_at":"2026-03-02 16:02:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":929460,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7445886/v1/0140879b-e1e9-43b3-90df-35aa4d0d10d0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Correlation Between Anorexia Nervosa and Childhood Traumatic Experience: the Mediating Role of Impulsivity","fulltext":[{"header":"Plain English summary","content":"\u003cp\u003eIn recent years, the incidence rate of anorexia nervosa (AN) in China has been rising, drawing significant attention. The causes of AN have long been a challenging and prominent research topic. In this study, we explored the childhood traumatic experience and personality traits of patients with AN. We found that different subtypes of AN are associated with varying childhood traumatic experience. AN patients with symptoms of binge eating and purging often suffered more emotional abuse in their childhood, such as being scolded, neglected, or belittled for a long time. We also found that impulsivity plays an important role in the development of AN. Through this study, we aim to elucidate the pathogenic mechanisms of AN and generate novel insights for its clinical intervention.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eAnorexia nervosa (AN) is an eating disorder featured predominantly by extreme dieting and significant weight loss, accompanied frequently by excessive concern about body weight and shape, as well as an intense fear of obesity in the affected individuals (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). AN is highly prevalent among adolescents and young women, which not only causes damage to the patient's mental health, but also leads to bradycardia, electrolyte disorders, osteoporosis, endocrine disorders and various other complications, even posing a threat to life in severe cases (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Given the development of media and the impact of novel coronavirus pandemic recently, the incidence of AN is on the rise, triggering significantly adverse impact on Chinese adolescents(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). According to the diagnostic criteria of the Diagnostic and Statistical Manual 5th Edition (DSM-5), it consists of the restricting-type (AN-R) and binge-eating/purging-type (AN-BP) based on the presence or absence of recurrent binge-eating or purging behaviors in the last 3 months. Patients with AN-BP has been found to have a heightened impulsivity trait, attributable intimately to their binge eating and purging behaviors (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Our prior research has documented more pronounced impulsivity in AN-BP patients than that in AN-R cases, which was evidenced by lack of planning, pursuit of sensation-seeking behaviors, and difficulty in adhering to tasks, yet with poor understanding on the early factors contributing to the heterogeneity currently (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIt should be acknowledged that AN has a complex pathogenesis involving multiple biological, psychological, and sociocultural factors (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In recent decades, great concern has been attached to the potential role of childhood traumatic experience in the pathogenesis of AN. Childhood traumatic experience, including emotional abuse, physical abuse, and sexual trauma, has been confirmed to be associated with the development of several mental disorders (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). As evidenced by the results of neuroimaging (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), childhood traumatic experience can cause emotional disturbance, presenting with emotional instability, behavioral impulsivity, and interpersonal difficulties, with influence in prefrontal-limbic system functions. The childhood traumatic experience of AN patients may affect disease development by affecting the emotion regulation and impulsivity of individuals. So far, there are still relatively few studies in China on the differences of childhood traumatic experience in different subtypes of AN and their correlation with AN. Accordingly, the present study was conducted to compare childhood traumatic experience in patients with different subtypes of AN, to explore the correlation of childhood traumatic experience with impulsivity and disease severity, and to unveil the mediating role of impulsivity, so as to provide a scientific basis for early intervention and individualized treatment of AN patients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eFrom September 2019 to August 2024, this study included 164 patients who were admitted to the Psychosomatic Medicine Ward and Psychological Counseling Clinic of Shanghai Mental Health Center as the AN group. Subsequently, patients in the AN group were further divided into the AN-R group (n\u0026thinsp;=\u0026thinsp;76) and the AN-BP group (n\u0026thinsp;=\u0026thinsp;81), with 7 cases of atypical AN not included in the subgroups.\u003c/p\u003e\u003cp\u003eThe healthy control (HC) group included 124 cases from the recruited population and students of Shanghai Jiao Tong University.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003eThe inclusion criteria for AN group were as follows: female; Han Chinese; 13\u0026ndash;30 years old; confirmed diagnosis of AN by clinical psychologists or psychiatrists at deputy director-level and above based on the criteria of the DSM-5; body mass index (BMI) ranged between 13-18.5 kg/m\u003csup\u003e2\u003c/sup\u003e. The exclusion criteria for AN group were as follows: met the diagnostic criteria of other mental disorders except AN; serious passive suicidal ideation or behaviors; serious somatic diseases or physical complications; pregnant or breastfeeding.\u003c/p\u003e\u003cp\u003eThe inclusion criteria for HC group were as follows: females; Han Chinese; 13\u0026ndash;30 years old; BMI ranged between 18.5\u0026ndash;23.9 kg/m\u003csup\u003e2\u003c/sup\u003e. The exclusion criteria for HC group were as follows: met any of the diagnostic criteria of DSM-5; serious somatic diseases or physical complications; pregnant or breastfeeding.\u003c/p\u003e\n\u003ch3\u003eAssessment scales\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eGeneral information questionnaire\u003c/h2\u003e\u003cp\u003eGeneral information of all the enrolled participants was acquired by using a self-designed general information questionnaire, including study number, name, gender, age, occupation, marriage, education level, height, weight, BMI, contact information, history of major illnesses, history of suicide attempts, and history of pregnancy. For AN patients, additional data should also be included, such as the age at onset, total course of disease, precipitating factors, current diagnosis (including subtype), outpatient number, or hospitalization number.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEating Disorder Examination-questionnaire (EDE-Q 6.0)\u003c/h3\u003e\n\u003cp\u003eEDE-Q 6.0 is a self-rating scale with 28 entries, which is divided into four subscales, including dietary restriction, eating concerns, body image concerns, and weight concerns. The Chinese version of this questionnaire has good reliability and validity (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In this study, EDE-Q 6.0 was employed to assess the clinical behavioral and psychological characteristics of AN, and to evaluate the disease severity of AN by rating the frequency and intensity of symptoms.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eBarratt Impulsiveness Scale 11th Version (BIS-11)\u003c/h2\u003e\u003cp\u003eBIS-11 is a self-assessment questionnaire with 30 entries. It is the most common self-report scale for measuring impulsivity from attentional impulsivity, motor impulsivity, and unplanned impulsivity, with good reliability and validity (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The assessed with higher scores would have higher impulsivity.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEarly Trauma Inventory-short form (ETI-SF)\u003c/h3\u003e\n\u003cp\u003eIn order to investigate the traumatic experience of participants before the age of 18, this study employed the self-assessment questionnaire ETI-SF for assessing environmental factors. The questionnaire has 27 items from four dimensions of general trauma, physical trauma, emotional abuse, and sexual trauma. The Chinese version of this questionnaire has been validated to possess good reliability and validity (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Each entry has two options of \u0026ldquo;yes\u0026rdquo; and \u0026ldquo;no\u0026rdquo;, with \u0026ldquo;yes\u0026rdquo; scoring 1 point and \u0026ldquo;no\u0026rdquo; scoring 0 point.\u003c/p\u003e\n\u003ch3\u003eEmotional-Related Assessment Scales\u003c/h3\u003e\n\u003cp\u003eTo assess the participants' emotional states, this study used Beck Depression Inventory (BDI) to evaluate depressive symptoms and Beck Anxiety Inventory (BAI) to assess anxiety symptoms, respectively. Both of these scales are self-report scales, and their Chinese versions have demonstrated good reliability and validity.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analyses\u003c/h2\u003e\u003cp\u003eDatabase establishment and data analysis were completed in SPSS 26.0. Measurement data were evaluated for normality by Kolmogorov-Smirnov normality test and stem-and-leaf plot, with normally distributed data expressed as x\u0026thinsp;\u0026plusmn;\u0026thinsp;s. Inter-group and multi-group comparisons employed independent samples t-test, and one-way analysis of variance, respectively, and pairwise comparison adopted the LSD method. Pearson correlation analysis was utilized to profile the correlations of continuous variables. Finally, the percentile Bootstrap method (PROCESS plug-in) was used to perform mediation effect test (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), with the random sampling set as 5,000 times and reported 95% confidence interval (CI). The presence of statistically significant difference was determined when \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eComparison of childhood traumatic experience\u003c/h2\u003e\u003cp\u003eInter-group statistical comparison revealed no statistically significant differences in the distribution of age, height and years of education between AN and HC groups (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), with BMI of the AN group significantly lower than that of the HC group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Meanwhile, the age, years of education, weight, and BMI of the AN-R group were significantly lower than those of the AN-BP group (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), without any significant differences in height between groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.972).\u003c/p\u003e\u003cp\u003eAccording to the comparison of childhood traumatic experience among groups, the AN-BP group had significantly higher ETI-SF total score and emotional abuse scores than those of the AN-R and HC groups (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Inter-group comparison between the AN-R and HC groups revealed no significant difference in the ETI-SF total score, scores of physical trauma, emotional abuse, and sexual trauma (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In addition, the general trauma score in the AN-R group was obviously lower than that in the AN-BP and HC groups (both \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\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\u003eComparison of childhood traumatic experience between AN-R group, AN-BP group, and HC groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAN-R\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;76)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAN-BP\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;81)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHC\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;124)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u003cp\u003ePairwise comparison \u003cem\u003ep\u003c/em\u003e-values\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eAN-R Vs AN-BP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eAN-R Vs HC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eAN-BP Vs HC\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eETI-SF\u003c/p\u003e\u003cp\u003eTotal score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.27\u0026plusmn;\u003c/p\u003e\u003cp\u003e3.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.64\u0026plusmn;\u003c/p\u003e\u003cp\u003e4.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.20\u0026plusmn;\u003c/p\u003e\u003cp\u003e3.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6.203\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.082\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.017\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGeneral trauma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.59\u0026plusmn;\u003c/p\u003e\u003cp\u003e1.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.09\u0026plusmn;\u003c/p\u003e\u003cp\u003e1.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.21\u0026plusmn;\u003c/p\u003e\u003cp\u003e1.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.643\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.028\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.071\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.613\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysical trauma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.37\u0026plusmn;\u003c/p\u003e\u003cp\u003e1.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.89\u0026plusmn;\u003c/p\u003e\u003cp\u003e1.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.56\u0026plusmn;\u003c/p\u003e\u003cp\u003e1.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.780\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.171\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.063\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.424\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.182\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional abuse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.11\u0026plusmn;\u003c/p\u003e\u003cp\u003e1.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.29\u0026plusmn;\u003c/p\u003e\u003cp\u003e1.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.24\u0026plusmn;\u003c/p\u003e\u003cp\u003e1.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e10.574\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.593\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSexual trauma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.15\u0026plusmn;\u003c/p\u003e\u003cp\u003e0.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.38\u0026plusmn;\u003c/p\u003e\u003cp\u003e0.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.19\u0026plusmn;\u003c/p\u003e\u003cp\u003e0.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1.922\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.149\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.069\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.689\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.096\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eCorrelation analysis between AN and childhood traumatic experience\u003c/h2\u003e\u003cp\u003eAccording to the correlation analysis, the ETI-SF total score revealed significantly positive correlations with EDE-Q 6.0 total score, BDI score and BAI score (r\u0026thinsp;=\u0026thinsp;0.249\u0026ndash;0.350, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000-0.006). Furthermore, emotional abuse in the ETI-SF scale also yielded significantly positive correlations with EDE-Q 6.0 total score, BDI score and BAI score (r\u0026thinsp;=\u0026thinsp;0.401\u0026ndash;0.471, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000). Physical trauma was significantly positively correlated with BDI score and BAI score (r\u0026thinsp;=\u0026thinsp;0.282, p\u0026thinsp;=\u0026thinsp;0.002; r\u0026thinsp;=\u0026thinsp;0.257, p\u0026thinsp;=\u0026thinsp;0.005). However, general trauma and sexual trauma in the ETI-SF scale had none obvious correlations with clinical characteristics of AN (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.01).\u003c/p\u003e\u003cp\u003eOur correlation analysis also showed that the ETI-SF total score exhibited significantly positive correlations with the BIS-11 score (r\u0026thinsp;=\u0026thinsp;0.240, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.014). Meanwhile, emotional abuse in the ETI-SF scale was significantly and positively correlated with the BIS-11 score (r\u0026thinsp;=\u0026thinsp;0.285, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003). However, no significant correlation was observed in general trauma, physical trauma, and sexual trauma with BIS-11 score (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\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\u003eCorrelation between AN and childhood traumatic experience\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\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=\"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\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eETI-SF total score\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGeneral trauma\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePhysical trauma\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eEmotional abuse\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSexual trauma\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eEDE-Q 6.0 total score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePearson correlation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.249**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.058\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.409\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e-0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSignificance (bilateral)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.530\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.127\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.987\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBDI score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePearson correlation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.290**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e-0.012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.282**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.401**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.053\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSignificance (bilateral)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.898\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.569\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBAI score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePearson correlation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.350**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.018\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.257**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.471**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.194\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSignificance (bilateral)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.845\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.005\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.034\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBIS-11 score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePearson correlation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.240\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.103\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.149\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.285\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.091\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSignificance (bilateral)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.295\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.127\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.351\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eMediation effect test of impulsivity\u003c/h2\u003e\u003cp\u003eGiven the strong correlations of emotional abuse in childhood traumatic experience with impulsivity and disease severity, Model 4 of the PROCESS plug-in was used for modeling, with emotional abuse as the independent variable, disease severity as the dependent variable, and impulsivity as the mediator variable. Based on the results of regression analysis, emotional abuse indicated a significant positive predictive effect on impulsivity (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.551, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.995, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003) and disease severity (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.304, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.123, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000), suggesting 0.304-unit increase in disease severity per one-unit increase in emotional abuse. Moreover, after the control of emotional abuse, there was still a significant direct effect of impulsivity on disease severity (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.047, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.492, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eOur study continued to investigate the mediation effect on impulsivity between emotional abuse and disease severity in AN patients by employing a Bootstrap method. The results showed that the total effect of emotional abuse on disease severity was 0.377, with a CI not containing 0 (95% CI: 0.229\u0026thinsp;~\u0026thinsp;0.524). The direct effect of emotional abuse on disease severity was 0.304, with the CI not containing 0 (95% CI 0.158\u0026thinsp;~\u0026thinsp;0.450). The mediation effect of impulsivity between emotional abuse and disease severity was 0.073, with the CI of Bootstrap not containing 0 (95% CI 0.013\u0026thinsp;~\u0026thinsp;0.153) and an effect proportion of 19.363%. As a result, impulsivity might exert a partial mediation effect between emotional abuse and disease severity.\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\u003eRegression analysis of the mediation model\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u003cp\u003eDependent variable\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eDisease severity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eDisease severity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eImpulsivity\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003et\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional abuse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.123\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.066\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.995\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImpulsivity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.492\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eR\u003c/em\u003e\u0026sup2; value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e0.287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.201\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.081\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eF\u003c/em\u003e value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e20.336\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e25.660\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e8.971\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMediation effect analysis of impulsivity\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffect type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEffect value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSE\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRelative effect ratio/%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.377\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.074\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.229\u0026thinsp;~\u0026thinsp;0.524\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e100.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDirect effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.304\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.073\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.158\u0026thinsp;~\u0026thinsp;0.450\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e80.637\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndirect effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.073\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.036\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.013\u0026thinsp;~\u0026thinsp;0.153\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19.363\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIt has been well-established with regard to the pathogenesis of AN, a complex, multifactorial disease, generally involving the combined effects of genetic, environmental, and personality factors. Previous research has been dedicated to discovering the potential risk factors that may exist in the growth environment of AN. As early as 1989, a survey in the United States found the experience of sexual abuse in 38% of women with eating disorders (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In 2001, a twin study in the United Kingdom revealed that AN patients had suffered from more physical and sexual trauma than their healthy sisters through the interview of 45 pairs of sisters using the Eating Disorder Risk Factor Questionnaire from Oxford University (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Similar to the results of a cross-sectional study (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), the present study found that AN-BP patients had more significant childhood traumatic experience than AN-R patients according to the evaluation and comparison of childhood traumatic experience between two subtypes of AN. Moreover, differences between the two subtypes were mainly manifested in the emotional abuse. Consistently, a study in the United States supported childhood abuse as an inducing factor of emotional disturbance in AN patients, with the strongest relationship between emotional abuse and the severity of AN symptoms (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Therefore, childhood traumatic experience, especially emotional abuse, may be an essential contributor to the pathogenesis of AN. Emotional abuse may stem from parental or caregiver misunderstanding, indifference, criticism, belittlement, or neglect. As documented by a Chinese study, AN patients often experienced an uncomfortable family environment characterized by low intimacy, low emotional expression, low entertainment value, and high ambivalence (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Beyond that, emotional abuse may also originate from school, social, and other environments, such as humiliation or ridicule of classmates, cyberbullying, or verbal aggression. Accumulated evidence has revealed more traumatic experiences (e.g., sexual and physical trauma) in AN patients than the general population (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). However, this study failed to uncover significant difference in sexual and physical trauma between the two subtypes of AN and HC. It may be explained by the relatively low incidence of sexual and physical trauma with social progress and the continuous improvement of the rule of law. In addition, some participants of study may choose to conceal some experience owing to privacy-exposing factors, leading to potential reporting bias.\u003c/p\u003e\u003cp\u003eOn the basis of previous study, it can be understood that AN-BP patients exhibited more significant impulsivity than AN-R patients, evidenced by increased attentional impulsivity, motor impulsivity, and unplanned impulsivity, which was in line with the recurrent binge eating and purging behaviors (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Furthermore, individuals with serious childhood traumatic experience might also develop maladaptive personality traits. It has been reported that childhood abuse can increase the risk of developing impulsive, antisocial, obsessive-compulsive, and anxious personalities in adulthood (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In 2016, Spinhoven et al. found that childhood traumatic experience mediated by maladaptive traits can predict higher psychological stress levels, which might increase the risk of mental illness (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Similarly, Chinese researchers have also found significantly increase the risk of multiple mental problems in adolescents in subjects experiencing emotional and physical abuse in childhood (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This study also showed a similar conclusion that childhood traumatic experience was significantly and positively correlated with impulsivity in AN, highlighting more significant correlation between emotional abuse and impulsivity. Prior research has also revealed the relationship of emotional abuse during childhood in AN patients with impulsive behavior under negative emotions (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFurthermore, our study also get into the bottom of the mediating role of impulsivity between emotional abuse and disease severity in childhood traumatic experience. Beyond direct exacerbation of the clinical manifestations of AN, emotional abuse would also indirectly exacerbate the disease severity by shaping high impulsivity traits. It was highly consistent with the theory of the emotion dysregulation-impulsivity model in dialectical behavioral therapy. In other words, emotional abuse in childhood traumatic experience can compromise the regulatory role of individuals on negative emotions to induce impulsive coping strategies (e.g., binge eating, vomiting, autolesion, and substance abuse), behaviors that are core features of AN-BP (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Accordingly, it may provide use with some insights into clinical psychotherapy, where different psychological treatment methods can be used for targeted interventions on childhood traumatic experience of patients (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). For example, family therapy can be employed to adjust family interaction mode, repair family relationships, and reduce family environment-induced emotional neglect or emotional abuse (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Dialectical behavior therapy targeting impulsivity may facilitating patients\u0026rsquo; understanding and grasp of emotional regulation skills and mindfulness skills, thus dealing with emotional dysregulation and impulsive behaviors caused by childhood traumatic experience (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Additionally, cognitive behavioral therapy can be used to deal with traumatic memory; while gradual exposure and cognitive reconstruction can be utilized to reduce negative emotions and impulsive behaviors caused by traumatic experience (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, AN-BP patients have more significant childhood traumatic experience than AN-R patients, which is particularly prominent in emotional abuse. Emotional abuse in childhood traumatic experience can affect the disease severity either through direct effects or through mediation effects of impulsivity. Therefore, clinical interventions should focus on both the relief of clinical symptoms of AN, and the management of trauma and emotional disturbance taking into consideration of the family environment, personality traits, and other factors of patients. However, this study still has some limitations. For example, as a cross-sectional study, this study established correlations between all factors, but their causal relationship necessitate further exploration and validation. In addition, this study only included impulsivity as a single mediating variable in the mediation effect model. Therefore, future in-depth studies can be conducted by establishing a more complete mechanism model based on the inclusion of more personality traits, as well as integration of neuroimaging, biochemical indicators, and other variables.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnorexia nervosa\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAN-R\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003erestricting-type of Anorexia nervosa\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAN-BP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ebinge-eating/purging type of Anorexia nervosa\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealthy controls\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eETI-SF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEarly Trauma Inventory-short form\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBIS-11\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBarratt Impulsiveness Scale 11th Version\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEDE-Q 6.0\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEating Disorder Examination-questionnaire 6.0\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBDI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBeck Depression Inventory\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBAI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBeck Anxiety Inventory\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDSM-5\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ethe Diagnostic and Statistical Manual 5th Edition\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBody mass index\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConfidence Interval\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eP-Valu\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eF-Value\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBeta-Value\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStandard Error\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe official ethical approval was granted by the Ethics Committee of our Health Center (Approval No. 2018-28), with written informed consent provided by adult patients themselves, or by pediatric patients themselves and their guardians.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript is original and has never been published or presented elsewhere. All the authors have approved the manuscript and agree with submission to your esteemed journal.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on 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\u003eThe Integrated Innovation Team of Shanghai Mental Health Center; National Natural Science Foundation of China (grant number: 82471573); Clinical Science and Technology Innovation Project of Shanghai Hospital Development Center (grant number: SHDC12023122); and Chinese Medicine Education Association (grant number: 2022KTM033) supported this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJZ is responsible for study design, data analysis and writing of the initial manuscript. YRH contributed to the recruitment of participants in the healthy control group, data acquisition and critical input. QK contributed to revisions. MTW contributed to appraisal of data. YLZ and SFP contributed to the recruitment of participants in the case group and data acquisition. JC contributed to study design, project supervision and revisions.\u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are grateful to all participants in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e¹Department of Psychological Medicine, Shanghai Xuhui District Dahua Hospital, Shanghai, China.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e²Department of Clinical Psychology, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e³Shanghai Changning Mental Health Center, Shanghai, China.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCorrespondence: Jue Chen, Department of Clinical Psychology, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, 600 Wan Ping Nan Road, Shanghai, 200030. Email: [email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eZhang L, Wu MT, Guo L, Zhu ZY, Chen J. Psychological distress and associated factors of the primary caregivers of offspring with eating disorder during the coronavirus disease 2019 pandemic. Journal of Eating Disorders. 2021;9(1).http://doi.org/10.1186/s40337-021-00405-9.\u003c/li\u003e\n \u003cli\u003eNitsch A, Kearns M, Mehler P. Pulmonary complications of eating disorders: a literature review. Journal of eating disorders. 2023;11(1):12.http://doi.org/10.1186/s40337-023-00735-w.\u003c/li\u003e\n \u003cli\u003eRosval L, Steiger H, Bruce K, Isra\u0026euml;l M, Richardson J, Aubut M. Impulsivity in women with eating disorders: problem of response inhibition, planning, or attention? International Journal of Eating Disorders. 2010;39(7):590-3.http://doi.org/10.1002/eat.20296.\u003c/li\u003e\n \u003cli\u003eGrange DL, Crosby RD, Engel SG, Li C, Ndungu A, Crow SJ, et al. DSM‐IV‐Defined Anorexia Nervosa Versus Subthreshold Anorexia Nervosa (EDNOS‐AN). European Eating Disorders Review. 2013;21(1):1-7.http://doi.org/10.1002/erv.2192.\u003c/li\u003e\n \u003cli\u003eHan C, Jing Z, Xiao-Ping LI, Hui-Qin H, Meng-Ting WU, Yan C, et al. Correlation study on personality traits of patients with anorexia nervosa. Journal of Shanghai Jiaotong University (Medical Science). 2021;41(12).http://doi.org/10.3969/j.issn.1674-8115.2021.12.015.\u003c/li\u003e\n \u003cli\u003eTreasure J, Duarte TA, Schmidt U. Eating disorders. Lancet. 2020;395(10227):899-911.http://doi.org/10.1016/s0140-6736(20)30059-3.\u003c/li\u003e\n \u003cli\u003eCheng-Mei Y, Jia H, Zhen W, Ze-Qin L, Zhi-Yang W. Correlation analysis of early trauma experience and depression and suicidal tendency of patients with depression. Journal of Shanghai Jiaotong University. 2010;30(6):628-30\u003c/li\u003e\n \u003cli\u003eLi P, Cheng J, Gu Q, Wang P, Lin Z, Fan Q, et al. Intermediation of perceived stress between early trauma and plasma M/P ratio levels in obsessive-compulsive disorder patients. Journal of Affective Disorders. 2021;285:105-11.http://doi.org/10.1016/j.jad.2021.02.046.\u003c/li\u003e\n \u003cli\u003eDvir Y, Ford JD, Hill M, Frazier JA. Childhood Maltreatment, Emotional Dysregulation, and Psychiatric Comorbidities. Harv Rev Psychiatry. 2014;22(3):149-61.http://doi.org/10.1097/HRP.0000000000000014.\u003c/li\u003e\n \u003cli\u003eLian G, Jue C, Yue H, Qing K, Jia-Bin H, Yan-Ling H, et al. Validity and reliability of the Chinese version of the Eating Disorder Examination Questionnaire 6.0 in female patients with eating disorders. Chinese Mental Health Journal. 2017;31(5):350-5\u003c/li\u003e\n \u003cli\u003eZhou L, Xiao SY, He XY, Li J, Liu H. Reliability and validity of Chinese version of Barratt Impulsiveness Scale-11. Chinese Journal of Clinical Psychology. 2006;14(4):343-4\u003c/li\u003e\n \u003cli\u003eZhen W, Jiang D, Jue C, Cheng-Mei Y, Yuan W, Min Z, et al. Reliability and validity of Chinese version of early trauma inventory-short form. Chinese Journal of Behavioral Medicine and Brain Science. 2008;17(10):956-8\u003c/li\u003e\n \u003cli\u003eHayes AF. An Index and Test of Linear Moderated Mediation. Multivariate Behavioral Research. 2015;50(1):1-22.http://doi.org/10.1080/00273171.2014.962683.\u003c/li\u003e\n \u003cli\u003eHall RC, Tice L, Beresford TP, Wooley B, Hall AK. Sexual abuse in patients with anorexia nervosa and bulimia. Psychosomatics. 1989;30(1):73\u003c/li\u003e\n \u003cli\u003eA. KARWAUTZ, S. RABEHESKETH, X. HU, J. ZHAO, P. SHAM, A. COLLIER D, et al. Individual-specific risk factors for anorexia nervosa: a pilot study using a discordant sister-pair design. Psychological Medicine. 2001;31(2):317-29.http://doi.org/10.1017/S0033291701003129.\u003c/li\u003e\n \u003cli\u003eJaite C, Schneider N, Hilbert A, Pfeiffer E, Lehmkuhl U, Salbach-Andrae H. Etiological role of childhood emotional trauma and neglect in adolescent anorexia nervosa: a cross-sectional questionnaire analysis. Psychopathology. 2012;45(1):61-6.http://doi.org/10.1159/000328580.\u003c/li\u003e\n \u003cli\u003eRacine SE, Wildes JE. Emotion dysregulation and anorexia nervosa: an exploration of the role of childhood abuse. The International journal of eating disorders. 2015;48(1):55-8.http://doi.org/10.1002/eat.22364.\u003c/li\u003e\n \u003cli\u003eQing K, Jue C, Wen-Hui J, Shan-Qin WU, Qiang L, Han C, et al. Relationship between features of family environment and clinical symptoms in patients with anorexia nervosa. Chinese Mental Health Journal. 2014\u003c/li\u003e\n \u003cli\u003eConnors ME, Morse W, . Sexual abuse and eating disorders: a review. The International journal of eating disorders. 1993;13(1):1-11\u003c/li\u003e\n \u003cli\u003eBrown L, ., Russell J, ., Thornton C, ., Dunn S, . Experiences of physical and sexual abuse in Australian general practice attenders and an eating disordered population. Aust N Z J Psychiatry. 1997;31(3):398-404\u003c/li\u003e\n \u003cli\u003eCaspi A, Poulton R. Role of genotype in the cycle of violence in maltreated children. Science. 2002;297(5582):851-4\u003c/li\u003e\n \u003cli\u003eZanarini MC. CHILDHOOD EXPERIENCES ASSOCIATED WITH THE DEVELOPMENT OF BORDERLINE PERSONALITY DISORDER. The American journal of psychiatry. 1997;154(8):1101-6\u003c/li\u003e\n \u003cli\u003eSciolla A, Glover DA, Loeb TB, Zhang M, Myers HF, Wyatt GE. Childhood sexual abuse severity and disclosure as predictors of depression among adult African American and Latina women. Journal of Nervous and Mental Disease. 2011;199(7):471-7.http://doi.org/10.1097/NMD.0b013e31822142ac.\u003c/li\u003e\n \u003cli\u003eP S, BM E, AM VH, M dR, BW P. Childhood maltreatment, maladaptive personality types and level and course of psychological distress: A six-year longitudinal study. Journal of affective disorders. 2016;191:100.http://doi.org/10.1016/j.jad.2015.11.036.\u003c/li\u003e\n \u003cli\u003eHuang K, Tao FB, Kim S, Ye Q, Sun Y, Zhang CY, et al. Correlation between psychopathological symptoms,coping style in adolescent and childhood repeated physical,emotional maltreatment. Chinese Journal of Pediatrics. 2006;44(9):688.http://doi.org/10.1360/aps040120.\u003c/li\u003e\n \u003cli\u003eJin-Meng L Y-MG, Chun-Xi L, Xia L. The potential addictive mechanism involved in repetitive nonsuicidal self-injury: The roles of emotion dysregulation and impulsivity in adolescents. Journal of behavioral addictions. 2022;11(4):953-62.http://doi.org/10.1556/2006.2022.00077.\u003c/li\u003e\n \u003cli\u003eGu L, Zou Y, Huang Y, Liu Q, Chen J. The effect of group cognitive behavior therapy on Chinese patients with anorexia nervosa: an open label trial. Journal of Eating Disorders. 2021;9(1).http://doi.org/10.1186/s40337-021-00469-7.\u003c/li\u003e\n \u003cli\u003eFisher CA, Skocic S, Rutherford KA, Hetrick SE. Family therapy approaches for anorexia nervosa. Cochrane Database of Systematic Reviews. 2019.http://doi.org/10.1002/14651858.CD004780.pub4.\u003c/li\u003e\n \u003cli\u003eBankoff SM, Karpel MG, Forbes HE, Pantalone DW. A Systematic Review of Dialectical Behavior Therapy for the Treatment of Eating Disorders. Eating Disorders. 2012;20(3):196-215.http://doi.org/10.1080/10640266.2012.668478.\u003c/li\u003e\n \u003cli\u003eVogel EN, Singh S, Accurso EC. A systematic review of cognitive behavior therapy and dialectical behavior therapy for adolescent eating disorders. Journal of Eating Disorders. 2021(1).http://doi.org/10.1186/S40337-021-00461-1.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"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":"Anorexia nervosa, Childhood traumatic experience, Emotional abuse, Impulsivity, Mediating role","lastPublishedDoi":"10.21203/rs.3.rs-7445886/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7445886/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe pathogenesis of anorexia nervosa (AN) involves multiple factors, among which childhood traumatic experience has attracted attention. It may affect AN by influencing emotional regulation and impulsivity. However, relevant research has rarely been conducted in China. The purpose of this study is to compare differences in childhood traumatic experience of patients with different subtypes of AN, and explore the correlation between AN and childhood traumatic experience, as well as elucidating the mediating role of impulsivity between emotional abuse in childhood traumatic experience and disease severity.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study included 164 patients with AN, including 76 with the restricting type (AN-R) and 81 with the binge-eating/purging type (AN-BP), as well as 124 matched healthy controls (HC). Childhood traumatic experience was evaluated using Early Trauma Inventory-short form (ETI-SF), impulsivity assessed by Barratt Impulsiveness Scale 11th Version (BIS-11), and clinical symptoms via Eating Disorder Examination-questionnaire (EDE-Q 6.0), Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI). Furthermore, inter-group differences in childhood traumatic experience were determined by one-way analysis of variance, the correlation between childhood traumatic experience and AN by Pearson correlation analysis, and the mediating role of impulsivity between emotional abuse and disease severity was clarified by the Bootstrap method.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCases in the AN-BP group had significantly higher exposure to childhood traumatic experience compared with the AN-R and HC groups (both \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Childhood traumatic experience was positively correlated with AN impulsivity and disease severity (both \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and emotional abuse in childhood traumatic experience was obviously positively correlated with AN impulsivity and disease severity (both \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In addition, the mediation effect of impulsivity between emotional abuse and disease severity was 0.073 (95% \u003cem\u003eCI\u003c/em\u003e 0.013\u0026thinsp;~\u0026thinsp;0.153), with an effect proportion of 19.363%.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAN-BP patients have more significant childhood traumatic experience than AN-R patients. Childhood traumatic experience, especially emotional abuse, has established correlation with impulsivity and disease severity in AN, with impulsivity playing a mediating role between emotional abuse and disease severity.\u003c/p\u003e","manuscriptTitle":"The Correlation Between Anorexia Nervosa and Childhood Traumatic Experience: the Mediating Role of Impulsivity","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-08 08:29:36","doi":"10.21203/rs.3.rs-7445886/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-08T20:53:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-06T11:55:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-28T18:03:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"206147455368598908298143662907438085266","date":"2025-08-28T09:16:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"283992786235685778861142657736669357024","date":"2025-08-27T19:38:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-27T18:56:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-25T22:34:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-25T22:34:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Eating Disorders","date":"2025-08-24T11:29:33+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":"7d8ab53a-0659-45fe-a280-baaff26fe4d6","owner":[],"postedDate":"September 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-02T16:00:44+00:00","versionOfRecord":{"articleIdentity":"rs-7445886","link":"https://doi.org/10.1186/s40337-026-01557-2","journal":{"identity":"journal-of-eating-disorders","isVorOnly":false,"title":"Journal of Eating Disorders"},"publishedOn":"2026-02-26 15:57:40","publishedOnDateReadable":"February 26th, 2026"},"versionCreatedAt":"2025-09-08 08:29:36","video":"","vorDoi":"10.1186/s40337-026-01557-2","vorDoiUrl":"https://doi.org/10.1186/s40337-026-01557-2","workflowStages":[]},"version":"v1","identity":"rs-7445886","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7445886","identity":"rs-7445886","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}