Results are largely consistent with our hypotheses and previous research demonstrating higher rates of psychiatric comorbidity , emotion regulation difficulties, and reward sensitivity in ED-SUD samples. Partially consistent with previous research , our results suggested a trend towards a higher frequency of binge eating in ED-SUD, although there were no differences between ED and ED-SUD groups on purging. Furthermore, patients with bulimic syndromes were not significantly more likely to have a SUD. While this is somewhat inconsistent with previous research , results support examining substance use across ED diagnoses. In contrast, with previous research, we did not find evidence for higher levels of self-harm or BPD symptoms in the ED-SUD group. Previous research supporting increased self harm in ED-SUD has been in adolescent samples , which may also explain this discrepancy. While previous research has found higher cluster B symptoms in ED-SUD , the lack of significant differences between ED and ED-SUD in our sample may be due to the relatively high scores on the BEST in both groups. Indeed, both groups scored similarly to patient samples with BPD .Taken together with previous research, several of these findings have important implications for developing a treatment approach for the ED-SUD population, and provide a rationale for the usefulness of DBT to target these disorders concurrently.Overall, results demonstrating a greater number of comorbid diagnoses for the ED-SUD group support the need for integrated treatment, which is consistent with recent calls from experts within the field . DBT takes a behavioral approach, treating behaviors, regardless of their diagnostic association, according to a specific hierarchy. Given the complexity of ED-SUD cases and the tendency for these patients to vacillate between ED and substance use behaviors over time , an integrated, transdiagnostic approach may be useful in treating both behavioral presentations. Importantly,vertical growing rack we did not find evidence for ED diagnostic differences between ED-SUD and ED only groups, lending further support for a transdiagnostic approach to ED-SUD treatment.

DBT provides a comprehensive framework for effectively working with the multiple comorbidities observed in ED-SUD patients. In particular, the focus on the DBT hierarchy may help address vacillation between ED-SUD and other comorbid symptoms. The DBT hierarchy systematically addresses the most severe and life-threatening symptoms first, to help avoid shifting treatment targets throughout treatment. Additionally, skills generalization may be particularly important in this population. Phone coaching, which is a part of DBT, may be useful in helping patients to generalize skills to multiple behaviors across environments. Regarding specific disorders, the non-statistically significant elevation in the likelihood of PTSD in the ED-SUD group compared to the ED alone group suggests that trauma symptoms may be a relevant treatment target for ED patients generally. Indeed, groups are working to develop protocols for the concurrent treatment of ED and PTSD , while existing trauma protocols are commonly used to treat PTSD in these populations such as the DBT/Prolonged Exposure protocol .Our study shows that ED-SUD patients report significantly greater difficulties with emotion regulation. More specifically, ED-SUD patients in our sample endorsed difficulties with regulating behavior when distressed, engaging in goal directed behavior when distressed, and accessing strategies for feeling better when distressed. Moreover, ED-SUD patients were more likely to already be prescribed a mood stabilizer; thus, despite previous treatment for emotion dysregulation they continued to have difficulty in this area. This is consistent with our hypothesis and points to emotion regulation as a critical treatment target. As previously discussed, DBT was specifically developed to provide education on emotion dysregulation and provide individuals with adaptive emotion regulation skills. Several skills were added to the DBT for SUD model to specifically address the heightened impulsivity reported by ED-SUD patients. These skills include Burning Bridges to persons, places, and things associated with substance abuse and Adaptive Denial of urges for substance use.The present findings that patients with ED-SUD report higher reward sensitivity to highlight the importance of assessing for and addressing temperament in this treatment population.

Reward sensitivity may be an underlying mechanism that drives an individual’s substance use and ED behaviors. For instance, substance use and ED behaviors may be highly rewarding in the moment; hence, patients seek the short-term rewards of addictive behaviors despite their long-term, negative consequences. Furthermore, a potential obstacle to abstinence from ED behaviors and substances of abuse is the non-rewarding aspect of abstinence . Several skills taught in DBT for SUDs target these barriers. Contingency management strategies to reduce cues and access to substances and behaviors , as well as reinforcement of adaptive behavior, are essential to treatment. Specifically, Community Reinforcement , and Abstinence Sampling focus on the reinforcement of healthy behaviors. In conjunction with findings on reward sensitivity, the trend towards the significance of increased punishment sensitivity in this ED-SUD population suggests that for some patients, holding patients accountable to treatment goals and implementing consequences and rewards accordingly may be important for behavior change. For example, using behavioral contracts and administering drug analysis screens to monitor substance use may be helpful. The DBT skill of Pros and Cons may help patients to identifying negative consequences of substance use.The present study has several strengths, including the use of structured clinical interviews to assess diagnoses and an examination of a broad range of constructs theoretically relevant to eating and substance use disorders. As such, this study adds to the limited literature investigating factors characterizing the ED-SUD population. However, there are several limitations worth noting. First, participants were drawn from a treatment-seeking sample presenting at a higher level of care. As such, results may not be representative of individuals with ED-SUD in the broader community. The modest ED-SUD sample size may have limited our ability to detect significant differences between groups. Additionally, the present study did not assess tobacco use or caffeine use disorders, which may also be relevant substances for ED groups, given their association with appetite suppression. Further, although the present sample included males and non-binary individuals, the smaller numbers in these groups limits the generalizability of the results beyond females. Importantly, we did not assess the past history of SUD, so the relative influences of active substance use versus traits underlying substance use on our findings cannot be determined.

Finally, this study reviewed factors that provide a rationale for the applicability of DBT to treat EDs and co-occurring substance use in a cross-sectional study; however, future longitudinal studies and randomized controlled trials are needed to examine outcomes to determine the efficacy of DBT to treat ED-SUDs.Psychoneuroimmunology refers to the study of interactions between behavior, neural and endocrine systems, and the immune system . Alder and Cohen state that the field of psychoneuroimmunology is intended to “emphasize the functional significance” of the relationship between mind and body systems “in addition to” and “not in place of analysis of the mechanisms governing functions within a single system.” This growing field seeks to understand the associations between environmental exposures and neural, endocrine, and immune systems,cannabis vertical grow as well as the consequences of inflammatory responses on human behavior, to allow for new insights into mechanistic pathways that are involved in the development of psychopathology. Thus, identifying the impact of early life adverse experiences, such as childhood trauma, on immune system regulation, and subsequent clinical outcomes, such as functioning, provides important information regarding possible therapeutic targets for early intervention and prevention of psychopathology. Psychiatric illnesses that begin during adolescence and disrupt successful transition into adulthood represent one such category of mental disorders for which primary prevention is key, but therapeutic targets meeting the goal of prevention are lacking. This study seeks to provide rationale for and test the hypothesis that immune system dysregulation may serve as a biological mediator between the experience of childhood trauma and vulnerability for developing psychosis by evaluating associations between childhood trauma, inflammation, and clinical outcomes in a sample of subjects at clinical high risk for psychosis . Childhood trauma is defined as the experience of severe and/or chronic interpersonal stress including abuse or neglect . In the development of a validated childhood trauma assessment tool, the Childhood Trauma Questionnaire , Bernstein et al. defined subcategories of childhood trauma as follows: 1) sexual abuse is defined as sexual activity between a minor child and an adult or older person ; 2) Physical abuse is defined as bodily assault imposed upon a minor by an adult, which resulted in risk or experience of injury; 3) Emotional abuse is defined as verbal assaults on an individual’s sense of worth or well-being, including verbal humiliation, intimidation, or demeaning behavior directed towards a minor by an adult; 4) Physical neglect is defined as the failure of caretakers to provide for a child’s basic physical needs, including food, clothing, shelter, safety, and health care, as well as poor parental supervision if such behavior places a minor’s safety in jeopardy; and 5) Emotional neglect is defined as a failure for a caretaker to provide a minor with appropriate emotional support or validation. Sub-types of trauma differ in prevalence.

The United States Department of Health and Human Services Administration for Children and Families report that the national number of children receiving a child protective services investigation response increased 10.0% percent from 2013 to 2017 , with the national rounded number of victims in 2017 approximated at 674,000 children. Three-quarters of these victims experienced neglect, 18.3 percent physical abuse, and 8.6 percent sexual abuse . However, prevention of childhood trauma extends far beyond mere desire to protect children, as research has established that the consequences of childhood trauma are severe and long-lasting. Firstly, experience of childhood trauma increases risk for medical illnesses such as lung disease, arthritic disorders, cardiac disease, diabetes, and autoimmune disorders . Moreover, the development of medical disorders is found to be directly proportional to the number and magnitude of childhood traumas experienced . Secondly, experience of childhood trauma is associated with significantly increased lifetime risk for developing serious mental illnesses, such as major depressive disorder , bipolar disorder , post-traumatic stress disorder , schizophrenia , as well as personality disorders and substance use disorders . Research on sub-types of childhood trauma and early life stress reveal that physical abuse, sexual abuse, and neglect are associated with the development of mood disorders and anxiety disorders, while emotional abuse is associated with development of personality disorders and schizophrenia . Other studies have identified sub-types of emotional abuse and neglect to be among the most significant predictors of developing a mood disorder in adulthood . Experience of multiple childhood traumas is a significant predictor of increased chronicity of depression, increased suicidal behavior, as well as poor response to antidepressant or combined psychosocial and pharmacological treatment.Incidence of childhood trauma is a significant predictor for severity of manic and depressive symptoms, psychotic symptoms, rapid cycling, greater number of depressive episodes, and increased risk of suicide attempts in individuals diagnosed with BD Importantly, childhood trauma has been reliably shown to be associated with increased risk for developing psychosis later in life . Research on the relationship between childhood adversity and psychosis not only links childhood abuse and neglect to psychotic symptoms, specifically hallucinations, but also indicates that the relationship is causal, with a dose-effect . A large cohort study by , demonstrated that youth who experienced trauma in the first 17 years of life were 2.91 times more likely to have psychotic symptoms at 18 years of age, and those who experienced 3 or more types of childhood trauma were 4.7 times more likely to have psychotic symptoms. Exposure to trauma during childhood is associated with increased emotional and psychotic reactivity to stress in patients diagnosed with psychotic disorders . This increased stress reactivity may represent both an expressed genetic liability, as well as an acquired vulnerability due to exposure to traumatic events. Exposure to childhood trauma may actually sensitize patients with psychosis liability for the later exposure to daily life stress . In fact, Varese et al. , argues the relationship between childhood trauma and psychosis is so significant, that removing childhood trauma from the population would yield a 33% decrease in number of individuals with psychosis. While studies have repeatedly shown that experience of childhood trauma is associated with an increased risk for developing both physical and mental illnesses later in life, the biological mechanisms by which this risk manifests are less explicit .