Psychological and clinical associations of adverse childhood experiences in Chinese patients with eating disorders

Eating disorders (EDs) are severe mental illnesses with significant morbidity and mortality. Adverse childhood experiences (ACEs) are recognized risk factors, but their specific impact across ED subtypes and the mediating psychological mechanisms require further elucidation. In this cross-sectional study (2008–2015), 970 outpatients with eating disorders (919 female) were assessed for adverse childhood experiences and clinical behaviors with the Eating Disorder Questionnaire, and for psychological traits with the Eating Disorder Inventory-1. This study used factorial ANOVA, Lasso regression, and mediation analysis to clarify the effects of ACEs and diagnostic subtypes, identify specific influencing factors, and explore the mediating role of psychological traits. ACEs were nominally associated with most clinical behaviors except dieting; after correction, the most robust associations were observed for binge eating, laxative use, and several onset-age variables. Childhood emotional abuse most profoundly impacted psychological traits. The cumulative number of ACEs was associated with increased severity of psychological traits and a higher likelihood of clinical behaviors. Mediation analyses revealed that psychological traits significantly mediated the relationship between ACEs and clinical behaviors. For instance, ineffectiveness mediated the link from cumulative ACE count (mediation proportion = 0.481), “criticism and blame” (mediation proportion = 0.629), and “abandonment threats” (mediation proportion = 0.601) to binge eating. Childhood emotional abuse and cumulative ACEs significantly correlated with worsened psychological traits and clinical ED behaviors, with notable implications for binge-eating/purging symptoms. Several psychological traits showed substantial indirect associations between ACE exposure and clinical ED behaviors. These findings highlight the necessity of routine ACE assessment and trauma-informed interventions targeting these psychological vulnerabilities in ED treatment. Eating disorders are serious mental illnesses, and adverse childhood experiences may shape how these illnesses develop and appear in clinical care. This study examined 970 Chinese outpatients with eating disorders to understand how adverse childhood experiences, such as emotional abuse, physical abuse, and sexual abuse, were related to eating-disorder symptoms and psychological difficulties. Patients who reported adverse childhood experiences tended to show more severe psychological traits, including feelings of ineffectiveness, perfectionism, difficulties sensing internal body states, body dissatisfaction, and bulimia-related concerns. Emotional abuse, especially repeated criticism, blame, and threats of abandonment, showed particularly strong links with these psychological traits. Having more types of childhood adversity was also associated with a greater likelihood of behaviors such as binge eating, purging, laxative use, and diet pill use. The analyses suggested that psychological traits may help explain the statistical association between childhood adversity and later eating-disorder behaviors. These findings support routine assessment of childhood adversity in eating-disorder services and highlight the importance of trauma-informed treatment that addresses self-worth, emotion regulation, and body-related psychological difficulties.