Anorexia nervosa is among the most severe psychiatric disorders of adolescence, carrying the highest mortality of any mental illness and substantial medical morbidity. Over the past two decades, researchers have accumulated strong evidence that childhood traumatic experiences, particularly sexual abuse, emotional maltreatment, and neglect, are more common among people with eating disorders and are linked to greater symptom severity, psychiatric comorbidity, suicidality, and poorer treatment outcomes. What has remained far less clear is the optimal timing and method for addressing trauma in severely underweight adolescents, whose bodies and minds may have little reserve to absorb the emotional shockwaves of traumatic recall.

The girl’s history illustrates how insidious the illness can be. Described from early childhood as emotionally sensitive, perfectionistic, and highly responsive to the expectations of others, she had marked difficulty expressing distress. Restrictive eating began at age 12, when her body mass index stood at 22.6 kg/m², starting as apparently health-oriented dietary changes that slid into severe caloric restriction, calorie counting, excessive exercise, and intense fear of weight gain. By 13 years and 8 months she required her first hospitalization after losing roughly 15 kilograms, developing sinus bradycardia with a heart rate of 46 beats per minute and malnutrition. Extensive investigations excluded organic causes, and she was diagnosed with restrictive anorexia nervosa under DSM-5-TR criteria, receiving multidisciplinary inpatient treatment with nutritional rehabilitation, psychiatric management, and aripiprazole before partial weight restoration.

From 2021 to 2024 she was treated in a specialist public multidisciplinary eating-disorder service, combining medical and nutritional monitoring, psychiatric follow-up, and individual psychotherapy aimed at reconstructing her developmental history and identifying the mechanisms maintaining the eating disorder. Behavioral and nutritional stabilization was only partial. She continued to show exaggerated emotional reactions, self-depreciation, difficulty managing negative emotions, and persistent fear of weight gain and body control. Then, in early 2024, a childhood sexual abuse perpetrated by an adult family acquaintance when she was about 8 years old, which had been disclosed to her parents shortly after it occurred but never psychologically processed, was revisited in greater depth during psychotherapy. In her later retrospective account, the sessions became progressively

The deterioration that followed was both rapid and medically serious. Over roughly six months, the adolescent lost approximately 12 kilograms, bringing her body mass index down to 16.26 kg/m². Her mood darkened, she withdrew socially, and her restrictive eating behaviors intensified markedly. Escitalopram was prescribed to address the associated depressive and anxiety symptoms, but the persistent refusal of oral intake, particularly of carbohydrate-rich foods, made outpatient stabilization impossible. During medical monitoring she was found to be hypoglycemic, with a blood glucose of 60 mg/dL, and the combination of inadequate intake and dehydration ultimately required hospitalization for intravenous fluids and electrolyte replacement to restore hydration and correct her metabolic abnormalities.

The laboratory findings recorded during this second admission painted a picture of advanced malnutrition. She presented with electrolyte disturbances, including a potassium level of 3.2 mEq/L, a phosphorus level of 2.9 mEq/L, and a sodium level of 132 mEq/L, along with mild thrombocytopenia, with platelets counted at 122,000 per microliter. These abnormalities matter clinically because electrolyte shifts, particularly of potassium and phosphorus, are among the most dangerous complications of both starvation and the refeeding process that follows it. Hypophosphatemia in particular can affect cardiac, neurological, and muscular function, and it is a hallmark risk during nutritional rehabilitation in severely underweight patients. Repeat investigations during the hospitalization again excluded alternative organic causes of weight loss, confirming that the deterioration reflected the psychiatric illness itself rather than a hidden medical condition.

Because oral intake remained inadequate, temporary nasogastric feeding was introduced to guarantee sufficient nutrition and support progressive rehabilitation. The team proceeded with careful monitoring during refeeding, acutely aware of the metabolic complications that can arise when a starved body is suddenly refed. Secondary amenorrhea also emerged as an additional manifestation of the prolonged state of energy deficiency, a well-recognized consequence of hypothalamic suppression in chronic undernutrition that signals the body’s shift into an energy-conserving mode. Together, these features underscore that the relapse was not merely a psychological setback but a systemic medical event affecting nearly every organ system.

What makes this temporal sequence clinically interesting, the authors argue, is not the well-established association between childhood trauma and eating disorders, which has been documented extensively in the literature, but rather the specific timing of the relapse in relation to the therapeutic exploration of the abuse. The traumatic experience had been disclosed years earlier but never psychologically processed. When it was revisited in greater detail during psychotherapy that was not formally trauma-focused, the discussion became, in the patient’s own retrospective account, progressively overwhelming. The restrictive symptoms that followed can be understood, through the lens of developmental trauma models, as an attempt to regulate emotional states that had become unbearable. Food restriction, rigid rituals, and excessive control over the body may function as mechanisms of emotional numbing and experiential avoidance rather than as expressions of body-image concern alone, and in this patient those mechanisms appear to have been reactivated when the trauma narrative was opened without sufficient containment.

Developmental trauma models suggest that early interpersonal trauma can disrupt emotional regulation, identity development, bodily integration, and interpersonal security, producing clinical presentations that extend well beyond classical post-traumatic stress disorder. In adolescents, whose sense of self and body is still consolidating, these disruptions may interact with restrictive symptoms in particularly complex ways. The case suggests that for some patients, restriction serves as a primary defensive and affect-regulatory structure, and that dismantling or destabilizing the underlying emotional equilibrium without first strengthening the patient’s regulatory capacities can precipitate a dangerous escalation of the eating disorder itself.

The authors are careful to note that this observation does not imply that trauma should never be discussed with adolescents who have anorexia nervosa. Trauma-focused interventions have shown promising feasibility even in underweight patients, provided they are delivered within carefully structured, well-supervised therapeutic frameworks with continuous monitoring of emotional and nutritional stability. The clinical question, therefore, is not whether to address trauma but when and how. In severely vulnerable patients, the report suggests, a phase-based approach may be essential: first stabilizing nutrition, weight, and medical parameters; then building emotional regulation skills and therapeutic alliance; and only subsequently engaging with traumatic material in a graded, contained manner. This phased logic, drawn from broader trauma-informed treatment models, recognizes that premature or unstructured exploration of trauma can overwhelm a patient whose coping resources are already stretched to their limits.

The case also highlights the importance of multidisciplinary communication. The psychotherapy in question took place within a specialist eating-disorder service that included medical and nutritional monitoring, yet the severe relapse still occurred. This suggests that even in well-resourced settings, the emergence of previously unprocessed traumatic material during routine therapeutic work may be difficult to anticipate and contain. Structured communication between psychotherapist, psychiatrist, pediatrician, and nutrition team, with explicit protocols for escalating monitoring when distress rises, may help close this gap. The report was prepared according to the CARE guidelines for case reports, reflecting an effort to document the temporal sequence of clinical events transparently so that other clinicians can learn from the observation.

Several limitations inherent to a single case report deserve emphasis. A temporal association between the revisiting of trauma and clinical deterioration does not establish causation. Other factors may have contributed to the relapse, including the natural course of the illness, adolescent developmental pressures, family circumstances such as the parents’ separation years earlier, and a paternal history of anxiety disorder that may reflect genetic or environmental vulnerability. The patient’s retrospective account of the therapy sessions was collected after the deterioration, which may have shaped how she recalled the experience. Case reports generate hypotheses rather than test them, and the authors present this observation as a prompt for further research into therapeutic pacing rather than as definitive evidence about the dangers of trauma exploration.

Nevertheless, the clinical implications are significant for pediatricians, child and adolescent psychiatrists, and psychotherapists working with eating disorders. The report underscores the need to assess emotional regulation capacities and medical stability before traumatic experiences are revisited in severely underweight adolescents, and to ensure that such exploration occurs within a phase-based, trauma-informed, multidisciplinary framework. It also serves as a reminder that in some patients with restrictive anorexia nervosa, the eating disorder itself may be functioning as the primary defense against overwhelming emotional states, and that therapeutic work which destabilizes that defense without adequate preparation and support can have serious medical consequences. For clinicians navigating the delicate balance between addressing the traumatic roots of an eating disorder and protecting a medically fragile patient, this case offers a sobering and instructive data point in an area where controlled evidence remains limited and clinical judgment carries enormous weight.

Subject of Research: The interaction between childhood sexual abuse trauma exploration and clinical deterioration in adolescent anorexia nervosa

Article Title: Clinical deterioration after revisiting childhood sexual abuse during psychotherapy for restrictive anorexia nervosa: a case report

Article References: Cirillo, F., Bozzola, E., Spina, G., Irrera, M., Marchesi, A., Marotta, R., & Marchili, M. R. (2026). Clinical deterioration after revisiting childhood sexual abuse during psychotherapy for restrictive anorexia nervosa: a case report. Frontiers in Pediatrics, 14, Article 1958194. https://doi.org/10.3389/fped.2026.1958194

Image Credits: AI Generated

DOI: 10.3389/fped.2026.1958194

Keywords: anorexia nervosa, childhood sexual abuse, adolescent psychiatry, trauma-informed care, emotional dysregulation, case report, eating disorders, PTSD, psychotherapy, nutritional rehabilitation, developmental trauma, multidisciplinary treatment

The study, conducted at Chrysalis Associates, a specialist developmental trauma and attachment service in the north of England, evaluated a 30-hour neuro-collaborative Theraplay-informed intervention delivered between April 2020 and April 2024. The therapeutic package comprised three equal components: ten hours of Theraplay-informed family therapy involving parents and children, ten hours of therapeutic parenting sessions guided by the principles of dyadic developmental parenting, and ten hours of sensory regulation work delivered directly to children or psycho-educationally to parents. This integrative design deliberately expands on Perry’s neurosequential model, which proposes treating trauma by targeting the brainstem first, then the limbic system, and finally the cortex. Instead of moving sequentially, the neuro-collaborative approach addresses multiple brain systems concurrently, pairing body-based regulation with attachment-focused play and reflective parenting support.

The researchers compared 35 autistic care-experienced children with 172 non-autistic children who received the same intervention. The autistic group had an average age of just over nine years, ranged from four to seventeen, and attended on average more than 96 percent of their scheduled sessions. Outcomes were measured before and after therapy using four well-validated caregiver-report instruments: the Trauma Symptom Checklist for Young Children, the Child Behaviour Checklist, the Behaviour Rating Inventory of Executive Function, and the Assessment Checklist for Children. Paired t-tests and analyses of covariance controlling for age and gender were used to assess change within and between the groups.

The results told a nuanced story. Across the full cohort, every outcome measure improved significantly, and after applying a Bonferroni correction for multiple comparisons, total post-traumatic stress, post-traumatic stress arousal, total behavioural problems, and oppositional defiant problems remained significantly reduced, with effect sizes ranging from small to approaching medium. The larger non-autistic group alone also showed statistically significant improvements on most measures. The smaller autistic group did not reach statistical significance, but scores moved consistently in the direction of improvement with encouraging effect sizes, including a moderate effect for reduced rule-breaking behaviour. Crucially, the analyses of covariance found no significant difference in treatment response between autistic and non-autistic children once pre-treatment scores, age, and gender were accounted for.

The theoretical rationale for the intervention rests on how early relationships shape developing regulatory systems. Drawing on Schore’s account of right-hemisphere development and Porges’ polyvagal theory, the authors argue that attachment experiences sculpt the autonomic and nonverbal systems underlying emotional attunement, bodily awareness, and social engagement. Theraplay, a structured, playful, and largely preverbal approach organised around the domains of structure, engagement, nurture, and challenge, is designed to intervene precisely at this nonverbal, embodied level. Because autistic children often process sensory input and social cues differently, the therapy was adapted flexibly, honouring the child’s developmental stage and sensory profile rather than demanding eye contact or touch that could prove dysregulating.

The authors also invoke monotropism theory, which describes the intensely focused attentional tunnel characteristic of autism, to explain how trauma and autistic hypersensitivity can interact. A child whose nervous system is hypervigilant for danger after trauma, and whose attention is already narrowly channelled by autistic monotropism, may become overwhelmed by stimuli inside that channel while missing cues outside it. The intervention’s sensory regulation component, drawing on the Just Right State program and the Alert Program, helps parents create predictability and reduce overload, while Theraplay-informed sessions teach carers to synchronise with the child’s attention rather than fight against it, building experiences of being seen, understood, and co-regulated.

Not every measure responded identically across groups. On the Assessment Checklist for Children, which probes attachment-related relational behaviours, the non-autistic group improved significantly while the autistic group’s scores on indiscriminate and non-reciprocal scales remained stable or rose slightly. The researchers argue this divergence is expected and even reassuring: non-reciprocal and indiscriminate friendliness in trauma-exposed children typically reflects damaged internal working models, which attachment-rich therapy can repair, whereas analogous presentations in autistic children stem from innate neurobiological differences in social reciprocity. Attempting to modify those differences therapeutically would be neither appropriate nor neurodiversity-affirming, and the authors caution that the checklist itself may simply be insufficiently sensitive to capture relational change in autistic children.

The study’s significance lies partly in dismantling a persistent clinical misconception. Some practitioners have assumed that Theraplay’s emphasis on touch and eye contact makes it unsuitable, or even harmful, for autistic children. This evaluation found no evidence of deterioration in functioning and instead suggests the model can be adapted in a neurodiversity-affirming way to achieve trauma-related outcomes comparable to those of non-autistic peers. Prior scoping reviews had already found that interventions relying less on verbal skills and emphasising caregiver involvement, both hallmarks of Theraplay, suit neurodivergent children who have experienced interpersonal trauma. The present study extends that literature to the specific and understudied intersection of autism, developmental trauma, and attachment disruption in care-experienced children.

Nevertheless, the authors are candid about the limitations inherent in practice-based evidence. The evaluation was retrospective rather than randomised, the autistic subgroup was small, the integrative design makes it impossible to isolate which component drove change, and all outcome data relied on caregiver report vulnerable to expectancy effects. Formal treatment fidelity checks were not routinely conducted, dropout information was not collected, and the generic psychometric measures were not adapted to autistic symptomatology. Changes in executive function and attachment-related outcomes, while directionally positive and at times showing moderate effect sizes, did not reach significance, likely reflecting insufficient statistical power.

The research team concludes that the 30-hour neuro-collaborative Theraplay-informed intervention is effective for children with developmental trauma and attachment disruption, and may also benefit autistic children, though larger, adequately powered trials are needed to confirm this. They call for qualitative research capturing the lived experiences of autistic children, their carers, and their therapists, alongside the development of autism-sensitive assessment tools. For now, the message for services supporting care-experienced autistic children is cautiously optimistic: attachment-based, sensory-informed, neurodiversity-affirming therapy deserves a place in the treatment conversation, and services are encouraged to evaluate and publish their own anonymised data to build the collective evidence base.

Subject of Research: Evaluation of a neurocollaborative Theraplay-informed psychotherapeutic intervention for developmental trauma and attachment difficulties in autistic looked after children

Article Title: The Impact of a Neurocollaborative Theraplay®-Informed Intervention on the Presentations of Developmental Trauma and Attachment Difficulties in a Sub-Group of Autistic Looked after Children: a Retrospective Service Evaluation

Article References: Purrington, J., Hartley, G., Price, A., Bass, E., Godfrey, C., Lynch, J., & Mukherjee, R. (2026). The Impact of a Neurocollaborative Theraplay®-Informed Intervention on the Presentations of Developmental Trauma and Attachment Difficulties in a Sub-Group of Autistic Looked after Children: a Retrospective Service Evaluation. Journal of Child & Adolescent Trauma. https://doi.org/10.1007/s40653-026-00964-6

Image Credits: AI Generated

DOI: 10.1007/s40653-026-00964-6

Keywords: autism, developmental trauma, attachment disruption, Theraplay, looked after children, sensory regulation, therapeutic parenting, neurodiversity, psychotherapy outcomes, service evaluation, child and adolescent trauma, care system