Clinical characteristics of eating disorder patients who report sexual or physical abuse

Comparing the clinical presentation of eating disorder patients with and without trauma history and/or comorbid PTSD

This study examined whether clinical characteristics among patients presenting to residential eating disorder (ED) treatment differed according to patients' trauma history and current PTSD diagnostic status. Participants (699 girls and women) completed surveys at treatment onset. One-way analysis of covariance (ANCOVA) tests assessed cross-sectional differences between three groups of patients: those reporting no trauma history (No Trauma, n = 185), those with trauma history but without PTSD (Trauma, n = 263), and those with current PTSD (PTSD, n = 251). Relative to the No Trauma group, the combined Trauma and PTSD groups reported greater ED symptoms, anxiety and depressive symptoms, experiential avoidance, anxiety sensitivity, and lower mindfulness. The PTSD group reported greater ED, anxiety, and depressive symptoms, greater anxiety sensitivity, and lower mindfulness, relative to the Trauma group. In sum, ED patients with any history of trauma experienced more symptoms and other psychopathology relative to patients who did not report trauma history. Among patients reporting trauma, those with current PTSD experienced even greater symptom severity. Interventions focused on improving emotional functioning could be especially beneficial for ED patients with trauma histories.

Suicide attempts in bulimia nervosa: Personality and psychopathological correlates

Background

Little evidence exists about suicidal acts in eating disorders and its relation with personality. We explored the prevalence of lifetime suicide attempts (SA) in women with bulimia nervosa (BN), and compared eating disorder symptoms, general psychopathology, impulsivity and personality between individuals who had and had not attempted suicide. We also determined the variables that better correlate with of SA.

Method

Five hundred sixty-six BN outpatients (417 BN purging, 47 BN non-purging and 102 subthreshold BN) participated in the study.

Results

Lifetime prevalence of suicide attempts was 26.9%. BN subtype was not associated with lifetime SA (p = 0.36). Suicide attempters exhibited higher rates on eating symptomatology, general psychopathology, impulsive behaviors, more frequent history of childhood obesity and parental alcohol abuse (p < 0.004). Suicide attempters exhibited higher scores on harm avoidance and lower on self-directedness, reward dependence and cooperativeness (p < 0.002). The most strongly correlated variables with SA were: lower education, minimum BMI, previous eating disorder treatment, low self-directedness, and familial history of alcohol abuse (p < 0.006).

Conclusion

Our results support the notion that internalizing personality traits combined with impulsivity may increase the probability of suicidal behaviors in these patients. Future research may increase our understanding of the role of suicidality to work towards rational prevention of suicidal attempts.

Childhood trauma, dissociation, and the internal eating disorder 'voice'

Many individuals diagnosed with eating disorders describe their disorder as being represented by an internal 'voice'. In line with cognitive models of voice-hearing, previous research has identified associations between voice appraisals and eating psychopathology in anorexia nervosa. Whether these findings generalise to other eating disorder subtypes remains unknown. The aetiology of the internal eating disorder voice also remains unclear. Traumatic-dissociative models of voice-hearing, which link such experiences to decontexualised material arising from early traumatic events, might also be relevant to eating disorder groups. To determine whether cognitive models of trauma and voice-hearing apply across eating disorder subtypes, 85 individuals fulfilling ICD-10 criteria for an eating disorder completed self-report measures regarding eating disorder cognitions, voice-related appraisals, childhood trauma, and dissociation. The relative power of the eating disorder voice was found to be positively associated with experiences of childhood emotional abuse, and this relationship was partly mediated by dissociation. In addition, eating disorder voices appraised as powerful and benevolent predicted more negative attitudes towards eating across diagnostic groups, but were unrelated to disordered eating behaviours or weight. These findings suggest that the eating disorder voice plays a meaningful role in eating pathology across diagnoses and that this experience might be related, in part, to experiences of childhood maltreatment. Therapeutic implications are discussed.

Anorexia nervosa and childhood sexual abuse: Treatment outcomes of intensive enhanced cognitive behavioural therapy

Sexual abuse has been widely studied as a risk factor in anorexia nervosa, but data on its influence on treatment outcomes are scarce. Hence, we compared short- and long-term outcomes of inpatient enhanced cognitive-behavioural therapy (CBT-E) in patients with anorexia nervosa who had and had not suffered sexual abuse. Eighty-one patients were recruited, and body mass index (BMI), Eating Disorder Examination, Brief Symptom Inventory, and Work and Social Adjustment Scale scores were recorded before and after treatment, and at 6- and 12-month follow-ups. Twenty patients (24.7%) reported experiencing childhood sexual abuse before anorexia nervosa onset, while 61 (75.3%) reported none. Both groups displayed similar characteristics before treatment, and similarly large increases in BMI, eating-disorder, general psychopathology, and work and social functioning from baseline to 12-month follow-up. Based on these findings, childhood sexual abuse does not appear to compromise outcomes in patients with anorexia nervosa treated via intensive CBT-E.

Different outcomes, psychopathological features, and comorbidities in patients with eating disorders reporting childhood abuse: A 3-year follow-up study

The aim of this study was to evaluate the role of childhood adversities in long-term outcomes in eating disorders (EDs). One hundred thirty-three eating disorder patients were studied by means of the Structured Clinical Interview for DSM-IV and psychometric tests, at baseline, at the end of individual cognitive behavioural therapy, and at 3-year follow-up. As compared with the other patients, those reporting childhood abuse (overall: 24.8%; physical abuse: 20.3%; sexual abuse: 13.6%) showed higher impulsivity, psychiatric comorbidity, lower full recovery at follow-up (12.1% vs. 31%), and higher diagnostic crossover (39.4% vs. 13.0%). The different rates of recovery were mostly due to a higher persistence of depression in abused patients (77.8% vs. 26.7%). Patients with both abuse and neglect had a higher probability of dropout. Eating disorder patients with childhood abuse represent a group of persons with more complex psychopathological features and a worse long-term outcome, thus requiring specific treatment strategies.

Childhood maltreatment and eating disorder pathology: a systematic review and dose-response meta-analysis

BACKGROUND

Meta-analyses have established a high prevalence of childhood maltreatment (CM) in patients with eating disorders (EDs) relative to the general population. Whether the prevalence of CM in EDs is also high relative to that in other mental disorders has not yet been established through meta-analyses nor to what extent CM affects defining features of EDs, such as number of binge/purge episodes or age at onset. Our aim is to provide meta-analyses on the associations between exposure to CM (i.e. emotional, physical and sexual abuse) on the occurrence of all types of EDs and its defining features.

METHOD

Systematic review and meta-analyses. Databases were searched until 4 June 2016.

RESULTS

CM prevalence was high in each type of ED (total N = 13 059, prevalence rates 21-59%) relative to healthy (N = 15 092, prevalence rates 1-35%) and psychiatric (N = 7736, prevalence rates 5-46%) control groups. ED patients reporting CM were more likely to be diagnosed with a co-morbid psychiatric disorder [odds ratios (ORs) range 1.41-2.46, p < 0.05] and to be suicidal (OR 2.07, p < 0.001) relative to ED subjects who were not exposed to CM. ED subjects exposed to CM also reported an earlier age at ED onset [effect size (Hedges' g) = -0.32, p < 0.05], to suffer a more severe form of the illness (g = 0.29, p < 0.05), and to binge-purge (g = 0.31, p < 0.001) more often compared to ED patients who did not report any CM.

CONCLUSION

CM, regardless of type, is associated with the presence of all types of ED and with severity parameters that characterize these illnesses in a dose dependent manner.

Associations between adverse childhood experiences and clinical characteristics of eating disorders

Patients with eating disorders (EDs) frequently report a history of childhood trauma (CT). We investigated whether certain subtypes of CT are associated with more severe features of EDs, independently of psychiatric comorbidity, and whether they act additively. One hundred and ninety-two patients with DSM-V-defined EDs were consecutively recruited. Five clinical characteristics were assessed: restraint, eating, shape and weight concerns on the EDE-Q, and daily functioning. CT was assessed by the childhood traumatism questionnaire. The clinical features were associated with at least one CT subtype (emotional, sexual or physical abuse, emotional neglect). Multivariate analyses adjusted for lifetime comorbid psychiatric disorders revealed that emotional abuse independently predicted higher eating, shape and weight concerns and lower daily functioning, whereas sexual and physical abuse independently predicted higher eating concern. A dose-effect relationship characterised the number of CT subtypes and the severity of the clinical features, suggesting a consistent and partly independent association between CT and more severe clinical and functional characteristics in EDs. Emotional abuse seems to have the most specific impact on ED symptoms. Last, not all CT subtypes have the same impact but they do act additively.

Sexual Abuse and Eating Disorders in a Community Sample of Mexican American Women

The purpose of this study was to examine the association between sexual abuse and eating disorders in a voluntary community sample of Mexican American women. Eighty eating disorder cases were compared to 110 healthy controls on presence of sexual abuse and on characteristics of the abuse. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision) and the Eating Disorder Examination were used to determine diagnoses and psychiatric comorbidity. Results indicated that compared to controls, cases were more likely to report sexual abuse and had experienced more instances and longer duration of abuse. For the majority of cases, sexual abuse occurred before onset of eating disorder symptoms. There was no relationship between sexual abuse and type of eating disorder or psychiatric comorbidity. Sexual abuse seems to be a risk factor for disordered eating in Mexican Americans. Prolonged abuse and revictimization may increase this risk.

Disordered Eating and Perceptions of Childhood Abuse Among Women in a Primary Care Setting

Research has demonstrated links between sexual abuse and disordered eating among women in college student and mental health samples. Little is known about such relationships among women from other samples or the relationship between other forms of childhood abuse as well as disordered eating (vomiting, starvation, laxative abuse). Prevalence of disordered eating was significantly higher among women who indicated a perceived childhood history of sexual, physical, or emotional abuse or who had personally witnessed violence.

History of sexual abuse and suicide attempts in alcohol-dependent patients

History of child abuse is considered one of the important risk factors of suicide attempt in general population. At the same time it has been shown that suicide attempts appear significantly more frequently in alcoholics than in healthy individuals. The objective of this study was to investigate associations between history of childhood sexual abuse and suicide attempts in a sample of Polish alcohol dependent patients. A sample of 364 alcohol-dependent subjects was recruited in alcohol treatment centers in Warsaw, Poland. Information was obtained about demographics, family history of psychiatric problems, history of suicide attempts, sexual and physical abuse during childhood and adulthood and severity of alcohol problems. When analyzed by gender, 7.4% of male and 39.2% of female patients had a lifetime history of sexual abuse; 31.9% of the study group reported at least one suicide attempt during their lifetime. Patients who reported suicide attempts were significantly younger (p=0.0008), had greater severity of alcohol dependence (p=0.0002), lower social support (p=0.003), and worse economic status (p=0.002). Moreover, there was a significant association between history of suicide attempts and family history of psychiatric problems (p=0.00025), suicide attempts in the family (p=0.0073), childhood history of sexual abuse (p=0.009) as well as childhood history of physical abuse (p=0.002). When entered into linear regression analysis with other dependent variables history of childhood sexual abuse remained a significant predictor of suicide attempt (OR=2.52; p=0.035). Lifetime experience of sexual abuse is a significant and independent risk factor of suicide attempts in alcohol-dependent individuals.

Cortisol awakening response in patients with anorexia nervosa or bulimia nervosa: relationships to sensitivity to reward and sensitivity to punishment

BACKGROUND

Sensitivity to punishment (SP) and sensitivity to reward (SR) are personality characteristics that may have relevance for the pathophysiology of eating disorders (EDs). Moreover, personality characteristics are known to modulate the activity of the hypothalamus-pituitary-adrenal (HPA) axis, which is the main component of the endogenous stress response system. As stress has been implicated in the aetiology and the maintenance of EDs, we aimed to study the HPA axis activity in relation to SP and SR, as conceptualized by Gray's reinforcement sensitivity theory (RST), in patients with anorexia nervosa (AN) or bulimia nervosa (BN).

METHOD

Twenty-five women with AN, 23 women with BN and 19 healthy women volunteered for the study. HPA axis activity was assessed by measurement of the salivary cortisol awakening response (CAR). The subjects' SP and SR were measured by the behavioural inhibition system (BIS)/behavioural approach system (BAS) scales.

RESULTS

The CAR was significantly enhanced in AN patients, but not in BN patients, compared to healthy women. The CAR correlated significantly with BAS measures, negatively in healthy controls and positively in binge-purging AN patients and BN women. SP, measured by the BIS scale, was higher in patients than in controls.

CONCLUSIONS

These findings confirm the occurrence of an enhanced activity of the HPA axis in symptomatic AN, but not in symptomatic BN, and show for the first time that the CAR is associated with SR, as conceptualized by the RST, negatively in healthy subjects but positively in binge-purging ED patients.

Eating disorders among patients incarcerated only for repeated shoplifting: a retrospective quasi-case-control study in a medical prison in Japan

BACKGROUND

Shoplifting is a serious problem among patients with eating disorders. For more than a decade, we have treated many patients with eating disorders incarcerated in Hachioji Medical Prison only for repeated shoplifting.

METHODS

We analyzed the prison records and medical records of female psychiatric patients transferred to Hachioji Medical Prison between 2002 and 2011. Based on the offense listed at the time of sentencing, we extracted a shoplifting group and a drug-offense group from among all patients with eating disorders. One patient from the former group who had used substances and two from the latter group who had never shoplifted were excluded from the study. The groups had 41 and 14 patients, respectively. A control group comprised patients with other mental disorders (n = 34). We compared eating disorder histories and subtypes, weight changes, comorbidities, life histories, past behavioral problems, and clinical behavioral problems among the three groups.

RESULTS

The shoplifting group exhibited less impulsive behavior, substance abuse, antisocial features, borderline personality disorder, and past bulimia than did the drug-offense and control groups. The shoplifting group had higher educational achievement and steadier employment; however, their eating disorder histories and interpersonal dysfunction were more severe, and they had a higher psychiatric treatment dropout rate. There were also significant relationships with low body weight, anorexia nervosa-restricting type, obsessive-compulsive behaviors, and obsessive-compulsive personality disorder in the shoplifting group. During the clinical course, food refusal, excessive exercise, food hoarding, and falsification of dietary intake amounts were more frequently observed in the shoplifting group. Conversely, drug requests and occurrences of self-harm were less frequent in the shoplifting group than in the drug-offense group.

CONCLUSIONS

Although these results may be associated with specific characteristics of patients with eating disorders in the medical prison setting, we concluded that the repeated shoplifting by these patients is unrelated to antisocial or impulsive characteristics but is deeply rooted in these patients' severe and undertreated eating disorder psychopathology. Strong supportive treatment should be considered for patients with eating disorders who develop shoplifting behaviors. Further research is required to elucidate the mechanisms responsible for the relationship between shoplifting and eating disorders.

Childhood emotional abuse and eating symptoms in bulimic disorders: an examination of possible mediating variables

OBJECTIVE

We sought to estimate prevalences of childhood emotional abuse (CEA) in bulimic and normal-eater control groups, and to replicate previous findings linking CEA to severity of eating symptoms in BN. We also examined potential mediators of the link between CEA and disordered eating.

METHOD

Women diagnosed with a bulimic disorder (n = 176) and normal-eater women (n = 139) were assessed for childhood traumata, eating-disorder (ED) symptoms and psychopathological characteristics (ineffectiveness, perfectionism, depression, and affective instability) thought to be potential mediators of interest.

RESULTS

CEA was more prevalent in the bulimic than in the nonbulimic group, and predicted severity of some eating-symptom indices. Ineffectiveness and affective instability both mediated relationships between CEA and selected ED symptoms.

DISCUSSION

We found CEA to predict eating pathology through mediating effects of ineffectiveness and affective instability. CEA might influence severity of ED symptoms by impacting an individual's self-esteem and capacity for affect regulation.

The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: meta-analysis and implications for DSM

Eating disorder not otherwise specified (EDNOS) is the most prevalent eating disorder (ED) diagnosis. In this meta-analysis, the authors aimed to inform Diagnostic and Statistical Manual of Mental Disorders revisions by comparing the psychopathology of EDNOS with that of the officially recognized EDs: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). A comprehensive literature search identified 125 eligible studies (published and unpublished) appearing in the literature from 1987 to 2007. Random effects analyses indicated that whereas EDNOS did not differ significantly from AN and BED on eating pathology or general psychopathology, BN exhibited greater eating and general psychopathology than EDNOS. Moderator analyses indicated that EDNOS groups who met all diagnostic criteria for AN except for amenorrhea did not differ significantly from full syndrome cases. Similarly, EDNOS groups who met all criteria for BN or BED except for binge frequency did not differ significantly from full syndrome cases. Results suggest that EDNOS represents a set of disorders associated with substantial psychological and physiological morbidity. Although certain EDNOS subtypes could be incorporated into existing Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) categories, others-such as purging disorder and non-fat-phobic AN-may be best conceptualized as distinct syndromes. (PsycINFO Database Record (c) 2009 APA, all rights reserved).

Eighty-five per cent of what? Discrepancies in the weight cut-off for anorexia nervosa substantially affect the prevalence of underweight

BACKGROUND

DSM-IV cites <85% of expected body weight (EBW) as a guideline for the diagnosis of anorexia nervosa (AN) but does not require a specific method for calculating EBW. The purpose of the present study was to determine the degree to which weight cut-off calculations vary across studies, and to evaluate whether differential cut-offs lead to discrepancies in the prevalence of individuals who are eligible for the AN diagnosis.

METHOD

Two coders independently recorded the EBW calculation methods from 99 studies that either (a) compared individuals with AN to those with subclinical eating disorders or (b) conducted AN treatment trials. Each weight cut-off was applied to a nationally representative (n=12001) and treatment-seeking (n=189) sample to determine the impact of EBW calculation on the proportion who met the AN weight criterion.

RESULTS

Coders identified 10 different EBW methods, each of which produced different weight cut-offs for the diagnosis of AN. Although only 0.23% of the national sample met the lowest cut-off, this number increased 43-fold to 10.10% under the highest cut-off. Similarly, only 48.1% of treatment seekers met the lowest cut-off, whereas 89.4% met the highest.

CONCLUSIONS

There is considerable variance across studies in the determination of the AN weight cut-off. Discrepancies substantially affect the proportion of individuals who are eligible for diagnosis, treatment and insurance reimbursement. However, differences may not be fully appreciated because the ubiquitous citation of the 85% criterion creates a sense of false consensus.

Assessment of trauma symptoms in eating-disordered populations

Research suggests that individuals with eating disorders (EDs) are relatively likely to have been abused or neglected as children, or to have been victimized in adolescence or adulthood. These experiences, in turn, are often associated with a range of psychological symptoms, as well as, in some cases, a more severe or complex ED presentation. In this article, we review both generic and more trauma-specific psychological tests that can be used to (a) identify clinically relevant trauma histories in the ED patient and (b) uncover trauma-relevant symptoms that may complicate or intensify a given instance of ED. We also discuss the clinical implications of a detailed trauma assessment, including its usefulness in guiding treatment for ED-trauma patients.

Trauma and multi-impulsivity in the eating disorders

BACKGROUND

Multiple impulsive behaviours are common in the eating disorders, and multi-impulsive patients appear to do more poorly in treatment. However, comparatively little is known about the origins of multi-impulsivity in such cases. This study addresses the links between reported childhood trauma and multi-impulsivity in the eating disorders, examining whether specific types of trauma are predictive of specific impulsive behaviours in this population.

METHOD

The sample consisted of 102 individuals who met strict criteria for an eating disorder, and who were interviewed regarding trauma history and comorbid impulsive behaviours.

RESULTS

Any reported history of childhood trauma was associated with a higher number of impulsive behaviours and with the presence of multi-impulsivity. Childhood sexual abuse was particularly important, and was associated with self-cutting, alcohol abuse, and substance abuse (amphetamines, cocaine, cannabis and 'other substances', including ketamine and benzodiazepines).

DISCUSSION

These findings indicate the importance of considering the psychological consequences of trauma during both assessment and treatment of the eating disorders. In particular, eating-disordered women who report a history of childhood sexual abuse should be examined for a pattern of comorbid impulsive behaviours.

Suicide and attempted suicide in eating disorders, obesity and weight-image concern

Suicide in anorexia nervosa and bulimia nervosa is a major cause of death. Meta-analyses have shown that individuals suffering from anorexia nervosa and bulimia nervosa commit suicide more often than their counterparts in the general population; also a few studies have suggested that suicide is the major cause of death among patients with anorexia nervosa, refuting the assumption that inanition generally threatens the life of these patients. Data concerning suicide in bulimia nervosa, on the other hand, are still scarce but suicide attempts are easily found among cohorts of patients with bulimia nervosa, which constitutes a risk factor for completed suicide. Suicidality in obesity and individuals with disturbed weight status has been reported. Both in the case of bulimia nervosa and obesity more long-term follow-up studies need to be completed before the risk of suicide for such disorders may be compared with that for anorexia nervosa.

Suicidality in eating disorders: Occurrence, correlates, and clinical implications

This review summarizes the published studies on suicide and suicide attempts in individuals with eating disorders, highlighting rates of occurrence, clinical correlates, and implications for practitioners. Multiple studies find high rates of suicide in patients with anorexia nervosa (AN) [Standardized Mortality Ratio (SMR) for suicide range from 1.0 to 5.3], whereas suicide rates do not appear to be elevated in bulimia nervosa (BN). In contrast, suicide attempts occur in approximately 3-20% of patients with anorexia nervosa and in 25-35% of patients with bulimia nervosa. Clinical correlates of suicidality in eating disorders include purging behaviors, depression, substance abuse, and a history of childhood physical and/or sexual abuse. Patients with eating disorders, particularly those with comorbid disorders, should be assessed routinely for suicidal ideation, regardless of the severity of eating disorder or depressive symptoms.

Suicide attempts versus suicidal ideation in bulimic female adolescents

BACKGROUND

Suicide attempts by adolescents continue to be a major public health problem. The purpose of this study was to examine the difference in the family functioning and sociopsychopathological risk factor relationship between female bulimic adolescents with suicidal ideation only, and those who attempted suicide.

METHODS

A group of 211 patients were observed for 12 months. Data from 63 subjects (SUG [suicide group], age 17.2 +/- 1.3 years) who had attempted suicide were then compared with 148 (control group, age 18.1 +/- 1.5 years) who had expressed suicidal ideation but did not follow through.

RESULTS

Those in the suicide attempt group had been exposed more frequently to physical/sexual violence in childhood. As adults they either lived alone or were dissatisfied with their partnership. The frequency of borderline personality disorders and depressive disorders in this group was significant. Psychosomatic symptoms, disturbed coenesthesia, substance abuse, social impairment and interference with their perception of their own life circumstances, as well as their job performance, often preceded the suicide attempt. Nine genuine risk factors that occurred significantly more often in the SUG were calculated out of all the stress factors using stepwise logistic regression: 'as a child I was even hit with a stick or whip', 'I had no set orientation in life', 'I had a feeling of loneliness despite family and friends', 'I could not relax', 'incapable of dealing with the public', 'I do not like to be touched', 'parents have psychiatric disorders', 'misuse of stimulants', and 'as a child I felt lonely' (odds ratio, 10.56-1.90).

CONCLUSION

Adverse family experiences and multiple sociopsychopathological factors may increase the risk of suicide in female bulimic adolescents.

Familial and sociopsychopathological risk factors for suicide attempt in bulimic and in depressed women: prospective study

OBJECTIVE

This study was carried out to examine sociopsychopathological predictors of prospective observed suicide attempts in bulimic women purging type without comorbid major depression (BNG) at the time of study entry and in woman with major depression without comorbid eating disorder at the time of study entry (MDG).

METHODS

Data from 28 BNG (age 23.5 +/- 3.6) and 126 MDG women (age 33.4 +/- 5.1) who had attempted suicide during 12 months' monitoring were compared.

RESULTS

A univariate comparison of the two groups revealed various differences. Analysis of risk factors for suicide attempts using stepwise logistic regression was conducted separately for each group. The derived logistic models showed that patients from the BNG group had a history of higher incidence of sexual abuse in childhood, as well as abuse of laxatives and illicit drugs; they also lacked orientation in life, felt lonely despite family and friends, tended to direct their anger outward, and were unable to relax.

CONCLUSIONS

Sociopsychopathological risk factors for suicide attempts in the BNG and MDG appear to vary.

The impact of childhood sexual abuse in anorexia nervosa

OBJECTIVE

The aim of this study was to examine the impact of childhood sexual abuse (CSA) on clinical characteristics and premature termination of treatment in anorexia nervosa (AN).

METHOD

The participants were 77 consecutive patients with AN admitted to an inpatient eating disorders unit. The patients were assessed in terms of eating disorder symptoms, general psychopathology, and CSA history at admission to hospital.

RESULTS

Thirty-seven patients (48%) reported a history of CSA before the onset of the eating disorder. Individuals with a history of CSA reported significantly greater psychiatric comorbidity, including higher levels of depression and anxiety, lower self-esteem, more interpersonal problems, and more severe obsessive-compulsive symptoms. Patients with the binge-purge subtype of AN (AN-BP) were significantly more likely to report a history of CSA prior to the onset of the eating disorder as compared with patients with the restricting subtype (AN-R) of the illness (65% of the AN-BP patients vs. 37% of the AN-R patients; p<.02). Contrary to our predictions, abused patients were not significantly more likely to dropout of treatment overall. However, patients of the binge-purge subtype (AN-BP) with a history of CSA were significantly more likely to terminate treatment prematurely as compared with the other patients.

CONCLUSIONS

Consistent with previous findings, the present results indicate that the prevalence of CSA is high among individuals seeking inpatient treatment for AN. A history of CSA was associated with greater psychiatric disturbance overall and a higher rate of dropout for patients of the binge-purge subtype.

Retrospective measurement of childhood sexual abuse: a review of instruments

In this comprehensive review of retrospective childhood sexual abuse (CSA) instruments, instruments from studies published between 1986 and 2001 are examined according to administration method, number and specificity of questions, CSA operational definitions, psychometric properties, and the use of scales. It was found that both self-administered and interview instruments range from the vagueness of a single question to the preciseness of multiple, specific questions. Furthermore, the review demonstrated that CSA instruments generally lack standardization. Many are developed for one-time use and others modified when reused. Descriptive CSA instruments have been preferred by researchers and primarily used to measure CSA dichotomously. However, little consensus exists as to how to operationally define CSA. One positive trend is the development of scales that measure CSA as an interval-level variable, allowing for more extensive psychometric data to be collected.

Child abuse, dissociation, and core beliefs in bulimic disorders

OBJECTIVE

This study of bulimic women examined the relationship between the severity of four forms of reported child abuse (emotional abuse, neglect, physical abuse, sexual abuse) and bulimic pathology. ln addition, it investigated the relationship of abuse with dissociation and core beliefs.

METHOD

A sample of 23 women with bulimic disorders completed standardized self-report measures of child abuse, dissociation, core beliefs, and bulimic symptomatology. They also completed diary records of bulimic behaviors.

RESULTS

No dimensional relationship was found between any form of child abuse and bulimic pathology. However, within this group of bulimics, neglect and sexual abuse were correlated with dissociation. In addition, a subset of core beliefs was associated with child abuse, with different cognitive profiles associated with each form of trauma.

CONCLUSIONS

The findings need to be interpreted with caution because of the small, heterogeneous sample involved. Further research involving larger, homogenous samples is needed to investigate the generalizability of these findings, in order to determine if particular abusive experiences and core beliefs need to be addressed therapeutically in such cases. In addition, future research should consider the relationships between abuse, core beliefs and other impulsive behaviors.

Eating disturbance and sexual trauma in childhood and adulthood

OBJECTIVE

This study examined the relationship between sexual trauma and eating disorder behavior, taking into account the effects of developmental stage of the victim and the effects of multiple sexual assaults.

METHOD

Four groups of adult women took part in this study. Subjects were either victims of childhood sexual abuse, victims of rape in adulthood, victims of both childhood sexual abuse and rape, and controls who were not traumatized sexually. All subjects were assessed with semistructured interviews and self-report inventories that assessed eating disorder behavior, general psychopathology, and impulsivity.

RESULTS

Victims of childhood sexual abuse differed from controls on measures of eating disorder behavior and individuals who had experienced both childhood sexual abuse and rape in adulthood were most likely to display eating disorder-related psychopathology. Victims of childhood sexual abuse also distinguished themselves with high levels of eating disorder behavior plus multiple forms of impulsive self-destructive behavior.

DISCUSSION

This study provides additional support for the association between childhood sexual abuse and eating disorder behavior. Childhood sexual abuse may be particularly linked to the presence of binge eating behavior and several other forms of impulsive self-destructive behavior.

Sexual victimization and adolescent weight regulation practices: a test across three community based samples

OBJECTIVE

This study had four objectives: 1) to examine the association between sexual victimization and weight regulation across three samples of adolescent girls, 2) to assess whether sexual victimization is associated with more extreme forms of weight regulation in girls, 3) to discern whether sexual victimization has implications for the use of multiple forms of weight regulation, and 4) to address the role of physical victimization in explaining these relationships.

METHOD

Data from three separate samples of 9th-12th graders were used to test these hypotheses. Girls from the upper Midwest responded to survey questions related to victimization and weight regulation in a largely urban sample (N = 2,086), a rural sample (N = 2,629), and a statewide sample (N = 966).

RESULTS

Logistic regression revealed that sexual victimization was consistently associated with weight regulation in adolescent girls, independent of the effects of physical victimization. In the urban sample, being sexually victimized was associated with an increase in the probability of purging by 18% relative to not being sexually victimized. Sexual victimization was associated more strongly with extreme forms of weight regulation and significantly discriminated whether girls would choose multiple weight regulation forms.

CONCLUSIONS

Sexual victimization contributes unique variance to the probability that girls will practice weight regulation techniques. Data from three independent samples confirms that being violated sexually places girls at risk for various health compromising eating behaviors.

Child sexual abuse and bulimic symptomatology: relevance of specific abuse variables

OBJECTIVE

This study examined specific aspects of child sexual abuse in relation to symptom severity among hospitalized patients diagnosed with bulimia nervosa.

METHOD

Participants were 45 hospitalized bulimic women who reported a history of child sexual abuse. Structured interviews were conducted in order to obtain detailed information regarding specific features of the abusive event(s). Participants also completed instruments that measured depression and eating pathology.

RESULTS

There were no significant differences in severity of depression or eating disturbance among women reporting differing abusive experiences including intrafamilial versus extrafamilial abuse, abuse with or without the use of physical force, one versus multiple incidents, early abuse versus abuse occurring after age 14, contact versus noncontact abuse, disclosed versus undisclosed, and combined physical/sexual abuse versus sexual abuse alone.

CONCLUSION

The specific characteristics of child sexual abuse are not related to the level of symptomatology for hospitalized bulimic patients. This study suggests that differences in the nature of the abuse may not be as important as the fact that the abuse occurred in the first place.

Self-injurious behavior in anorexia nervosa

Recent reports have postulated the existence of two different types of self-injurious behavior: impulsive and compulsive. The aim of the present study is to analyze the dimensionality of self-injurious behavior and to study the link between self-injurious behavior and clinical features in anorexia nervosa. The study involved 236 consecutive patients with anorexia nervosa, diagnosed by DSM-IV criteria. Subjects were evaluated by means of a semistructured interview and self-reported questionnaires, such as the Eating Disorders Inventory and Hopkins Symptom Checklist. A principal component analysis was used to study the dimensionality of different types of self-injurious behavior, including purging. Our findings confirm the distinction between impulsive and compulsive self-injurious behavior. The dimensions appear to be represented as a continuum in both the anorexia nervosa diagnostic subgroups. A third distinct dimension emerged that included self-induced vomiting and laxative/diuretics abuse. Childhood sexual abuse and anxiety significantly predict the presence of impulsive self-injury, whereas obsessionality and age predict compulsive self-injury. The coexistence of a positive score on both dimensions of self-injurious behavior was the strongest predictor of treatment dropout. The present study highlights the importance of self-injurious behavior; it should be given due consideration in future outcome studies on anorexia nervosa

Parental representation in eating disorder patients with suicide

OBJECTIVE

We examined parental, personality, and symptomatological characteristics in relation to suicide attempts among eating disorder patients.

METHODS

Fifty-one eating disorder inpatients, divided into two groups according to lifetime suicide attempts, and 107 non-psychiatric subjects were compared on the following variables: Parental Bonding Instrument (PBI), Global Clinical Score (GCS), Eating Disorder Inventory-91 (EDI-91), Eating Attitudes Test-26 (EAT), clinical and personality characteristics, and family backgrounds.

RESULTS

Suicidal patients reported significantly higher overprotection by both parents than non-suicidal patients and non-psychiatric subjects. Suicidal patients had a more prevalent history of child abuse, affective instability, unstable self-image, avoidance of abandonment, maladaptive perfectionism, personality disorder, and mood disorder. There were no differences in symptomatological factors or the severity of the eating disorders.

CONCLUSION

The results suggest that high overprotection is associated with suicidal behaviour in eating disorder patients. The association between overprotective parenting and personality characteristics, and methods of suicide prevention are discussed briefly.

Determinants of the risk and timing of alcohol and illicit drug use onset among natives and non-natives: similarities and differences in family attachment processes

This study examines data from Native Ontario reserve residents (Embree, 1993) and a sample from the Ontario Health Survey Supplement (1990-91) in order to compare and contrast the importance of family attributes such as parent-child attachment to Native and Non-native patterns of drug and alcohol use onset. Proportional Hazards modeling (Cox, 1972) was employed to identify factors associated with the risk and timing of onset of alcohol and illicit drugs for both cultural groups. For both Natives and Non-natives alike, and considering both drinking and drug use onset together, age cohort predominates as a risk factor, with youngest groups at greatest risk, and especially in the case of drug use other than alcohol. For the model of drug use timing, age of alcohol use onset is the second best predictor for Natives, although its effect is still apparent, albeit weaker, in the case of Non-natives. As for family characteristics, a number of factors emerge as determinants of risk and depend, in part, on the cultural group and the substance under consideration. Consistent with attachment theory's prediction about the universal applicability of the need for close parent-child relations (Bowlby, 1969), the findings for both Natives and Non-natives alike point to the salience of psychosocial attachment and other indicators of family functioning in affecting early onset drinking and drug use, behaviors well-recognized to lead to potentially adverse mental and physical health consequences as well as to negative social outcomes.

Impact of a history of physical and sexual abuse in eating disordered and asymptomatic subjects

The present study aimed to explore the impact of sexual and/or physical abuse among eating disordered patients (ED) and asymptomatic subjects. A total of 86 patients with anorexia nervosa, 69 patients with bulimia nervosa and 81 asymptomatic subjects were assessed. Among ED, we did not find a significant association between abuse experiences and the severity of the eating disorder, or between abuse and dissociative symptoms. Among ED, self-destructive behaviour appears to be the most important predictor of a history of sexual and/or physical abuse. In contrast, in the asymptomatic group, the score on the Dissociation Questionnaire is the only significant predictor of reported abuse experiences.

Impulsive and compulsive self-injurious behavior in bulimia nervosa: prevalence and psychological correlates

A specific link between self-injurious behavior and bulimia nervosa has been observed. In affective spectrum disorders, some authors propose a distinction between impulsive and compulsive self-injurious behavior. One of the aims of the present study is to examine how different kinds of self-injurious behavior, including purging behavior, may be classified in bulimia nervosa. The clinical impact of the different types of self-injury will be studied. The subjects of the study were 125 consecutive patients with bulimia nervosa, diagnosed by DSM-IV criteria. Subjects were evaluated by means of a semistructured interview and self-report questionnaires (Eating Disorders Inventory and Hopkins Symptom Checklist). In our sample, the distinction between compulsive and impulsive self-injurious behavior appeared to be confirmed by a principal component analysis. Self-induced vomiting loaded on the compulsive dimension and laxative abuse on the impulsive dimension. To study the clinical impact of the two kinds of behavior, bulimic subjects were divided according to their position in the two dimensions. The presence of impulsive self-injurious behavior is associated with a history of sexual abuse and with higher scores on the Symptom Checklist. The presence of both impulsive and compulsive behavior is associated with greater depression, whereas the presence of impulsive features in the absence of compulsive ones seems to be linked to a longer duration of illness and to a higher dropout rate. Both compulsive and impulsive self-injurious behaviors are associated with a greater lack of interoceptive awareness.

Disordered eating, weight dissatisfaction and dieting in relation to unwanted childhood sexual experiences in a community sample

A study was conducted to examine the relationships among eating pathology, weight dissatisfaction and dieting, and unwanted sexual experiences in childhood. An unselected community sample of 201 young and 268 middle-aged women were administered questionnaires assessing eating behaviors and attitudes, and past and current sexual abuse. Results showed differential relationships among these factors for the two age cohorts: for young women, past sexual abuse predicted weight dissatisfaction, but not dieting or disordered eating behaviors, whereas for middle-aged women, past abuse was predictive of disordered eating, but not dieting or weight dissatisfaction. Current physical or sexual abuse was also found to be predictive of disordered eating for the young women. These findings underscore the complexity of the relationships among unwanted sexual experiences and eating and weight pathology, and suggest that the timing of sexual abuse, and the age of the woman, are important mediating factors.

Relationship of childhood sexual abuse and eating disorders

OBJECTIVE

To review the literature that has examined the relationship between childhood sexual abuse and the eating disorders.

METHOD

Each of the five authors reviewed all identified empirical studies to be certain that inclusion/exclusion criteria were met. Two teams of raters then independently reviewed each study to determine whether it supported any of a series of six hypotheses that had been tested in this literature.

RESULTS

This review indicates that childhood sexual abuse is a nonspecific risk factor for bulimia nervosa, particularly when there is psychiatric comorbidity. There is some indication that childhood sexual abuse is more strongly associated with bulimic disorders than restricting anorexia, but it does not appear to be associated with severity of the disturbance.

CONCLUSION

Childhood sexual abuse is a risk factor for bulimia nervosa with significant comorbidity. Further study of the nature of this relationship is warranted.

Suicidality in eating disorders: clinical and psychological correlates

Although many authors have described eating disorders as often being associated with suicidal feelings and behavior, few studies to date have evaluated the prevalence and characteristics of suicidal behaviour in eating disordered patients. In the present study, in which a consecutive series of 495 out-patients was studied, 13% of the patients reported at least one suicide attempt and 29% reported current suicidal ideation; 26% of attempters reported multiple attempts. A history of suicide attempt was more prevalent among binge-eating/purging anorexics and among purging bulimics than in the other subgroups. In cases with anorexia nervosa, suicide attempters were older, had a longer illness duration, weighed less, had more often used drugs and/or alcohol and tended to be more obsessive than non-attempters. In cases with bulimia nervosa, attempters presented with more psychiatric symptoms and had more frequently been sexually abused.

Histories of childhood trauma and complex post-traumatic sequelae in women with eating disorders

The profound self-destructiveness and tenacity of eating disorders found among women abused and neglected in childhood become comprehensible when understood within a complex posttraumatic conceptualization as desperate attempts to regulate overwhelming affective states and construct a coherent sense of self and system of meaning. Trauma leads to the predictable consequences of dysregulation of the arousal system, avoidance, and constriction of affect; coherence of self and world are shattered. Abused patients' childhood experiences teach them that to need is to expose oneself to the pain of abandonment and betrayal at the hands of individuals responsible for their care. Consequently, needs-psychological, physical, and spiritual-come to be perceived as dangerous, and human relationships are simultaneously yearned for and feared. Robbed of the opportunity to develop a cohesive self and a coherent system of meaning and faith to sustain from within, the traumatized eating-disorder patient turns to the culture to tell her who to be and how to live; she learns that to conquer rather than satisfy needs and to be "in control" (an internal state of equanimity manifested externally in a thin body) will bring meaning and purpose. Binge eating, purging, and starving become apt metaphors for the boundless hunger, the wish to fulfill needs together with the wish to rid oneself forever of need, the desire to "purify" the damaged psychic and physical self, and the hope of restoring meaning. The treatment of the traumatized eating disorder patient is complex. Individual therapy provides the opportunity for intensive relational work that begins to restore faith in human connection and that provides a "safe base" from which to examine the trauma and separate past from present. Therapy groups for eating-disordered women and trauma survivors provide relief from isolation, valuable perspectives from others who have "been there," and the opportunity to contribute to others' healing as one heals. Ultimately, these patients must be willing to leave the world of obsession with food and weight, which guarantees safety from interpersonal hurt while it simultaneously guarantees that hope will not be restored. Though reconnecting with humanity carries the risk of further pain, it opens up the opportunity for connection, healing, and growth.