Adult physical illness and childhood sexual abuse

Identifying radiation therapists' perceptions of potentially triggering aspects of care for survivors of sexual violence undergoing radiotherapy

INTRODUCTION

Research shows that for survivors of sexual violence (SV), cancer procedures can be retraumatizing due to perceived similarities to the original SV. To date, there is no training program designed specifically for the radiation therapist (RTT) on how to deliver care sensitively to survivors of SV. A key component of sensitive practice is working with patients to identify and develop strategies to manage situations that could be triggering. The goal of this study was to understand the RTT recognition of potential sensory/environmental, relational, and mixed triggers in radiation oncology settings.

METHODS

This quantitative research study conducted a secondary analysis on RTT responses to a learning activity from an online cancer education training program. The first section of the activity asked trainees to identify two potential triggers in a brachytherapy video, and the second portion of the activity asked trainees to describe two potential triggers in their own work.

RESULTS

Descriptive statistics, χ2 tests, and t tests were used to analyze 50 RTT responses. RTTs tended to identify different types of triggers depending on the question (brachytherapy video vs. self-reflection). Data indicated that despite a lack of formal didactic training in trigger management, RTTs could identify triggers, and were most likely to recognize "mixed" type triggers.

DISCUSSION

Triggers identified are consistent with past research on childhood sexual abuse survivors' healthcare retraumatization in obstetrics and gynecology, and cancer care. As in past research, invasive techniques, and situations where the patient was in a submissive position were identified as triggering aspects of care. It is interesting to note when reflecting on their own practice, the least identified triggers all fell under the environmental/sensory trigger category. RTTs may not fully appreciate a variety of potential triggers such as sounds of treatment or silence because they are outside of the room administering the beam when the machine is delivering treatment. Thus, they may not hear certain sounds or silence during their daily routine.

CONCLUSIONS

Relatively few trainees identified sensory/ environmental triggers (e.g., restricted visibility and sounds of treatment, including silence) when reflecting on their own practice, which could potentially reduce their likelihood of helping patients minimize the impact of (or avoid) such triggers. Future research should identify a comprehensive list of triggers and then develop a training specific to the RTT focused on identifying environmental/sensory triggers from the perspective of the patient in the often unfamiliar and frightening radiotherapy suite.

Adverse childhood experience and adult persistent pain and disability: protocol for a systematic review and meta-analysis

BACKGROUND

A growing body of research highlights the pervasive harms of adverse childhood experiences (ACEs) on health throughout the life-course. However, findings from prior reviews and recent longitudinal studies investigating the association between types of ACEs and persistent pain have yielded inconsistent findings in the strength and direction of associations. The purpose of this review is to appraise and summarize evidence on the relationship between ACEs and persistent pain and disability outcomes in adulthood. The specific aims are (1) to determine whether there is a relationship between exposure to ACE and persistent pain and disability in adults and (2) to determine whether unique and cumulative ACEs exposures (number and type) increase the risk of developing persistent pain and disability in adulthood.

METHOD

A systematic review and meta-analysis of observational studies will be conducted. Our eligibility criteria are defined following a PECOS approach: population, adults with persistent (≥ 3 months) musculoskeletal and somatoform painful disorders exposed to single or cumulative direct ACEs alone (i.e., physical, sexual, emotional abuse or neglect) or in combination to indirect types of ACE (e.g., parental death, exposure to domestic violence) in the first 18 years of life; comparators, unexposed individuals; outcomes, measurements for persistent pain (≥ 3 months) and disability using discrete and/or continuous measures; and settings, general population, primary care. A comprehensive search of MEDLINE (Ovid) and nine other pertinent databases was conducted from inception to 29 August 2019 using a combination of key words and MeSh terms (the search will be updated prior to conducting the analyses). Pairs of reviewers will independently screen records and full text articles, and a third reviewer will be consulted in cases of disagreement. Data will be extracted using Endnote and Covidence and a meta-analysis will be conducted using Review Manager (RevMan) Version 5.3. The Scottish Intercollegiate Guidelines Network (SIGN) and the Joanna Briggs Institute (JBI) checklists will be used to assess the quality of the included studies. If heterogeneity is high, the findings will be presented in narrative form.

DISCUSSION

The present review will help consolidate knowledge on persistent pain and disability by evaluating whether frequency and type of adverse childhood experiences produces the most harm. Findings may help inform practitioners and policy-makers who endeavor to prevent and/or mitigate the consequences of ACEs and promote healthy development and well-being of children, youth, and families.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020150230.

Longitudinal Intergenerational Birth Cohort Designs: A Systematic Review of Australian and New Zealand Studies

BACKGROUND

The longitudinal birth cohort design has yielded a substantial contribution to knowledge of child health and development. The last full review in New Zealand and Australia in 2004 identified 13 studies. Since then, birth cohort designs continue to be an important tool in understanding how intrauterine, infant and childhood development affect long-term health and well-being. This updated review in a defined geographical area was conducted to better understand the factors associated with successful quality and productivity, and greater scientific and policy contribution and scope.

METHODS

We adopted the preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach, searching PubMed, Scopus, Cinahl, Medline, Science Direct and ProQuest between 1963 and 2013. Experts were consulted regarding further studies. Five inclusion criteria were used: (1) have longitudinally tracked a birth cohort, (2) have collected data on the child and at least one parent or caregiver (3) be based in Australia or New Zealand, (4) be empirical in design, and (5) have been published in English.

RESULTS

10665 records were initially retrieved from which 23 birth cohort studies met the selection criteria. Together these studies recruited 91,196 participants, with 38,600 mothers, 14,206 fathers and 38,390 live births. Seventeen studies were located in Australia and six in New Zealand. Research questions initially focused on the perinatal period, but as studies matured, longer-term effects and outcomes were examined.

CONCLUSIONS

This review demonstrates the significant yield from this effort both in terms of scientific discovery and social policy impact. Further opportunities have been recognised with cross-study collaboration and pooling of data between established and newer studies and international studies to investigate global health determinants.

The influence of childhood abuse and adult attachment style on clinical relationships in breast cancer care

OBJECTIVE

In a previous report, breast cancer patients reporting a history of childhood abuse were less likely to feel fully supported in their relationships with clinical staff than were patients who did not report an abuse history. Our aims were to replicate this effect, to test whether surgeons' difficulties in these relationships mediated the relationship of abuse to patients feeling less supported, and to test whether patients' attachment style mediates the influence of abuse on patients' or surgeons' experience of the relationship.

METHOD

Women with primary breast cancer (N = 100) completed self-report questionnaires around the time of surgery to assess: emotional distress; adult attachment (models of self and other); sexual, physical and emotional abuse before age 16; and childhood parental care. After consultation three weeks post-operatively patients and surgeons completed self-report questionnaires to measure, respectively, patients' perceptions of support from the surgeon, and surgeons' perceptions of difficulty in their relationship with the patient.

RESULTS

Patients recalling abuse were more than seven times more likely to feel incompletely supported by the surgeon than those not recalling abuse, after controlling for emotional distress. Surgeons reported greater difficulty in relationships with patients recalling abuse than with non-abused patients. Attachment (poor model of self) mediated the relationship of abuse with patient perceptions of incomplete support, but not the relationship with surgeon ratings of difficulty.

CONCLUSION

The damaging effects of childhood abuse on adult relationships extend to relationships with surgeons in cancer care. While effects of abuse on attachment can explain the damage that patients experience, mediators of the difficulty that surgeons experience need further research.

Psychological factors and chronic pelvic pain in women: a comparative study with women with chronic migraine headaches

Chronic pelvic pain (CPP) is often attributed to psychogenic causation. To determine if women with CPP possess a unique psychological profile, this study examined the comparative pain experience, psychological functioning, and marital/sexual satisfaction of women with either CPP or chronic migraine headache (CH). Patients with CPP reported greater dissatisfaction with their marriage and greater sexual dysfunction. No differences were obtained for ratings of depression, anxiety, mood factors, or additional personality traits. These data suggest that, in general, when psychological disorders are observed in CPP patients, they most likely reflect the effects of chronic pain rather than be causative to it.

Post-traumatic stress disorder moderates the relation between documented childhood victimization and pain 30 years later

Cross-sectional designs and self-reports of maltreatment characterize nearly all the literature on childhood abuse or neglect and pain in adulthood, limiting potential for causal inference. The current study describes a prospective follow up of a large cohort of individuals with court-documented early childhood abuse or neglect (n=458) and a demographically matched control sample (n=349) into middle adulthood (mean age 41), nearly 30 years later, comparing the groups for risk of adult pain complaints. We examine whether Post-Traumatic Stress Disorder (PTSD) mediates or moderates risk of pain. Assessed prospectively across multiple pain measures, physically and sexually abused and neglected individuals generally showed a significant (p<.05) but notably small (η(2)=.01) increased risk of pain symptoms in middle adulthood. Although PTSD was associated with both childhood victimization (p<.01) and risk of middle adulthood pain (p<.001), it did not appear to mediate the relationship between victimization and pain. However, across all pain outcomes other than medically unexplained pain, PTSD robustly interacted with documented childhood victimization to predict adult pain risk: Individuals with both childhood abuse/neglect and PTSD were at significantly increased risk (p<.001, η(2) generally=.05-.06) of pain. After accounting for the combined effect of the two factors, neither childhood victimization nor PTSD alone predicted pain risk. Findings support a view that clinical pain assessments should focus on PTSD rather than make broad inquiries into past history of childhood abuse or neglect.

Sexual abuse in childhood and postoperative depression in women with breast cancer who opt for immediate reconstruction after mastectomy

INTRODUCTION

Breast reconstruction is routinely offered to women who undergo mastectomy for breast cancer. However, patient-reported outcomes are mixed. Child abuse has enduring effects on adults' well-being and body image. As part of a study into damaging effects of abuse on adjustment to breast cancer, we examined: (i) whether women with history of abuse would be more likely than other women to opt for reconstruction; and (ii) whether mood problems in women opting for reconstruction can be explained by greater prevalence of abuse.

PATIENTS AND METHODS

We recruited 355 women within 2-4 days after surgery for primary breast cancer; 104 had mastectomy alone and 29 opted for reconstruction. Using standardised questionnaires, women self-reported emotional distress and recollections of childhood sexual abuse. Self-report of distress was repeated 12 months later.

RESULTS

Women who had reconstruction were younger than those who did not. Controlling for this, they reported greater prevalence of abuse and more distress than those having mastectomy alone. They were also more depressed postoperatively, and this effect remained significant after controlling for abuse.

CONCLUSIONS

One interpretation of these findings is that history of abuse influences women's decisions about responding to the threat of mastectomy, but it is premature to draw inferences for practice until the findings are replicated. If they are replicated, it will be important to recognise increased vulnerability of some patients who choose reconstruction. Studying the characteristics and needs of women who opt for immediate reconstruction and examining the implications for women's adjustment should be a priority for research.

Separate and cumulative effects of adverse childhood experiences in predicting adult health and health care utilization

OBJECTIVES

Objectives of this population-based study were: (1) to examine the relative contribution of childhood abuse and other adverse childhood experiences to poor adult health and increased health care utilization and (2) to examine the cumulative effects of adverse childhood experiences on adult health and health care utilization.

METHODS

Data from the Ontario Health Survey, a representative population sample (n=9,953) of respondents aged 15 years and older, were analyzed using logistic regression. Adverse childhood experiences examined were childhood physical and sexual abuse, parental marital conflict, poor parent-child relationship, low parental education and parental psychopathology.

RESULTS

Most (72%) respondents reported at least one adverse childhood experience and a considerable proportion of respondents (37%) reported two or more of these experiences. In examining the bivariate models, childhood physical and sexual abuse had a stronger influence than other types of adverse childhood experiences. With the addition of other adverse childhood experiences in the model, the odds ratios for childhood abuse were attenuated but remained statistically significant for most health outcomes. This suggests that childhood abuse may have a unique adverse influence on the development of poor adult health. When an aggregate variable was created to explore the cumulative effects of adverse childhood experience, the odds were increased, with each additional experience, for reporting multiple health problems [odds ratio (OR): 1.22], poor self-rated health (OR: 1.18), pain (OR: 1.24), disability (OR: 1.24), general practitioner use (OR: 1.12), emergency room use (OR: 1.29) and health professional use (OR: 1.19).

CONCLUSIONS

This study suggests that childhood abuse and other adverse childhood experiences are overlapping risk factors for long-term adult health problems and that the accumulation of these adverse experiences increases the risk of poor adult health.

PRACTICE IMPLICATIONS

This study highlights the importance of the many adverse childhood experiences influencing long-term health. In practice, childhood abuse is often difficult to identify as families tend to keep it hidden and reported cases represent only a small percentage of the actual cases. Assessments and interventions which focus on improving socio-economic status, strengthening marital and parent-child relationships, and supporting parents with mental health issues are less threatening for families than assessing their experiences with abuse and neglect and are more likely to be effective in identifying and supporting at-risk families.

Childhood abuse and treatment response in patients with irritable bowel syndrome: a post-hoc analysis of a 12-week, randomized, double-blind, placebo-controlled trial of paroxetine controlled release

OBJECTIVE

Although irritable bowel syndrome (IBS) is frequently comorbid with childhood trauma, information on the clinical implications of this comorbidity is limited. We investigated whether a history of abuse was associated with response to treatment in a double blind, randomized, placebo controlled trial of paroxetine controlled release (CR) in IBS.

METHODS

Seventy-two IBS subjects were randomized to receive paroxetine CR (dose 12.5-50 mg/day) or placebo for 12 weeks. Subject selection was independent of abuse history. Sixty-one subjects completed the Sexual and Physical Abuse Questionnaire about their childhood abuse history. IBS symptoms were recorded using the Interactive Voice Response System (IVRS). Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Perceived Stress Scale (PSS) and Clinical Global Impression (CGI) were also measured. The primary outcome was treatment response defined as > or =25% reduction in composite pain scores (CPS) on the IVRS from randomization to end of treatment.

RESULTS

The rate of abuse history was 50.8% (n = 31/61). Baseline demographic clinical characteristics (CPS, BDI, BAI, PSS, CGI scores) were not associated with abuse history. After 12 weeks of treatment, subjects with abuse history showed significantly higher CPS (t = 2.422, P = 0.018) than subjects without a history and less mean change of CPS (t = 3.506, P = 0.001). In a logistic regression analysis, history of abuse did not predict treatment response as measured by > or =25% reduction in CPS (OR = 0.481, CI = 0.164-1.406, P = 0.181), while the drug status (paroxetine CR) was significantly associated with treatment response as defined by a CGI improvement score of 1-2 (OR = 12.121, CI = 2.923-50.271, P = 0.001). Abuse history did not predict CGI-I (Fisher's exact, P = 0.500) improvements during the trial.

CONCLUSIONS

History of abuse did not appear to have any significant clinical correlates at baseline and did not predict treatment response. Further studies are needed to confirm whether SSRIs are effective in IBS patients irrespective of their abuse history.

The potentially somatizing effect of clinical consultation

Many patients who present physical symptoms that their doctors cannot explain by physical disease have persisting symptoms and impairment. An influential view has been that such symptoms are the somatization of emotional distress, but there has also been concern that medical practice contributes to shaping these presentations. Analysis of patients' accounts indicate that they approach these consultations with a sense of being the expert on the nature and reality of their symptoms and, in primary care at least, they seek convincing explanations, engagement, and support. They often describe doctors as doubting that their symptoms are real and as not taking their symptoms seriously. Observational research has demonstrated that patients presenting idiopathic symptoms in primary care generally provide cues to their need for explanation or to psychosocial difficulties. Their doctors tend to provide simple reassurance rather than detailed explanations, and often disregard psychosocial cues. Patients seem to intensify their presentation in consequence, elaborating and extending their accounts of their symptoms, perhaps in the effort to engage their doctors and demonstrate the reality of their symptoms. When doctors propose physical investigation and treatment in response to such escalating presentation, they thereby inadvertently somatize patients' psychological presentation. Consultations, therefore, have elements of contest, whereby patients seek engagement from doctors who seek to disengage. Although provision of a medical label, such as a functional diagnosis, can legitimize patients' complaints and avoid contest, this is at the risk of indicating that medicine can take responsibility for managing the symptoms. More collaborative relationships rely on doctors recognizing patients' authority in knowing about their symptoms, and providing tangible explanations that make sense to the patient and allow them to tolerate or manage the symptoms. Researchers need to study how doctors can best achieve these aims within routine consultations.

The relationship between posttraumatic stress disorder and self-reported health problems

OBJECTIVE

There is increasing awareness that posttraumatic stress disorder (PTSD) influences physical health. The current study used the National Comorbidity Survey (NCS) data to determine if the physical health risk imparted by PTSD was an artifact of a broad range of empirically identified confounding variables.

METHODS

Participants (n = 5877) were administered a modified version of the DSM-III-R PTSD module from the Diagnostic Interview Schedule (DIS). The prevalence of 14 classes of physical disorders was assessed along with six groups of variables predictive of negative health outcomes (demographics, perception of health, stress, health-related behaviors, insurance coverage, trauma/psychiatric history, and neuroticism).

RESULTS

The PTSD group had a higher frequency of most disorders and scored higher on variables predictive of negative health outcomes. To determine if the health risk imparted by PTSD was an artifact of these confounding variables, a mixed direct-sequential binary logistic regression was computed. After controlling for sex, health perceptions, stress, health-related behaviors, insurance coverage, total trauma exposure, total number of psychiatric diagnoses, and neuroticism, persons with PTSD were more likely to report the presence of a disorder.

CONCLUSIONS

Previous scholars have noted that PTSD could affect health outcomes. This study found that after controlling for a wide range of variables predictive of poor health, PTSD was predictive of poor health.

Childhood maltreatment and mental and physical health in Haitian adults

PURPOSE

To describe the prevalence of childhood maltreatment among Haitian adults and to examine its relationship to depression, general physical health, and quality of life.

DESIGN

Descriptive exploratory. Participants were men and women 18 years of age or older who were seated in the waiting area of a hospital-based medical clinic in a medium-sized city in Haiti. The author collected these data while on a Fulbright fellowship to Haiti in 2003.

METHODS

Two hundred fifty-eight participants completed the Childhood Trauma Questionnaire, Cohen-Hoberman Inventory of Physical Symptoms, Center for Epidemiologic Study-Depression Scale, and a visual analogue quality of life scale. Data were analyzed using descriptive statistics, Pearson's correlation, multiple regression, and Student's t test.

FINDINGS

Over half (60%) of the women and 85.7% of the men reported at least one type of childhood maltreatment at the moderate to severe level. Of the total sample, 53.9% had scores indicative of major depression and 43.9% reported an average score of "somewhat bothered" by 37 physical symptoms. Childhood maltreatment (each of five types) was related to physical symptoms and depression.

CONCLUSIONS

Rates of childhood maltreatment were high in this sample of Haitian adults, and their childhood maltreatment was related to physical and mental health symptoms in adulthood.

Is childhood abuse a risk factor for chronic pain in adulthood?

Childhood sexual and physical abuse often are viewed as important factors in the development and persistence of chronic pain syndromes in adulthood. Nevertheless, earlier reviews on this issue have reached conflicting conclusions regarding the veracity of the relationship. In this critical review of existing research on childhood abuse and pain in adulthood, surprisingly mixed evidence is found, with significant effects found most consistently in very large cross-sectional studies that rely on self-reported abuse status. The few prospective studies that are available do not support the relationship. When examining the literature from the perspective of epidemiological standards for inferring causation, the authors conclude that the evidence does not demonstrate a causal relationship. It appears that any overall relationship between childhood abuse and pain in adulthood probably is modest in magnitude, if it exists at all. Clinical implications and suggestions for future research directions are discussed.

The perceived health status of people with psychologically derived non-epileptic attack disorder and epilepsy: a comparative study

While a wealth of literature describes the short and longer term impact of living with epilepsy, there is, in contrast, very little information about the impact of psychologically derived non-epileptic attack disorder (PNEAD). In the absence of any physical disease, some clinicians may assume that this group requires little help. However, evidence suggests that there maybe a significant impact. Therefore, this study has set out to document the effects on perceived health status of PNEAD. We compared 97 people with PNEAD with a sample, case matched for age and gender, of 97 people who had been previously diagnosed with epilepsy. A questionnaire was administered to both groups requesting information about their perceived overall health (SF-36) and their clinical and demographic status. PNEAD patients described a significantly poorer profile of perceived health compared with the epilepsy group. People with PNEAD have substantially impaired perceived health status, to the extent of feeling in poorer health than people with organically explained epilepsy. Clinical interventions are necessary that can improve their perceived health.

The long-term health outcomes of childhood abuse. An overview and a call to action

While the association between abuse in childhood and adverse adult health outcomes is well established, this link is infrequently acknowledged in the general medical literature. This paper has 2 purposes: (1) to provide a broad overview of the research on the long-term effects of child abuse on mental and physical health including some of the potential pathways, and (2) to call for collaborative action among clinicians, psychosocial and biomedical researchers, social service agencies, criminal justice systems, insurance companies, and public policy makers to take a comprehensive approach to both preventing and dealing with the sequelae of childhood abuse.

Childhood family dysfunction and associated abuse in patients with nonepileptic seizures: towards a causal model

OBJECTIVE

A history of childhood sexual abuse is thought to characterize patients with nonepileptic seizures (NES). We tested the hypotheses: 1) that history of sexual abuse is more prevalent in patients with NES than in controls with epilepsy; 2) that such abuse is associated with NES, not directly but because it is a marker of family dysfunction; and 3) that family dysfunction and abuse are, in turn, linked to NES because they increase a general tendency to somatize.

METHODS

We compared 81 patients with NES with 81 case-matched epilepsy patients, using questionnaires to elicit recollections of sexual, physical, and psychological abuse and family atmosphere and to quantify current somatization.

RESULTS

Although each form of abuse was more prevalent in NES patients, only child psychological abuse uniquely distinguished NES from epilepsy. However, its association with NES was explained by family dysfunction. A general tendency to somatize explained part of the relationship of abuse to NES.

CONCLUSIONS

Abuse therefore seems to be a marker for aspects of family dysfunction that are associated with--and may therefore cause--somatization and, specifically, NES.

Lifetime prevalence of sexual abuse in a Swedish pregnant population

BACKGROUND

Our primary purpose was to determine the prevalence of sexual abuse in a non-selected pregnant population. We also endeavored to establish the age at which the abuse had occurred and the identity of the perpetrator and to analyze in sexually abused vis-à-vis non-abused women, various socio-economic and clinical variables.

METHODS

Over a period of 6 months, all women registered at antenatal clinics in Uppsala, Sweden, were questioned by their midwives regarding exposure to sexual abuse. Data from antenatal records were used to compare abused with non-abused women concerning socio-economic characteristics, previous ill health, reproductive history, pregnancy complications, and pregnancy outcome. Continuous variables were compared using the Student's t-test or the Mann-Whitney U-test and categorical variables using the chi-square test or Fisher's exact test.

RESULTS

Of 1038 women assessed, 84 (8.1%) reported that at some time in their life they had been forced to participate in or subjected to sexual activity against their will. In most cases the perpetrator was someone the woman knew. When compared with non-victims, those abused were more likely to report general health problems, especially gynecologic ill health and surgery, pulmonary disease/asthma, and/or psychiatric care. However, no differences were found regarding pregnancy outcome.

CONCLUSIONS

It was found that one pregnant woman in 12 had reported sexual abuse at some time in their life. To midwives and obstetricians who work closely both physically and emotionally with pregnant women, an awareness of the extent of the problem and of possible sequelae is essential.

Abuse, dissociation, and somatization in irritable bowel syndrome: towards an explanatory model

This study tested a preliminary model of the role of dissociation and somatization in linking abuse to irritable bowel syndrome (IBS). Outpatients with IBS (N = 64) or bowel symptoms explained by physical disease (N = 61) completed questionnaires to assess recollections of abuse as children or adults and current dissociation, somatization, and emotional distress. By comparison with physically diseased patients, patients with IBS recalled more sexual abuse as children and adults, more physical abuse as children, and more psychological abuse as adults. They were more anxious and depressed, and somatized and dissociated more. Analyses indicated a causal chain linking, in turn, abuse, dissociation, somatization, and IBS. The results are consistent with a model in which childhood abuse is linked to IBS because it causes a tendency to dissociate, and because dissociation causes a general increase in physical symptoms. Future research should identify factors that explain why a generally increased level of physical symptoms should, in some patients, lead specifically to IBS.

Childhood abuse and later medical disorders in women. An epidemiological study

BACKGROUND

There have been many studies documenting adverse psychiatric consequences for people who have experienced childhood and adult sexual and physical abuse. These include posttraumatic stress disorder, anxiety, depression, substance abuse, eating disorders and probably some personality disorders or trait abnormalities. Much less is known about the links between abuse and physical/psychosomatic conditions in adult life. Hints of causal links are evident in the literature discussing headache, lower back pain, pelvic pain and irritable bowel syndrome. These studies are not definitive as they use clinic-based samples.

METHODS

This study used interview data with a random community sample of New Zealand women, half of whom reported childhood sexual abuse and half who did not. Details about childhood physical abuse and adult abuse were also collected in a two-phase study.

RESULTS

Complex relationships were found, as abuses tended to co-occur. Seven of 18 potentially relevant medical conditions emerged as significantly increased in women with one or more types of abuse. These were chronic fatigue, bladder problems, headache including migraine, asthma, diabetes and heart problems. Several of these associations with abuse are previously unreported.

CONCLUSIONS

In this random community sample, a number of chronic physical conditions were found more often in women who reported different types of sexual and physical abuse, both in childhood and in adult life. The causal relationships cannot be studied in a cross-sectional retrospective design, but immature coping strategies and increased rates of dissociation appeared important only in chronic fatigue and headache, suggesting that these are not part of the causal pathway between abuse experiences and the other later physical health problems. This finding and the low co-occurrence of the identified physical conditions suggest relative specificity rather than a general vulnerability to psychosomatic conditions in women who have suffered abuses. Each condition may require separate further study.

A prospective study of the effects of sexual or physical abuse on back pain

A prospective investigation of the effects of abuse on future pain and disability was conducted in order to understand better the possible causal role of abuse. Participants were 422 females from a previous population study (Pain 73 (1997) 47-53) who either reported no spinal pain (n=194) or some spinal pain (n=228) at the baseline. A standardized questionnaire was used to assess self-reported physical and sexual abuse during childhood and as an adult. One year later, a follow-up questionnaire was used to evaluate pain and physical function outcomes. Results for the No Pain Group showed that only self-reported physical abuse at baseline was associated with an increased occurrence of new episodes of back pain (odds RATIO=2.65). Both sexual and physical abuse were linked to as much as four-fold increase in the occurrence of a new episode of functional problems at follow-up. However, for the Pain Group, no significant differences were found between those reporting and not reporting abuse at baseline and either pain or disability at follow-up. This unique prospective study with individuals from the general population underscores the probable importance of abuse in the etiology of a pain or disability problem. Nevertheless, since no clear relationship between abuse and pain was shown for those already reporting pain at baseline, the role of abuse in the development of persistent pain is still not comprehensible. There is a need for investigations with prospective designs employing patients as well as nonpatients as subject.

Homeopathy in survivors of childhood sexual abuse

The objective of this review was to ascertain the incidence of childhood sexual abuse: to ascertain the long-term effects of childhood sexual abuse and to collate the experiences of homeopaths in caring for survivors. Childhood sexual abuse (CSA) is common with a high percentage of homeopathic patients giving a positive history. It is associated with many common clinical conditions, particularly pelvic pain. Survivors are more likely to present for medical help and to be hospitalised. Homeopaths have found work with such patients to be difficult, with cases being complex and multi-layered. New models for case-analysis have been developed.

Physical symptoms, posttraumatic stress disorder, and healthcare utilization of women with and without childhood physical and sexual abuse

For four groups of women: no abuse, physical abuse alone, combined sexual and physical abuse, and unclear about memories of abuse, we examined the associations between childhood sexual and physical abuse, chronic physical symptoms in adulthood, PTSD, and health care utilization. Of a randomly selected sample of 600 adult femalc members of a health maintenance organization, 86 (14%) chose to participate. Women with a history of physical and sexual abuse in childhood reported significantly more cardiovascular, immune, musculoskeletal, neurologic, and reproductive symptoms than those without this history. While the Sexual/Physical Abuse group had the most chronic physical symptoms, medical visits, emergency room visits, prescriptions, and severe PTSD, the Unclear Memory group consistently ranked second on these same measures--higher than either Controls or the Physical Abuse group. Findings underscore the importance of screening for trauma history among patients seen in medical clinics, and the importance for psychotherapists of attending to patients' physical as well as psychological symptoms of childhood trauma.

Psychological characteristics of women presenting with breast pain

OBJECTIVE

Extensive evidence links unexplained physical symptoms in adults with childhood abuse. This study investigated a possible link between unexplained breast pain, recalled childhood abuse and emotional and somatic distress.

METHODS

Consecutive female out-patients presenting with breast pain were categorised as treatment-resistant (n=20), newly diagnosed and requesting treatment (n=37), or newly diagnosed but reassured and not seeking treatment (n=32) and compared with pain-free patients with breast lumps (n=31).

RESULTS

All breast pain groups were more anxious and depressed, somatised more and recalled a higher incidence of emotional abuse by comparison with breast lump patients. Logistic regression confirmed that emotional abuse and anxiety were independently associated with breast pain.

CONCLUSION

Clinical management of patients who present breast pain should be sensitive to the evidence that pain is a marker of emotional abuse in some women and is associated with widespread somatic and emotional distress.

Victimization in chronic fatigue syndrome and fibromyalgia in tertiary care: a controlled study on prevalence and characteristics

The authors studied the prevalence and characteristics of different forms of victimization in 95 patients suffering from chronic fatigue syndrome (CFS) or fibromyalgia (FM) compared with a chronic disease group, including rheumatoid arthritis (RA) and multiple sclerosis (MS) patients, and a matched healthy control group. The authors assessed prevalence rates, nature of victimization (emotional, physical, sexual), life period of occurrence, emotional impact, and relationship with the perpetrator by a self-report questionnaire on burdening experiences. CFS and FM patients showed significantly higher prevalences of emotional neglect and abuse and of physical abuse, with a considerable subgroup experiencing lifelong victimization. The family of origin and the partner were the most frequent perpetrators. With the exception of sexual abuse, victimization was more severely experienced by the CFS/FM group. No differences were found between healthy control subjects or RA/MS patients, and between CFS and FM patients. These findings support etiological hypotheses suggesting a pivotal role for chronic stress in CFS and FM and may have important therapeutic implications.

Lesbians surviving childhood sexual abuse

Abstract This qualitative, feminist study is focused on lesbians' experiences growing up in multiproblem families, surviving aftereffects of trauma, and struggling with alcohol problems. A multi-racial sample of 20 lesbians narrated life stories in a series of three in-depth interviews. The research report opens with one woman's narrative about surviving childhood sexual abuse and continues with explication of how differences and similarities within and between accounts pivot on the issues of sexual orientation, gender, and race. Results suggest that early in their lives, overwhelming violence and intrusive expectations were imposed, negating a clarity of experience about their authenticity. No participant expressed a belief that her sexual orientation was a result of childhood sexual abuse. The societal presumption of sexual abuse as an etiological factor in determining lesbian sexual orientation, nevertheless, was pivotal for these survivors because they had to constantly protect themselves from others' judgements about whether they were "real lesbians." They described a multi-faceted, ingenious strategy, gender-blurring, that helped them garner a place of some value in the family and stave off some of the violence, but this protective stance made them question whether they were "real women." Women also indicated that they grew up in families empty of cultural affiliation. Instead of knowledge and pride about connection with community, they experienced a gaping void about racial identification, ethnicity, parentage, and personal history. All in all, they survived a series of social identity exclusions. Conclusions call into question the usefulness and adequacy of theories about static psychological and social identities and suggest the importance of specific, localized analyses that explore narrative selves.

The reliability and validity of empirically scaled measures of psychological/verbal control and physical/sexual abuse: relationship between current negative mood and a history of abuse independent of other negative life events

A history of psychological, physical, and sexual abuse, and circumscribed negative life events are precursors of current psychosomatic symptomatology. However, it is not known whether a history of abuse predicts current symptomatology, independent of other negative life events. We developed three new abuse scales: Psychological/Verbal; Control; and Physical/Sexual, which emerged when survey evidence of a random sample of the general public (N = 195) was factor analyzed. Test-retest reliabilities conducted on university students (N = 62) were moderate to high: Psychological/Verbal (r = 0.86); Control (r = 0.76); Physical/Sexual (r = 0.74); and Negative Life Events (r = 0.84). A Negative Life Event scale was developed to measure the cumulative effects of events (over the lifespan). A total score was calculated by summing event scores, weighted in proportion to 11 independent judges' ratings of distress for later use (Kendall's W; chi 2 = 183.67, df = 67, p < 0.0001). Thirteen criterion measures of current symptomatology were administered to a subsample of the original sample (N = 92), and collapsed into one factor for use as the criterion in a regression analysis; results showed that, independent of negative life events and respondent demographics, the Psychological/Verbal and Control Abuse Scales predicted current negative mood and psychosomatic complaints, and the association between current symptomatology and the Physical/Sexual Abuse Scale approached, but did not achieve, statistical significance (t = 1.99, df = 71, p < .0501). The present study demonstrates that the three abuse scales may be powerful predictors of current symptomatology, and that they have the potential for further investigating a wider range of current medical, physiological, and psychological problems.

Beyond "true" and "false" memories: remembering and recovery in the survival of childhood sexual abuse

As survivors of childhood sexual abuse (CSA) struggle to grasp and reclaim their selves, their stories, and their futures from the grip of aftereffects of trauma, the processes of recovery and rehabilitation are interwoven with remembering. Questions about women's delayed memories of CSA have stirred a controversy that places clients' credibility at stake. Nurses need to understand the historical and political roots of this controversy and to be familiar with the empirical knowledgebase that exists about traumatic memory. This article is a critical feminist analysis of the topic. Its purposes are to provide a historical context for the current debate about "true" and "false" CSA memories; to discuss selected literature about conventional understandings of memory and their relevance to this debate; to present an integrative, phenomenological approach to memory in the recovery and rehabilitation of women CSA survivors; and to use the insights gained to draw conclusions from a nursing perspective about the authenticity of delayed CSA memories. Phenomenological concepts of reminding, reminiscing, recognition, body memory, place memory, and commemoration are discussed as they illuminate the complexity of traumatic memories and the recovery and rehabilitation needs of survivors of childhood sexual abuse.

Sociopsychological factors in chronic pelvic pain: a review

Chronic pelvic pain is a common gynecological problem. There has long been an assumption that social and psychological factors play a part in its genesis in a significant subgroup, but their precise role remains unclear. More recently, childhood sexual abuse has been implicated as a specific risk factor. For this review, PSYCHLIT and MEDLINE searches for relevant publications were supplemented by tracing back through the latter's related reference lists. One hundred thirty-one references directly concerning pelvic pain were identified with varying emphasis on social and psychological aspects. A further 449 references were in related fields. Forty-three were considered to be helpful in directly exploring the link between chronic pelvic pain and sociopsychological factors and 22 of these reported specific studies directly relevant. In common with other research into chronic pain conditions, it appears unhelpful to separate this type of pain into "psychogenic" and "organic" categories. Clear case definition is essential. The specificity of childhood sexual abuse as a risk factor is unclear. It may be helpful to consider clearly defined subgroups with the condition in future studies. An example of such a subgroup with pelvic venous congestion is discussed.

Sociopsychological factors in women with chronic pelvic pain with and without pelvic venous congestion

Social and psychological factors have long been proposed as being of importance in a sizeable subgroup of women complaining of unexplained chronic pelvic pain (CPP). The aim of this study was to examine this in two subgroups of CPP patients, thereby eliminating pain alone as the determining variable. Consecutive attenders at a clinic for CPP were assessed on a range of somatic, historical, social, and psychological variables using detailed interviews and questionnaires. They were subsequently allocated to one of two groups, based on the presence or absence of pelvic venous congestion (PVC). Significant associations emerged between some social arrangements, paternal parenting, and patterns of hostility in the group with pelvic venous congestion. The groups also differed in patterns of family illness, and the congested group tended to report more childhood sexual abuse (CSA). Clear case definition in CPP is important. In the subgroup with pelvic venous congestion early social experience may play an important role. Father-daughter relationships may be particularly relevant. Hostility patterns may influence the development of the condition. CSA does not appear to play a specific role in all unexplained CPP cases, but may have relevance for the subgroup with pelvic venous congestion.

Childhood abuse, alexithymia and personality disorder

I examined the relationships among childhood abuse, alexithymia, and personality disorder. Participants were 60 adults who were receiving outpatient psychotherapy. Both the participants and their therapists used the Toronto Alexithymia Scale to provide independently information concerning the client's level of alexithymia. The therapists provided information concerning DSM-III-R personality disorder diagnoses, and participants completed portions of the Personality Diagnostic Questionnaire-Revised. Information concerning childhood abuse history was obtained from the therapists. As expected, childhood abuse, alexithymia, and personality disorder were all associated with each other. The abilities to identify and communicate emotions were differentially associated with childhood abuse and personality disorder.

Delayed recall of childhood sexual abuse: psychiatric nursing's responsibilities to clients

In no other area of psychiatric care is such suspicion being cast on clients as in the area of delayed recall of childhood sexual abuse. Adult survivors of childhood abuse are encountered in nursing contexts of all kinds. Psychiatric nurses should be the ones that other nurses and members of the public can look to for guidance and clinical wisdom about dissociative amnesia for childhood abuse. It is incumbent on psychiatric nurses, especially those who publish about clinical issues, to provide the most accurate and complete available knowledge, to prioritize clients' needs, and to recommend care that meets the highest standards.

Sexual abuse and chronic musculoskeletal pain: prevalence and psychological factors

OBJECTIVE

We investigated the prevalence of a history of sexual abuse among patients with long-term musculoskeletal pain. Psychological factors associated with abuse and pain were also studied.

DESIGN

First, the prevalence of abuse was determined based on self-report on a valid and reliable abuse questionnaire. Subsequently, a cross-sectional method, in which patients were categorized as abused or nonabused, was employed and responses to a battery of questionnaires compared.

PATIENTS

Seventy-five consecutive patients undergoing assessment for chronic musculoskeletal pain participated.

OUTCOME MEASURES

These included Beck's Depression Inventory, the Coping Strategies Questionnaire, the Multidimensional Pain Inventory, the Uppsala Type A Behavior Questionnaire, the Pain and Impairment Rating Scale, as well as ratings of pain intensity.

RESULTS

Thirty-eight percent of the women and 10% of the men reported some form of sexual abuse, usually during adulthood. A majority (77%) had disclosed the abuse to someone, but >85% did not believe that the abuse negatively affected their pain or sex lives. Abused women, relative to nonabused ones, had poorer scores on 27 of the 29 assessment variables. Abused female patients had significantly higher levels of depression, stress from daily hassles, affective distress, and more frequent negative responses from spouses, in addition to having lower levels of social activities, life control and effective coping for pain than did the nonabused female patients.

CONCLUSION

These data extend the relationship between sexual abuse and pain to a Swedish population suffering from musculoskeletal complaints. Our findings suggest that intervention in the pain treatment setting may need to address further the problems of effective coping strategies and depression.

Interviewing for sexual abuse: reliability and effect of interviewer gender

An interview to detect histories of sexual abuse was administered to consecutive attenders at a gynecology clinic on two occasions, on one occasion by a male interviewer and on the other by a female interviewer. Fifty-six subjects were assessed, and at least partial agreement was found in 70% between the two interviews. Approximately one-third of incidents were reported at only one of the interviews, with gender of interviewer making little apparent difference to this. Contrary to expectation, subjects appeared more forthcoming at the first interview. Reasons for this are discussed. Interviews for sexual abuse must be carried out in an appropriate context, and simple routine screening questions may not be appropriate. Selection of interviewers on the basis of gender alone may not be helpful.

Geography of childhood sexual abuse: women's narratives of their childhood environments

This article explores the geography of childhood sexual abuse by describing characteristics of the home, school, and community environments in which abused girls grew up. Results of this focused life story research involving 20 women survivors who narrated their childhood experiences suggest a topography of 20 distinct characteristics integral to the milieux of these abusive childhood homes. Dynamics of the home environment were reinforced in school and community environments. Implications for prevention and early, environmentally based interventions for girls at risk of abuse and retraumatization are discussed.

The relationship of childhood physical and sexual abuse to adult illness behavior

A sample of 275 undergraduate subjects reported (i) their history of sexual and physical abuse in childhood and (ii) their health care utilization, somatization, and hypochondriasis as an adult. Physical and sexual abuse were recalled by largely separate groups, physical abuse predominating in males and sexual abuse in females. Both types of abuse were followed by a greater number of hospital admissions and surgical procedures in adulthood. Although sexual, and especially physical, abuse were associated with recall of emotionally disturbed parenting, this could not explain their influence on health care utilization because this was unrelated to parenting. Similarly, although abuse was followed by greater somatization and hypochondriasis, these also were unrelated to health care utilization. Physical and sexual abuse in childhood are risk factors, independent of their association with poor parenting, in the development of separate aspects of adult illness behavior.

Pervasive effects of childhood sexual abuse in lesbians' recovery from alcohol problems

In narratives of 35 lesbians in alcohol recovery, 46% unexpectedly disclosed having survived childhood sexual abuse (CSA), linking it with addiction and recovery experiences. This subgroup described unbounded difficulties that pervaded their lives well into recovery. They reported multiple addictions, self-harm, isolation, sexual problems, depression, self-loathing, physical illness, and inability to work more often than did other participants. Those not reporting CSA were more socially and occupationally stable, self-satisfied, and physically well in recovery; their alcohol problems seemed circumscribed and responsive to conventional intervention. Conclusions indicate that CSA history may foster health risks that complicate alcohol recovery, necessitating more comprehensive clinical attention.

Sexual and physical abuse and gastrointestinal illness

BACKGROUND

Clinicians are becoming aware of the increased attention paid to the occurrence of sexual and physical abuse in our society and its consequences. However, only recently has attention been paid to their association with medical and particularly gastrointestinal illnesses.

METHODS AND RESULTS

Recently, we investigated the frequency of sexual or physical abuse among female patients in our gastroenterology clinic, and their association with health status. Of 206 women, 89 (44%) reported some type of sexual or physical abuse in their lifetime. We also found that patients diagnosed with functional GI disorders when compared with those with organic diagnoses reported a significantly greater frequency of sexual (53% versus 37%) and physical abuse (13% versus 2%). Of these, 59% had never discussed the abuse experience outside their families, a third had never told anyone, and only 17% of their GI physicians were aware of this history. We also found that abuse history led to a poorer health outcome: more severe GI pain and a higher frequency of pelvic pain (16% versus 6%), more non-GI symptoms (7.1 versus 5.8), more physician visits in the previous six months (4.2 versus 3.3) and more lifetime operations (2.8 versus 2.0).

CONCLUSIONS

In a GI referral practice, abuse history is a hidden factor that is associated with poorer adjustment to illness, greater symptom severity and higher health care use rates. Since the publication of these data, several groups have supported our findings and obtained additional new data on associating factors and possible mechanisms of symptom generation. This paper will: (i) review this epidemiologic data, (ii) propose hypotheses about their association, (iii) offer suggestions to identify this information in a sensitive and supportive manner, and (iv) discuss how to initiate referral for ancillary psychosocial care.