Sexual abuse in patients with eating disorder, patients with depression, and normal controls. A comparative study

Anorexia Nervosa and EMDR: A Clinical Case

Numerous studies have identified links between psychopathology and a history of traumatic life events and dysfunctional attachment relationships. Hence, given the possible traumatic origins of this pathology, it may be useful to provide a trauma-focused intervention such as the eye movement desensitization and reprocessing (EMDR) therapy. This article illustrates a clinical case by describing the positive results of the EMDR therapy in the recovery of unremitting anorexia nervosa in a 17-year-old inpatient. She had previously been hospitalized on 4 occasions in the previous 4 years and received both psychodynamic and cognitive-behavioral therapy. At pretreatment, the client weighed (28 kg, 62 lb) and had a body mass index of 14. She was designated with a dismissing attachment style on the Adult Attachment Interview. EMDR therapy was provided for 6 months in hospital, in twice weekly 50-minute sessions and consisted of standard procedures primarily focusing on her relational traumas, interspersed with psychoeducational talk therapy sessions, and integrated with ego state therapy. At the end of treatment, the client weighed (55 kg, 121 lb) and had a body mass index of 21.5. She no longer met diagnostic criteria for anorexia nervosa, and her attachment style had changed to an earned free-autonomous state of mind. She reported an increase in self-confidence and in her ability to manage various social challenges. Results were maintained at 12 and 24 months follow-up. The treatment implications of this case study are discussed.

Protective Factors, Physical Abuse, and Purging from Community-Wide Surveys of Female Adolescents

This study explores resiliency in adolescent females who reported being physically abused. Employing data from the Search Institute on more than 100,000 adolescent females, this study addressed the following questions: Is a history of physical abuse associated with purging two or more times per week by female adolescents? What factors are associated with a decreased risk of purging among adolescent females who have a history of physical abuse? In addition to addressing these questions, the authors explored the relation between sexual abuse and purging. Both physical abuse and sexual abuse were associated with purging two or more times per week. Physically abused adolescents were less likely to purge two or more times per week if they received high levels of family support and had positive experiences in school. Physically abused adolescents were more likely to engage in purging if they had also been sexually abused.

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.

Disentangling the Association Between Child Abuse and Eating Disorders: A Systematic Review and Meta-Analysis

OBJECTIVES

The aim of this systematic review and meta-analysis was to estimate the association between distinct types of child abuse--sexual (CSA), physical (CPA), and emotional (CEA)--and different eating disorders (EDs).

METHODS

Electronic databases were searched through January 2014. Studies reporting rates of CSA, CPA, and CEA in people with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED), as compared with individuals without EDs, were included. Pooled analyses were based on odds ratios (ORs), with relevant 95% confidence intervals (CIs), weighting each study with inverse variance models with random effects. Risk of publication bias was estimated.

RESULTS

Thirty-two of 1714 studies assessed for eligibility met the inclusion criteria, involving more than 14,000 individuals. The association between EDs and any child abuse showed a random-effects pooled OR of 3.21 (95% CI = 2.29-4.51, p < .001) with moderate heterogeneity (I2 = 57.2%, p = .005), whereas for CSA, this was 1.92 (95% CI = 1.13-3.28, p = .017), 2.73 (95% CI = 1.96-3.79, p < .001), and 2.31 (95% CI = 1.66-3.20, p < .001), for AN, BN, and BED, respectively. However, adjusting for publication bias, the estimate for CSA and AN was not significant (OR = 1.06, 95% CI = 0.59-1.88, p = .85). Although CPA was associated with AN, BN, and BED, CEA was associated just with BN and BED.

CONCLUSIONS

BN and BED are associated with childhood abuse, whereas AN shows mixed results. Individuals with similar trauma should be monitored for early recognition of EDs.

TRIAL REGISTRATION

The protocol was registered in PROSPERO (an international prospective register of systematic reviews) with the reference number CRD42014007360.

Maternal-infant separation impedes changes in feeding behavior during estrous cycle of rats

Traumatic and stressful events during childhood are associated with the development of eating disorders. We conducted an animal study to test if association stress in childhood affects ingestive behavior later in life by using female rats that have an adjusted estrous cycle. First, electrical impedance of the vagina was conducted to test estrous cycle adjustment. Second, the effects of 6 h per day maternal separation from birth to weaning, which models a psychologically stressful experience in childhood, was used to test feeding behavior during an ovarian cycle in female adult rats with matched estrous cycles. Food and water intake in maternal separated and non-separated rats was measured in each estrous phase. Non-separated rats showed periodical changes, but maternal separated rats showed no significant changes in food and water intake during an estrous cycle. An opposing tendency for food and water intake was seen between maternal separated and non-separated rats. These observations suggest that electrical impedance of the vagina showed the highest value in the estrous phase of rats housed in a reversed light-dark cycle, and maternal separation was found to disturb changes in feeding behavior during the estrous cycle.

The comorbidity between eating disorders and anxiety disorders: prevalence in an eating disorder sample and anxiety disorder sample

OBJECTIVE

To investigate the prevalence of comorbid eating and anxiety disorders in women presenting for inpatient and outpatient treatment of an eating disorder and women presenting for outpatient treatment of an anxiety disorder.

METHODS

The prevalence of comorbidity was investigated from a sample of 152 women, which included 100 women presenting for treatment of an eating disorder and 52 women presenting for treatment of an anxiety disorder.

RESULTS

Of women presenting for treatment of an eating disorder, 65% also met criteria for at least one comorbid anxiety disorder; 69% of these reported the onset of the anxiety disorder to precede the onset of the eating disorder. Of the anxiety disorders diagnosed, social phobia was most frequently diagnosed (42%) followed by post-traumatic stress disorder (26%), generalised anxiety disorder (23%), obsessive-compulsive disorder (5%), panic/agoraphobia (3%) and specific phobia (2%). We also found that 13.5% of women presenting for anxiety treatment also met criteria for a comorbid eating disorder. Furthermore, 71% (n = 5) reported the onset of the anxiety disorder to precede the onset of the eating disorder.

DISCUSSION

The results of this study suggest that the prevalence of eating and anxiety disorder comorbidity is high. The present research should improve the clinical understanding of the comorbidity between eating disorders and anxiety disorders. In particular, it is anticipated that this research will have significant aetiological and therapeutic implications especially with regard to improving the clinical effectiveness of psychological treatments for eating disorders and highlighting the importance of screening for eating pathology in the clinical assessment of anxiety disorders.

The comorbidity of substance use disorders and eating disorders in women: prevalence, etiology, and treatment

Substance use disorders often co-occur with eating disorders in female populations. This review addresses the prevalence and etiology of this comorbidity in women. Thirteen peer-reviewed journal articles are reviewed. Conclusions are drawn concerning prevalence rates, theory, and implications for treatment. Current research supports distinct etiologies and growth trajectories for both disorders. Thus, comorbidity presents with unique challenges, and often, worse outcomes. Though comorbidity rates are high, little research has been done concerning treatment. Given the high prevalence rates of these comorbid disorders, a specific treatment needs to be developed that targets both disorders simultaneously.

Risk factors for full- and partial-syndrome early adolescent eating disorders: a population-based pregnancy cohort study

OBJECTIVE

To identify prospective predictors of eating disorders in a population-based sample of 14-year-old boys and girls, using previously collected antenatal, biomedical, familial, demographic, and psychosocial data.

METHOD

Participants (N = 1,597) were drawn from the Western Australian Pregnancy Cohort (Raine) Study. Data were collected during pregnancy, at birth, and when children were aged 1, 2, 5, 8, 10, and 14 years. An adapted version of the Eating Disorder Examination Questionnaire was used to assess eating disorder symptoms at age 14 years. Logistic regression was used to identify prospective predictors of eating disorder caseness, relative to general control and psychiatric control groups.

RESULTS

At age 14 years, 6% of the sample met full or partial criteria for a DSM-IV eating disorder. Being female and being perceived as overweight by one's parent were the strongest predictors of eating disorder caseness in the final multivariate models, relative to both control groups. Maternal body mass index, social problems, low social-related self-efficacy, and neurocognitive difficulties were also predictive of eating disorder caseness relative to the general control group only.

CONCLUSIONS

The results suggest that parent's perceptions of their child's weight are more powerful than objective child body weight in predicting the development of eating disorders. Parent-perceived child overweight was also a specific risk factor for eating disorders, whereas elevated maternal weight and childhood psychosocial difficulties seem to be associated with increased risk for psychiatric disturbance more generally. These results have implications for the prevention of eating disorders, particularly in light of recent increases in the prevalence of childhood obesity.

The co-morbidity of eating disorders and anxiety disorders: a review

OBJECTIVE

To critically review the literature examining the co-morbidity between eating disorders and anxiety disorders.

METHOD

A review of the literature on the co-morbidity between anorexia nervosa, bulimia nervosa and eating disorders not otherwise specified and the anxiety disorders of OCD, PTSD, social anxiety, GAD, panic and agoraphobia.

RESULTS

Of the empirical studies undertaken, it is clear that anxiety disorders are significantly more frequent in subjects with eating disorders than the general community. Researchers have shown that often anxiety disorders pre-date eating disorders, leading to a suggestion that early onset anxiety may predispose individuals to developing an eating disorder. To date however, the research presents strikingly inconsistent findings, thus complicating our understanding of eating disorder and anxiety co-morbidity. Furthermore, despite indications that eating disorder prevalence amongst individuals presenting for anxiety treatment may be high, there is a distinct lack of research in this area.

DISCUSSION

This review critically examines the available research to date on the co-morbidity of eating disorders and anxiety disorders. Some of the methodological limitations of previous research are presented, in order to highlight the issues which warrant further scientific investigation in this area.

Fertility and history of sexual abuse at 10-year follow-up of adolescent-onset anorexia nervosa

OBJECTIVE

We studied fertility and history of child sexual abuse (CSA) in a representative group of anorexia nervosa (AN) cases.

METHOD

Fifty-one adolescent-onset AN cases recruited after community screening and 51 matched comparison cases were interviewed 10 years after reported AN onset, at mean age 24 years, regarding children, miscarriages, and fertility problems. They completed anonymously the Finkelhor self-report questionnaire regarding history of CSA.

RESULTS

There were few fertility problems in our AN population. There was a tendency towards more subjects in the AN group to give birth to a child (10 AN and 4 comparison mothers). The prevalence of CSA was equal between groups. For example, 6% in each group had experienced CSA before the age of 10 years, and 14% of the AN and 12% of the comparison cases reported CSA.

DISCUSSION

Infertility and history of CSA may not be overrepresented in a population-based AN sample at long-term follow-up.

Predictors of development of adult psychopathology in female victims of childhood sexual abuse

The purpose of this study is to identify predictors of resilience and adult mental disorders in women with a history of childhood sexual abuse. This cross-sectional study was conducted in a family practice center using adult female (age 18-40) patients. Outcome measures assessed the prevalence of major depressive episode, panic disorder, agoraphobia, substance abuse, posttraumatic stress disorder, borderline personality disorder, bulimia, and suicidality. Seventy-six percent of the 90 women with sufficient data met criteria for at least one adult disorder. Mental health was related to high SES, lack of family alcohol abuse, lower frequency of first perpetrator abuse, and few perpetrators. Specifics of the abuse were associated with development of borderline personality disorder, substance abuse, major depressive episode, suicidality, bulimia, agoraphobia, and panic disorder. Maternal violence against the father, substance abuse within the household of origin, and maternal care and overprotection were also important. The specifics about the abuse and the family environment during childhood are important predictors of adult psychopathology.

Abnormal eating attitudes and sexual abuse experiences in Turkish university women

The aim of this study was to examine the direct and indirect relationship between abnormal eating attitudes and sexual abuse. The subject sample comprised 532 female Turkish undergraduate and nursing students in Istanbul. The Eating Attitudes Test (EAT), Sexual Abuse Questionnaire, the Setting Conditions for Anorexia Nervosa Scale, the Positive and Negative Perfectionism Scale and the Need for Control Scale (NCS) were the instruments of the study. The results showed that sexual abuse has a direct effect on EAT-Bulimia but not on EAT-Dieting. It also has some indirect effects on both of these through its effects on family functioning. Perfectionism, on the other hand, was independently linked with both EAT-Dieting and EAT-Bulimia but was not associated with sexual abuse.

Coming to Terms With Risk Factors for Eating Disorders: Application of Risk Terminology and Suggestions for a General Taxonomy

The aims of the present review are to apply a recent risk factor approach (H. C. Kraemer et al., 1997) to putative risk factors for eating disorders, to order these along a timeline, and to deduce general taxonomic questions. Putative risk factors were classified according to risk factor type, outcome (anorexia nervosa, bulimia nervosa, binge-eating disorder, full vs. partial syndromes), and additional factor characteristics (specificity, potency, need for replication). Few of the putative risk factors were reported to precede the onset of the disorder. Many factors were general risk factors; only few differentiated between the 3 eating disorder syndromes. Common risk factors from longitudinal and cross-sectional studies were gender, ethnicity, early childhood eating and gastrointestinal problems, elevated weight and shape concerns, negative self-evaluation, sexual abuse and other adverse experiences, and general psychiatric morbidity. Suggestions are made for the conceptualization of future risk factor studies.

Sexual abuse and eating disorders: clinical cases

The aim of this analysis of five clinical cases is to show how an experience of sexual abuse can contribute towards increasing individual vulnerability and become one of several factors that come together to aggravate and complicate the symptoms characterising eating disorders. It is also intended to enhance the importance of a "multifactorial" model for approaching this kind of psychopathology.

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.

A meta-analytic examination of the relationship between child sexual abuse and eating disorders

OBJECTIVE

This study had two goals. The first was to assess the magnitude and consistency of the relationship between child sexual abuse (CSA) and eating disorders (ED). The second was to examine methodological factors contributing to the heterogeneity of this relationship.

METHOD

Meta-analysis was used to examine both questions. Fifty-three studies were included in the analysis.

RESULTS

A small, significant positive relationship between CSA and ED emerged. The relationship was marked by heterogeneity. Effect sizes were largest when CSA was the grouping variable, the Eating Disorders Inventory (EDI) or the Eating Attitudes Test (EAT) was used as the measure of eating disorders, and nonclinical groups were compared with clinical samples.

DISCUSSION

Models of CSA and ED need to more clearly specify what aspects of ED (e.g., body image or binge eating) are most influenced by which types of CSA. These specific relationships then need to be examined empirically.

Abusive relationships in families of women with borderline personality disorder, anorexia nervosa and a control group

In a group of intact families, we examined the rates and parameters of verbal, physical, and sexual abuse in 35 women with borderline personality disorder (BPD), 34 women with anorexia nervosa (AN), and 33 women without a clinical history (NC); their experience of multiple abuse and its correlation with their SCL-90-R scores; and their reports of abuse of their siblings. Corroboration of abuse was obtained from some parents in each group. Women with BPD suffered more intrafamilial verbal and physical abuse. Whereas AN and NC women experienced relatively rare single events of extrafamilial sexual abuse at an older age, those with BPD suffered repeated intrafamilial sexual abuse at a younger age and also suffered more multiple abuse. All multiply abused women had more psychopathology. Siblings were reported abused in the same proportions as subjects; many parents of BPDs corroborated their daughters' reports of all three forms of abuse.

Child sexual abuse and later disordered eating: a New Zealand epidemiological study

OBJECTIVE

This community-based study examined how some women who have experienced childhood sexual abuse (CSA) develop an eating disorder (ED), whereas others develop depression and anxiety, and others show no adverse psychological sequelae.

METHODS

A two-stage random community sampling strategy was used to select two groups of women: (1) women with CSA prior to age 16 years and (2) a comparison group of women reporting no abuse. Both groups completed the Parental Bonding Instrument (PBI), the Present State Examination, and additional ICD-10 eating disorders questions. Information on the nature and frequency of the CSA was obtained at interview. CSA women with ED (CSA+ED) were compared with CSA women without ED (CSA-noED) and with CSA women with anxiety and/or depression (psychiatric comparison group).

RESULTS

Higher rates of EDs in women who have experienced CSA were confirmed in this study. Belonging to a younger age cohort, experiencing menarche at an early age, and high paternal overcontrol on the PBI independently increased the risk of developing an ED in women who had experienced CSA. Low maternal care was specifically associated with the development of anorexia nervosa, whereas early age of menarche differentiated women with bulimia nervosa. Younger age and early age of menarche also differentiated the CSA+ED women from the psychiatric comparison group.

DISCUSSION

Early maturation and paternal overcontrol emerged as risk factors for ED development in women with CSA. Although these variables are also risk factors in the general population, women with CSA may be vulnerable to ED development because these risk factors are particular domains of concern that emanate from experiences of CSA.

Effect of maternal separation on feeding behavior of rats in later life

Effects of maternal separation on feeding behavior, particularly on rebound hyperphagia, in adult rats were examined. Time-restricted scheduled feeding (2 h per day for 6 days), was given at the age of 3, 6, 9 or 12 weeks in rats that were maternal separated from postnatal days (PD) 1-21 and control rats. Following the time-restricted scheduled feeding, rats were fed freely for 24 h (rebound hyperphagia). Body weight, daily normal food consumption and food consumption during time-restricted scheduled feeding and rebound hyperphagia were measured. Body weight of 3-week-old maternally separated rats were less than those of control rats. There was no significant difference in normal daily food consumption. Food consumption during rebound hyperphagia was significantly increased in 6- to 9-week-old female maternally separated rats, but there was no difference observed in males. Postnatal maternal separation enhanced rebound hyperphagia of female rats in later life. These results indicate that postnatal maternal separation made rats more vulnerable to the development of abnormal feeding behavior in response to food restriction in later life.

The relationship between sexual abuse and purging: findings from community-wide surveys of female adolescents

OBJECTIVE

The first objective of this study was to examine the relationship between sexual abuse and a bulimic behavior, namely purging, with a large sample of female adolescents. If sexual abuse was found to be significantly related to bulimia, then the second objective was to determine if the relationship between abuse and purging remained significant when other factors were controlled.

METHOD

Two different analyses were conducted to address the questions outlined above--a contingency table chi-square test and a logistic regression analysis. A sample of 7,903 female adolescents was drawn from a large Midwestern state.

RESULTS

The results of the bivariate analysis provide evidence that a relationship exists between sexual abuse and purging. However, the relationships between sexual abuse and purging did not remain significant when several other factors, including physical abuse, were included in the analysis. Several individual (a history of physical abuse and religiosity), familial (i.e., family support and parent-adolescent communication), and extra-familial (i.e., other adult support) factors were significantly related to purging.

CONCLUSIONS

The data did not find a significant relationship between sexual abuse and purging when individual, familial, and extra-familial variables were included in the logistic regression. Unlike most earlier studies that focused on clinical samples, this study drew from a larger, more representative sample of female adolescents. The identification of significant predictors of purging at the individual, familial, and extra-familial levels suggests the importance of examining multiple levels of the teen's ecology for factors that may influence this behavior.

Sexual abuse in eating disorder subtypes and control women: the role of comorbid substance dependence in bulimia nervosa

OBJECTIVE

The relationship between sexual abuse and eating disorders remains uncertain. Recent data have raised the possibility of differential rates of sexual abuse among subtypes of eating disorders.

METHODS

We studied women with three subtypes of eating disorders: (1) 26 anorexia nervosa subjects (AN); (2) 20 bulimia nervosa subjects with comorbid substance dependence (BN + SDD); and (3) 27 bulimia nervosa subjects without substance dependence (BN - SDD). We compared women with these eating disorder subtypes to 44 control women (CW). Sexual abuse rates and diagnoses were assessed through direct structured interviews.

RESULTS

We found an order effect for sexual abuse which was most common (65%) in BN + SDD subjects, followed by a rate of 37% in BN - SDD subjects and 23% in AN subjects. Subjects of all eating disorder subtypes had significantly higher rates of sexual abuse compared to a rate of 7% in CW subjects.

DISCUSSION

Women with BN + SDD had the highest frequency and the most severe history of sexual abuse. However, the causal relationship between eating disorders and sexual abuse remains to be elucidated.

Recovered memories of childhood sexual abuse. Implications for clinical practice

BACKGROUND

The growth in the USA of 'recovered memory therapy' for past sexual abuse has caused great public and professional concern. It became apparent that the polarisation of views and fierce controversy within the American psychiatric community was in danger of bringing psychotherapy into disrepute and it seemed important to examine objectively the scientific evidence before such polarisation developed in the UK.

METHOD

A small working group reviewed their own experience, visited meetings and centres with expertise in this field, interviewed 'retractors' and accused parents, and then began a comprehensive review of the literature.

RESULTS

There is a vast literature but little acceptable research. Opinions are expressed with great conviction but often unsupported by evidence.

CONCLUSIONS

The issue of false or recovered memories should not be allowed to confuse the recognition and treatment of sexually abused children. We concluded that when memories are 'recovered' after long periods of amnesia, particularly when extraordinary means were used to secure the recovery of memory, there is a high probability that the memories are false, i.e. of incidents that had not occurred. Some guidelines which should enable practitioners to avoid the pitfalls of memory recovery are offered.

The Educational Needs of Occupational Therapists Who Work with Adult Survivors of Childhood Sexual Abuse

This study aimed to examine the education and training needs of occupational therapists who work with adult survivors of childhood sexual abuse (CSA). Two sample groups were used: occupational therapy pre-registration courses and occupational therapists working in mental health settings. Two postal surveys were designed in order to elicit both quantitative and qualitative data. Seventeen courses and 43 occupational therapists responded from around the United Kingdom.

The results indicated that although most of the occupational therapy courses offered some form of education around CSA issues, this had been available for a relatively short period of time (generally for less than 5 years). However, the majority of occupational therapists who responded were senior staff with more than 5 years' clinical experience who had not received such education as students. Consequently, the education offered differed greatly from that of 5 years ago. All the occupational therapists felt that their current level of knowledge could be improved. Recommendations regarding prospective educational requirements and further research are made.

Sexual abuse in people with alcohol problems. A study of the prevalence of sexual abuse and its relationship to drinking behaviour

BACKGROUND

There is evidence that people with a history of sexual abuse may have an increased risk of developing alcohol and drug problems.

METHOD

A self-completion sexual abuse questionnaire was designed and administered to a sample of attenders at three London alcohol services. Drinking behaviour was assessed using the Severity of Alcohol Dependence Questionnaire and the Alcohol Problems Questionnaire, and additional data were derived from case notes.

RESULTS

Fifty-four per cent of women and 24% of men identified themselves as victims of sexual abuse or assault For the majority this had started before the age of 16 and involved non-relatives. Subjects with a history of sexual abuse were younger, reached drinking milestones earlier, were more likely to have a family history of alcohol misuse and had more alcohol-related problems than non-abused subjects. Sexual abuse, age and alcohol dependence predicted level of problems in a regression analysis.

CONCLUSIONS

The high rates of sexual abuse and its association with indications of increased morbidity suggest it is an important issue for the management of alcohol problems. More use could be made of self-completion questionnaires for the investigation of sexual abuse.