The impact of childhood sexual abuse in anorexia nervosa

Abstract

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.

Résumé

Objectif

Le but de cette étude était d’examiner l’impact de l’agression sexuelle infantile (AS) sur les caractéristiques cliniques et l’abandon prématuré du traitement dans l’anorexie mentale (AM).

Méthode

Les participantes étaient 77 patientes anorexiques (AM) admises dans une unité d’hospitalisation spécialisée dans les troubles des conduites alimentaires. Les patientes ont été évaluées en terme de symptômes de troubles alimentaires, de psychopathologie et de passé d’AS lors de l’admission à l’hôpital.

Résultats

Trente-sept patientes (48%) ont rapporté un passé d’AS avant la survenue du trouble alimentaire. Les cas avec passé d’AS avaient une comorbidité psychiatrique significativement plus importante, comportant des niveaux plus élevés de dépression et d’anxiété, une estime de soi plus basse, davantage de problèmes relationnels, et des symptômes obsessionnels et compulsifs plus sévères. Les patientes du sous-groupe “boulimie-laxatifs” (AM-BL) étaient significativement plus susceptibles de raconter un passé d’AS antérieur au début du trouble alimentaire que les patientes du sous-groupe “restrictif” (AM-R) de la maladie, (65% des malades AM-BL versus 37% des malades AM-R; p < .02). Contrairement à ce que nous prévoyions, les patientes agressées n’étaient pas significativement plus sujettes à un abandon du traitement. Cependant, les patientes du sous-type “boulimie-laxatifs” (AM-BL) avec passé d’AS étaient significativement plus susceptibles d’arréter prématurément leur traitement que les autres patientes.

Conclusion

En accord avec des constatations antérieures, les résultats ci-dessus indiquent que la prévalence d’AS est élevée dans les cas ayant besoin d’une hospitalisation pour AM. Un passé d’AS est associé avec une plus grande perturbation psychiatrique globale et un taux plus élevé d’abandon de traitement chez les patientes du sous-groupe boulimie-laxatifs.

Resumen

Objetivo

El objetivo de este estudio fue examinar el impacto del abuso sexual infantil (CSA) en las características clínicas y un final prematuro del tratamiento en anorexia nervosa (NA).

Método

Los participantes fueron 77 pacientes consecutivos con AN admitidos a una unidad de internamiento de desórdenes del comer. Los pacientes fueron evaluados en términos de los síntomas del desorden del comer, psicopatología general, e historia de CSA en el momento de la admisión al hospital.

Resultados

Treinta y siete pacientes (48%) reportaron una historia de CSA antes del inicio del desorden del comer. Los sujetos con una historia de CSA reportaron significativamente mayor comorbilidad psiquiátrica, incluyendo niveles más altos de depresión y ansiedad, autoestima más baja, más problemas interpersonales, y síntomas obsesivo-compulsivos más severos. Los pacientes con el subtipo de comer demasiado impulsivamente -purgarse de AN (AN-BP) eran significativamente más propensos a reportar una historia de CSA antes del inicio del desorden del comer comparado con pacientes con el tipo restrictivo (AN-R) de la enfermedad (65% de los pacientes AN-BP versus 37% de los pacientes AN-R; p < .02). Contrario a nuestras predicciones, los pacientes abusados no fueron significativamente más propensos a abandonar el tratamiento. Sin embargo, los pacientes del tipo de comer demasiado impulsivamente-purgarse (AN-BP) con una historia de CSA presentaron significativamente mayor tendencia a abandonar el tratamiento de manera prematura comparado con otros pacientes.

Conclusiones

De acuerdo con los hallazgos previos, los resultados presentes indican que la prevalencia de CSA es alta en personas que buscan tratamiento con internamiento por AN. Una historia de CSA estuvo asociada con mayores trastornos psiquiátricos y una tasa mayor de abandono del tratamiento en los pacientes del tipo comer demasiado impulsivamente-purgarse (AN-BP).

Introduction

Several studies have shown that a significant proportion of individuals with eating disorders report a history of childhood sexual abuse (CSA). In addition, non-eating disordered individuals with a history of CSA typically share certain features with eating disordered individuals including intense feelings of shame, low self-esteem, and body image disparagement. Consequently, several researchers have hypothesized that sexual abuse may be a risk factor for the development of eating disorders (Oppenheimer, Howells, Palmer, & Chaloner, 1985). On balance, the findings of studies examining this hypothesis have shown that sexual abuse is not a specific risk factor for eating disorders but is associated with an increased risk of psychopathology in general (Steiger & Zanko, 1990; Thompson & Wonderlich, 2004; Welch & Fairburn, 1994; Wonderlich, Brewerton, Jocic, Dansky, & Abbott, 1997).

Reviews of the research on the association between CSA and eating disorders have noted variation across studies in the estimated prevalence rate of sexual abuse in both eating disorder and control populations (Brewerton, 2004, Thompson and Wonderlich, 2004). Such inconsistencies may reflect differences in the samples studied (e.g., clinic vs. community samples), methodological differences, as well as differences in the definitions used for sexual abuse (Wyatt and Peters, 1986a, Wyatt and Peters, 1986b). The use of face-to-face interviews has been found to be associated with higher prevalence estimates than self-report questionnaires (Wyatt & Peters, 1986a). Broader definitions of sexual abuse (e.g., abuse with or without physical contact) also produce higher prevalence rates than more restrictive definitions (Wyatt & Peters, 1986b).

There is some evidence that a history of CSA is associated with greater psychiatric disturbance in individuals with eating disorders. Rorty, Yager, and Rossotto (1994) found that CSA was associated with personality pathology in a community sample of people with bulimia nervosa. Two studies found that a history of sexual abuse predicted the presence of self-injurious behavior in patients with eating disorders (Favaro & Santonastaso, 2000; Nagata, Kiriike, Iketani, Kawarada, & Tanaka, 1999). Anderson, LaPorte, Brandt, and Crawford (1997) found that eating disorder patients with a history of sexual abuse reported higher levels of depression and anxiety as compared with patients without an abuse history. Two studies found an association between a sexual abuse history and obsessive-compulsive symptoms, particularly ritualistic cleaning behavior (Folsom et al., 1993, Lockwood et al., 2005).

With two exceptions, studies to date have found no evidence that sexual abuse is associated with more severe eating disorder psychopathology in patients with eating disorders. A study by Fullerton, Wonderlich, and Gosnell (1995) found that sexual abuse was associated with higher scores on a self-report measure of eating disorder attitudes and behaviors. Another study by Waller, 1992a, Waller, 1992b showed that a history of sexual abuse was associated with more frequent episodes of binge eating and vomiting. Several studies have shown that CSA is associated with the presence of binge eating and purging behaviors in patients with eating disorders (Bulik, Sullivan, Fear, & Joyce, 1997; Deep, Lilenfeld, Plotnicov, Pollice, & Kaye, 1999; Oliosi & Dalle Grave, 2003; Waller, Halek, & Crisp, 1993). Studies of personality differences between restricting anorexia nervosa (AN-R) patients and those who binge-eat or purge (AN-BP) have found that AN-R is associated with lower novelty seeking, higher harm avoidance, and more rigid and obsessional behavior as compared with patients with AN-BP (Halmi, Kleifield, Braun, & Sunday, 1999; Kleifield, Sunday, Hurt, & Halmi, 1994). Compared with AN-R patients, those who binge-eat or purge have been found to experience more lability of mood, to be more impulsive, and are more likely to have substance abuse problems (DaCosta & Halmi, 1992). A number of studies have found the presence of bulimic symptoms in AN to be associated with a poorer treatment outcome (e.g., Fichter & Quadflieg, 1999; Halmi et al., 1979, Martin, 1985, Theander, 1985). Given these findings, it is possible that the association between CSA and the eating disorder may be different in AN-R versus AN-BP.

To our knowledge, only two studies have examined whether a history of sexual abuse affects response to treatment for an eating disorder. Anderson et al. (1997) found that bulimia nervosa patients with a history of sexual abuse demonstrated lower rates of abstinence from binge eating and purging behaviors at the end of treatment as compared with patients without a history of abuse. In addition, a significantly greater proportion of abused patients relapsed during the first three months after completing treatment. In a follow-up study of patients who had received inpatient treatment for an eating disorder, Luadzers (1998) found that a sexual abuse history reduced the likelihood of recovery from the eating disorder. However, this study was limited by the use of a self-report questionnaire to assess sexual abuse history and eating disorder status as well as a low (52%) response rate.

The aim of the present study was to examine the association between CSA and clinical presentation as well as premature termination of treatment in anorexia nervosa (AN-R and AN-BP). It was hypothesized that a history of CSA would be associated with: (1) more severe eating disorder symptoms; (2) more severe general psychopathology; (3) having the binge-purge subtype of AN; and (4) an increased rate of premature termination of treatment.