Foreign Bodies

Eating Disorders, Childhood Sexual Abuse, and Trauma-Informed Treatment

Anat Gur

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781138600928
• eBook ISBN: 9780429893957
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Foreign Bodies: Eating Disorders, Childhood Sexual Abuse, and Trauma-Informed Treatment addresses the association between eating disorders and childhood sexual abuse, proposing a new way of treating those suffering from eating disorders who were sexually abused as children. Based on testimonies of survivors of abuse who subsequently developed eating disorders, it offers a new form of diagnosis and treatment, arguing that the eating-disorder field often ignores the traumatic sources of eating disorders, leading to some treatment programs not being commensurate, and at times conflicting, with the principles of childhood sexual abuse treatment.

The case studies used to highlight the link between childhood sexual abuse and eating disorders are presented from the perspective of the women involved, in their own words. Their voices are supplemented by Gur's own stance as a clinician specializing in the treatment of sexual abuse and CPTSD. The book is divided into three parts: the first deals with eating disorders, childhood sexual abuse, and the association between them; the second examines the treatment of eating disorders and childhood sexual abuse; and the third offers a new form of diagnosis and treatment for eating disorders.

This book will be of great interest to researchers and postgraduate students in the eating disorder field of psychotherapy, psychology, or psychiatry, plus those studying the treatment of trauma. It will also be of interest to clinical dieticians, psychologists, social workers, doctors, nurses, eating disorder specialists, and policymakers in the mental health field, as well as eating disorders sufferers and those who care for them.

Part I

Eating disorders, childhood sexual abuse, and the link between them

Introduction

The close link between childhood sexual abuse and eating disorders has only begun to come to the attention of those working in the field of eating disorders in recent years, following the publication of professional studies and clinical accounts reporting the high rate of childhood sexual abuse amongst women suffering from eating disorders. The increased awareness of childhood sexual abuse may be attributed to the growing public discourse with regard to the sexual abuse women suffer, a discourse that, legitimizing the breaking of the cycles of shame and silence amongst women suffering from eating disorders, allows them to speak about the sexual abuse they experienced as children.

Controversy nevertheless still rages within the eating disorders field over various issues – such as the rate of childhood sexual abuse amongst the eating disorder population, the existence of a causal relation between traumatic history and eating disorders, whether childhood sexual abuse is a central risk factor in the aetiology of eating disorders, and whether they are widespread amongst women in general.

The studies that have examined the rates of childhood sexual abuse amongst women suffering from eating disorders differ widely. Today, more and more, in particular clinical reports are documenting high levels – around 70 to 80 percent – of a history of childhood sexual abuse amongst women with eating disorders (Oppenheimer, Howells, Palmer, & Chaloner, 1985; Kearney-Cooke & Striegel-Moore, 1996).

The rates of childhood sexual abuse are very difficult to assess due to the secrecy, shame, silence, and dissociation characteristic of this type of molestation. Children are frequently sexually abused by close and loved family members at an age when they are too young to understand what is happening and are thus unable to conceptualize it or remember it with any certainty. Women with eating disorders find it particularly difficult to identify the phenomenon because, as we shall see below, these often serve as a means of dissociation from the sexual abuse and its horrors. The rates of childhood sexual abuse amongst women suffering from eating disorders may thus be far higher than reported, many women not speaking of their traumatic history due to full or partial amnesia of the events and the great difficulty in speaking about having been sexually abused.

In Part I, I review the various forms of eating disorders as defined in DSM-5 and the history of the development of the tendency to define them as a disorder. We shall examine the reasons behind the emergence of eating disorders as defined in the professional literature and the link between them and gender. I then look at childhood sexual abuse and its features and consequences, citing its close association with eating disorders and the theories adduced to explain this link. This is followed by accounts of eating disorders and childhood sexual abuse from women who have suffered from both and descriptions and narratives given by those interviewed for the study upon which this book is based regarding the link between childhood sexual abuse and eating disorders. The findings indicating that this connection is also closely linked with dissociative disorders, I shall also review the latter as defined in the DSM. Here, too, we shall hear the stories of women who suffer from such phenomena. The final chapter in this part addresses the associations between sexual abuse, eating disorders, and the female body.

References

Kearney-Cooke, A., & Striegel-Moore, R. H. (1996). Treatment of childhood sexual abuse in anorexia nervosa and bulimia nervosa: A feminist psychodynamic approach. In M. F. Schwartz & L. Cohn (Eds.), Sexual abuse and eating disorders (pp. 155–175). Bristol, PA: Brunner/Mazel.

Oppenheimer, R., Howells, K., Palmer, L., & Chaloner, D. (1985). Adverse sexual experiences in childhood and clinical eating disorders: A preliminary description. Journal of Psychiatric Research, 19, 157–161.

Chapter 1

Eating disorders

An eating disorder is a disease that is full of contradictions, surprising because it takes on its own life – another existence that is very stubborn … An eating disorder serves as a numbing drug, but also as a very exhilarating drug … It both strengthens and weakens at the same time … It’s frightening, but also gives a lot of power and courage … It’s composed of self-control (anorexia in the main) and bulimia – total loss of control … It hurts like hell but also forms the best comfort against pain … It isn’t clear at all, but you feel as though it provides the best explanation for what cries out so loudly inside … It makes you disappear, but somehow right then you get more attention … It doesn’t let you sleep … but you feel drowsy all the time … The more hungry you feel the more full and satisfied you feel … Your hair falls out … your teeth decay … your organs are eaten away … and you feel more clean and pure … An eating disorder makes you feel more physical sensations (such as an irregular pulse, weak or strong … dizziness, seeing black … extreme cold) and yet completely apathetic with respect to every mental feeling … emotions … An eating disorder leads to long-term damage but repairs short-term injuries … In short … while an eating disorder enables you to survive, it kills you at the same time … A sort of Dr. Jekyll and Mr. Hyde … There’s no doubt that anorexia is a sort of effective – and even necessary – survival mechanism.

—Noga¹

Although eating disorders have been described throughout history, they have now become a modern epidemic. Defined as a psychiatric disorder, they are now prevalent not only in the West but also in other cultures influenced by Western civilization. Those who suffer from them are virtually exclusively female – usually young girls and young adult women. Waging a savage assault on the female body, they are closely linked with morbidity and risk of death.

What causes young women to hurt themselves so dramatically? Why do they attack their bodies so viciously that they put their lives at risk, even to the point of paying the ultimate price of death? We still lack clear and definitive answers to these questions. Numerous explanations are adduced in the professional literature regarding the aetiology of eating disorders, including various intrapsychic, familial, and cultural factors. Neither clinicians nor scholars have yet to provide a convincing account of the predisposition to eating disorders, however.

In this chapter, I shall discuss eating disorders as they are classified today in psychiatric manuals, examining their gender aspect in light of the overwhelming preponderance of female sufferers. Surveying their history, I shall look at the first time they were defined as a psychiatric disorder, critically analysing the aetiology attributed to them in the professional literature. I shall also exemplify their nature and character via the words of some of the women who participated in the study on which this book is based.

The definition of eating disorders

Eating disorders are a female affliction, most of those who suffer from them being young adolescent girls and young adult women. Over the past three decades, eating disorders have become a prominent subject in the professional literature in the wake of their dramatic rise in frequency in the West and the high mortality rates (Latzer, Hochdorf, Bachar, & Conetti, 2003).

Eating disorders include severe disorders in eating behaviour – such as drastically reduced and unhealthy food intake or dire overeating – and feelings of pressure or over-preoccupation with body weight and/or image (NIMH, 2015). Alongside the eating disorders that are defined in psychiatric diagnostic manuals, a broad range of problems linked with eating and dieting are also recognized (Dana & Lawrence, 1999). Today, eating disorders are classified on the basis of weight and reduced food intake and/or bingeing and/or compensatory behaviours designed to reduce weight (e.g., voluntary vomiting, use of medication/laxatives, or excessive physical exercise). In recent decades, these definitions have been significantly revised. While clear and distinct criteria have been provided, they remain controversial. Clinical and research experience alike attest to a great overlap between the various disorders and their symptoms (Dana & Lawrence, 1999). Studies demonstrate that between 40 and 60 percent of women who suffer from eating disorders are diagnosed as afflicted with ‘non-specific eating disorders’, evincing the problematic nature of the criteria set out in the psychiatric manuals (Fairburn & Bohn, 2005). The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) expands the definition of eating disorders to include feeding and eating disorders. These are characterized by protracted feeding or eating behaviours – changes in the intake or absorption of food that significantly affect physical health or psycho-social performance. The DSM-5 lists eight eating disorders:

1. 1) Pica: Persistent eating of non-nutritive substances for a period of at least a month that is sufficiently severe as to warrant independent clinical attention, is inappropriate to the individual’s developmental level, and does not form part of a culturally supported or socially normative practice.
2. 2) Rumination disorder: Repeated regurgitation (re-chewing, re-swallowing, or spitting out of food) on a frequent basis – at least twice a week and often every day – over a period of at least one month that is not due to a medical condition nor occurs exclusively in the course of other eating disorders.
3. 3) Avoidant/restrictive food intake disorder: An eating/feeding disturbance manifested in a persistent failure to meet appropriate nutritional and/or energy needs that leads to significant loss of weight (or failure to achieve expected weight gain/faltering growth in children), significant nutritional deficiency, dependence on external feeding or oral nutritional supplements, and impaired psychosocial functioning.
4. 4) Anorexia nervosa: The three principal features of anorexia nervosa are: a) persistent restriction of energy intake; b) an intense fear of gaining weight/becoming fat or persistent behaviour that interferes with weight gain; and c) disturbance in the way body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight (the latter being defined as falling below the minimal normal level suitable to body form, age, sex, developmental trajectory, and physical health). Although anorexia nervosa is linked to significant loss of weight, it can also manifest itself in children and adolescents in the form of normal development problems – such as growth or height. Its incidence is 0.4 percent, the correlation between women and men being estimated at 10:1.
5. 5) Bulimia nervosa: Recurrent episodes of binge eating during a discrete period of time (e.g., within any two-hour period) of a larger amount of food than that eaten by most people during a similar period of time and under similar circumstances accompanied by a sense of lack of control (e.g., a feeling that one cannot stop eating or control what/how much one is eating). Recurrent inappropriate compensatory behaviours are also engaged in in order to prevent weight gain – self-induced vomiting, misuse of laxatives, diuretics or other medications, fasting, or excessive exercise. The binge eating and inappropriate compensatory behaviours occur on average at least once a week for a period of three months. Self-evaluation is unduly influenced by body shape and weight. The incidence of bulimia nervosa is between 1 and 1.5 percent. Although it is not clear how many males it affects, the correlation between women and men is estimated at 10:1.
6. 6) Binge-eating disorder: Recurrent episodes of binge eating over a discrete period of time (e.g., within any two-hour period) of a larger amount of food than that most people would eat during a similar period of time and under similar circumstances and a sense of lack of control over eating during the episode. This disorder is associated with eating much more rapidly than normal, eating until feeling uncomfortably full, consuming large amounts of food when not feeling physically hungry, eating alone because of feeling embarrassed by how much one is eating, and feeling disgusted with oneself, depressed, or guilty afterward. The incidence of this disorder is 1.6 percent amongst women and 0.8 amongst men.
7. 7) Other specified feeding or eating disorder: These are situations in which the symptoms of feeding or eating disorders cause clinically significant distress and impairment in areas of social or professional functioning but do not fully meet the criteria for any other feeding or eating disorder. A diagnosis may then be allocated that specifies a specific reason why the presentation does not meet the specifics of another disorder (e.g., low-level bulimia nervosa).
8. 8) Unspecified feeding or eating disorder: Behaviours that cause clinically significant distress/impairment of functioning but do not fully meet the criteria of any of the feeding or eating disorder criteria. This category is appropriate for cases in which clinicians choose not to specify why the criteria are not met, including presentations in which insufficient information is available to make a more specific diagnosis (e.g., in emergency room settings).

The changes made in DSM-5 were introduced in order to reduce the number of unspecified eating disorder diagnoses. Thus, for example, ‘refusal’ to maintain proper weight has been deleted from the anorexia nervosa criteria due to the difficulty in measuring it. The criterion of no menstrual cycle has also been dropped because in some cases the remaining criteria are met but the menstrual cycle continues. It is also irrelevant to men, pre-pubescent girls, and postmenopausal women. With respect to bulimia nervosa, the frequency of binge-eating sprees and purging rituals has been reduced to twice a week. As this edition was nearing publication, however, clinicians and scholars in the field estimated that the revisions have not resolved the problems attendant upon the definition of eating disorders (Fairburn & Cooper, 2010).

The interviews conducted for this study clearly indicate that eating disorders do not constitute a distinct and precisely defined category classifiable according to the criteria found in the psychiatric diagnostic manuals. Several of the women interviewed had suffered from various forms before they finally found an appropriate way to convey the horror of the sexual abuse they had experienced as children. They related how they had suffered from an undefined problem, seeking ways to express their distress that included diverse eating disorders – avoiding eating, vomiting, and bingeing. Olivia, for example, who had been sexually abused by her father but until recently had had no memory of the abuse, related that as she entered puberty she began to starve herself. Losing a lot of weight and receiving many complime...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Acknowledgements
• Preface
• Introduction
• Part I Eating disorders, childhood sexual abuse, and the link between them
• Part II Treatment of eating disorders and childhood sexual abuse
• Part III A new diagnosis and treatment proposal
• Epilogue
• Appendix: Dawn’s story
• Bibliography
• Index