Trauma, Dissociation, And Impulse Dyscontrol In Eating Disorders

P.E.R.

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134867370
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Published in 1997, Trauma, Dissociation, And Impulse Dyscontrol In Eating Disorders is a valauble contribution to the field of Psychotherapy.

1

Trauma History and Dissociative Experiences

Some case studies in the 1980s stimulated interest in the possible relationship between a history of traumatic experiences—especially physical and sexual abuse—and the development of an eating disorder (Goldfarb, 1987; Kearney-Cooke, 1988; McFarlane, McFarlane, & Gilchrist, 1988; Schechter, Schwarts, & Greenfeld, 1987; Sloan & Leichner, 1986; Torem, 1986a, b. The first reports suggested a higher frequency of traumatic experiences in bulimia nervosa patients than in patients with anorexia nervosa of the restricting type.*

Soon a rapidly growing number of studies on this subject appeared in the scientific literature together with a more general trend in psychiatry to look for a possible relationship between sexual abuse and the development of mental disorders.

Studies in Clinical Samples

After the first case reports, several retrospective studies on larger samples—both clinical and nonclinical—have been carried out. Op-penheimer, Howells, Palmer, and Chaloner (1985) published the first large-scale study of 78 female eating-disordered outpatients, and they reported sexual abuse during childhood and/or adolescence in 70% of these patients. They found no relationship between a history of sexual abuse and the type of eating disorder diagnosed. Finn, Hartman, Leon, and Lawson (1986) studied the relationship between sexual abuse and the prevalence of an eating disorder in a sample of 87 eating-disordered women. Prevalence of sexual abuse in the latter was 57%, but comparisons of women with and without histories of sexual abuse suggested no association between the occurrence of an eating disorder and a history of sexual abuse. Kear-ney-Cooke (1988) found a history of sexual trauma in 58% of 75 bulimic patients. Root and Fallon (1988) reported that 65% of women in a group of 172 eating-disorder patients had been physically abused, 23% raped, 28% sexually abused in childhood, and 23% maltreated in relationships. Hall, Tice, Beresford, Wooley, and Hall (1989) found the number of sexually abused women (50%) in a group of 158 eating-disordered patients to be significantly higher than in a control group of 86 other patients (28%). Bulik, Sullivan, and Rorty (1989) investigated childhood sexual abuse and family background in 34 bulimics: 34% of this sample had been sexually abused. Interestingly, when comparing abused with nonabused subjects, no differences were found in eating pathology and related characteristics.

Steiger and Zanko (1990) compared the prevalence of sexual abuse in a group of 73 eating-disordered subjects with two other control groups: 21 psychiatric patients and 24 “normal” women. About 30% of the eating disorder group reported sexual abuse histories, versus 33% in the psychiatric control group and 9% in the normal controls. Within the eating disorder group, restricting anorexia nervosa patients had significantly lower abuse rates (6%) than all other eating disorder subgroups. Palmer, Oppenheimer, Dignon, Chaloner, and Howells (1990) extended their first series of eating disorders (Oppenheimer et al., 1985) and studied the sexual abuse histories of 158 patients; of these, 31% reported childhood sexual abuse and another 27% reported other unpleasant or coercive sexual events. Again they did not find a significant association between rates of abuse and the particular type of eating disorder. In a systematic study of 112 consecutive referrals of normal-weight bulimic women, Lacey (1990) found that only eight patients (7%) mentioned a history of sexual abuse involving physical contact. Four of these (3.6%) described incest, but only in two cases (1.8%) did this occur during childhood. Lacey concluded that his therapeutic work confirmed the “impression that incest and child sexual abuse mostly occurred in multi-impulsive bulimics” (these are bulimic patients who show additional forms of impulse dyscontrol, as discussed in more detail in Chapter 3). DeGroot, Kennedy, Rodin, and McVey (1992) reported a sexual abuse rate of approximately 25% in a sample of 184 female outpatients with a DSM-III-R eating disorder diagnosis.

In Waller’s (1991, 1993a) series of 100 eating-disordered women, 50% were sexually abused and the prevalence of abuse appeared to be associated with diagnostic category: Women with bulimic disorders reported significantly higher rates of unwanted sexual experiences than did restricting anorectics. Waller (1992a) further showed that the frequency of bingeing and vomiting is significantly greater in women who report sexual abuse with particular characteristics: when the abuse was intrafamilial, involved force, or occurred before the woman was 14 years old. In another study of 100 anorectic women, Waller (1993b) found that 37% of the women reported that they had been subjected to unwanted sexual experiences. Again, the results showed a strong association between reported unwanted sexual experiences and purging behavior (vomiting and abuse of laxatives). Anorectics who did purge had lower reported rates of abuse.

Waller further studied the influence of other factors that might mediate the link between childhood sexual abuse and the development of an eating disorder. Waller’s (1994) study suggested that borderline personality disorder was associated with the report of sexual abuse and might be a psychologial factor that explains a small part of the causal link between sexual abuse and bulimic behavior, especially the frequency of bingeing. In other studies (Everill & Waller, 1995; Waller & Ruddock, 1993), the importance of the experience of initial disclosure as a mediator in eating disordered women was considered. The extent of psychopathology (particularly the frequency of vomiting and the presence of symptoms of borderline personality disorder) was associated with the nature of the perceived response to an attempted disclosure. A perceived lack of response or a negative, hostile response was associated with greater levels of both borderline and bulimic symptoms (particularly vomiting).

Folsom, Krahn, Nairn, Gold, Demitrack, and Silk (1993) published a well-controlled study in which they compared rates of physical and sexual abuse in 102 women with eating disorder and 49 with general psychiatric disorders. No differences in abuse rates were found between the two groups: sexual abuse on the one hand and physical abuse on the other were reported in 69% and 51%, respectively, of the eating disorder sample and in 80% and 56% of the psychiatric sample. No relationship between a history of sexual abuse and severity of the eating disorder was found. However, within the eating disorder group, sexually abused subjects reported more severe psychiatric disturbances of an obsessive and phobic nature than nonabused subjects. According to Folsom and colleagues, their findings suggest that although sexually abusive experiences may be related to increased psychological distress, they do not serve to increase eating disorder symptomatology.

Miller and McCluskey-Fawcett (1993) compared 72 bulimic women with 72 age-matched controls who had no signs of eating disorders on measures of sexual abuse, dissociation, and early family mealtime experiences. Rates of self-reported sexual abuse after the age of 12 with an adult relative as the perpetrator were significantly greater in the bulimics than the control women: 15.3% versus 1.4%. Nonsignificant but high rates of sexual abuse prior to the age 12 were also found in this group: 11.1% versus 1.4%. Dissociative experiences were significantly more common in the bulimic group overall, and higher still for bulimic women who reported sexual abuse in their childhood. Bulimic women had more negative and unusual mealtime experiences than nonbulimic women. The authors concluded that sexual abuse may be related to the subsequent onset of bulimia nervosa for some women.

Welch and Fairburn (1994) carried out one of the best controlled studies. They investigated four individually matched groups: 50 community cases of bulimia nervosa, 50 community controls without an eating disorder, 50 community controls with other psychiatric disorders (mostly depression), and 50 inpatients with bulimia nervosa. Assessment of abuse histories before the onset of the eating disorder was established by interview in the subjects’ own homes. Results showed that significantly more community cases of bulimia nervosa had been abused before the onset of their eating disorder (26%) than the community controls (10%). However, there was no difference between the rates of sexual abuse in the community cases of bulimia nervosa and the psychiatric controls (24%). A surprising result was the smaller number of inpatient cases of bulimia nervosa who had been sexually abused (16%). Welch and Fairburn concluded that childhood sexual abuse does increase the risk of psychiatric disorders including bulimia nervosa but that the increased risk is not specific to the eating disorder.

Though a history of sexual abuse may be not a specific risk factor for the development of an eating disorder, the follow-up study by Gleaves and Eberenz (1994) demonstrated that the presence of sexual abuse might be related to a poor prognosis in eating disorders. The authors studied 464 bulimic women in treatment at a residential facility for women with eating disorders, and they examined the connection between a history of sexual abuse and symptoms suggestive of poor prognosis including a history of multiple therapists or hospitalizations, self-injury or suicide attempts, and alcohol or drug problems. Of the women with all of the indicators of poor prognosis, approximately 71% reported a history of sexual abuse, versus 15% reported by subjects in the sample who did not have any predictors of poor outcome.

While most of these studies have focused on the incidence of sexual abuse, some researchers point also to the need to examine the full range of possible abusive experiences in women with eating disorders (Schmidt, Tiller & Treasure, 1993). Rorty, Yager, and Rossotto (1994a & b) compared 80 women with long histories of bulimia nervosa with 40 women who had never had an eating disorder or related difficulties. The bulimics reported higher levels of childhood physical abuse, psychological abuse, and multiple abuse. The authors concluded that their findings underscore the importance of examining the full range of possible abusive experiences in eating disorder patients, rather than focusing simply on sexual abuse alone.

Another interesting report, which is slightly tangential to the rest of this literature, is the study done by Kaner, Bulik, and Sullivan (1993). They assessed the presence of abuse (repeated physical battery) in the adult relationships of 20 bulimic women and 17 control women. Significantly more bulimic women than controls reported having been in relationships in which repeated physical battery occurred. Battered bulimic women were significantly more depressed than the controls. The authors stressed the need for a heightened sensitivity on the part of therapists to the presence and implications of recurrent abusive experiences in adult relationships.

Studies in Nonclinical Samples

Besides these studies in clinical populations—except for the Welch and Fairburn study (1994) comparing inpatients with community subjects—other studies have been conducted exclusively in nonclinical populations. Calam and Slade (1989) administered questionnaires to 130 female undergraduate students: 20% reported unwanted sexual experiences before the age of 14, with 13% reporting intrafamilial abuse. The experience of sexual events involving force was associated with abnormal eating attitudes and behaviors. Only early sexual intercourse (before age 14) against the participant’s wishes showed a significant correlation with bulimic tendencies. Bailey and Gibbons (1989) studied the relationship between bulimia nervosa and abuse histories in a sample of 294 college students: 13% reported childhood sexual abuse, 11% rape, 8% battery, and 6% other physical abuse. Only physical abuse correlated significantly with the presence of bulimic symptoms.

Smolak, Levine, and Sullins (1990) administered questionnaires to 298 undergraduate women: 23% reported child sexual abuse and this subgroup showed more eating disorder symptoms and related problems than the nonabused group. The eating pathology was related neither to the severity or type of abuse, nor to the identity of the perpetrator. Beekman and Burns (1990) investigated the relation between self-report of prior sexual abuse and current eating behaviors consistent with bulimia in 340 college women. Bulimic women in this sample did not report a higher incidence of past (intra/extrafamilial) childhood sexual experiences than did the control group. However, bulimic women did report significantly more experiences of extrafamilial sexual abuse after age 12 (during adolescence) than normal eaters. Strikingly, Abramson and Lucido (1991) obtained nearly identical percentages of bulimics and non-bulimics reporting childhood sexual abusive experiences (69%), and they found a significant correlation between eating behaviors and the total number of childhood adversive sexual experiences.

Two other studies focused on the relationship between family background, sexual abuse, and eating disorders. Kinzl, Traweger, Guenther, and Biebl (1994) found a sexual abuse incidence rate of 21% in a sample of 202 female university students. There were no differences in symptoms or related features of an eating disorder among women with no, one, or repeated incidents of sexual abuse. However, women who reported an adverse family background displayed significantly more eating disorder pathology than did women who assessed their family backgrounds as secure. The authors concluded that childhood sexual abuse is neither necessary nor sufficient for the later development of an eating disorder, while an adverse family background may be an important etiological factor. Hastings and Kern (1994) investigated the presence of sexual abuse and bulimia in a sample of female college students (N = 786) and its relationship with past family experiences (before the age of 12). Their findings appear to show that the association of sexual abuse and a chaotic family environment increase in an additive manner the probability of bulimia.

In contrast to previous reports, Schaaf and McCanne (1994) found no evidence that childhood sexual or physical abuse was associated with the development of body image disturbance in a sample of 670 female college students screened for childhood abuse. Furthermore, the results did not support the hypothesis that childhood sexual abuse and physical abuse are related to eating disorder symptomatology. It is suggested that victims of childhood sexual abuse manifest higher rates of a number of different types of psychopathology, including eating disorders.

Dissociative Symptoms in Eating Disorders

At the end of the 19th century, the eminent French philosopher and psychiatrist, Pierre Janet, was probably the first author to systematically study the relationship between traumatic experiences and dissociation in the etiology of a wide range of psychiatric problems, including eating disorders. He described dissociation as a crucial psychological mechanism with which the organism reacts to over-whelming trauma. Memories and idées fixes (fixed ideas), referring to the traumatic experience, can be split off from conscious awareness and result in a wide variety of dissociative (“hysterical”) symptoms (Janet, 1907; Van der Kolk & van der Hart, 1989). Hence, Janet described dissociation as a kind of mental avoidance (“escape”) technique; in his view the resulting amnesia for the traumatic event was the most specific clinical characteristic in pathological dissociation.

After Janet the interest in the concept of dissociation in eating dis-orders disappeared for more than half a century, but reemerged in recent decades (for a detailed review, see Vanderlinden & Vandereycken, 1988). The presence of minor dissociative “hysterical” mechanisms in bulimic patients was reported by Russell in 1979. In the mid 1980s, Torem was among the first clinicians pointing again to the possible presence of dissociative mechanisms and symptoms in eating disorders. In a study in 30 eating disorder patients, Torem (1986a), found that 12 of them had dissociated ego-states that were in disharmony with one another. Consequently, Torem (1986 a & b, 1990) stressed the importance of systematic screening for dissociative symptoms in eating disorder patients. Based on a case report, Chandarana and Malla (1989) also suggested a relationship between dissociation and bulimia.

In recent years, researchers have begun systematically to study the presence of dissociative symptoms in eating disorders. Sanders (1986), who developed a new scale for the measurement of dissoci-ation (the Perceptual Alteration Scale or PAS), demonstrated that binge-eating college students reported a higher degree of dissociative phenomena than normal controls. Demitrack, Putnam, Brewerton; Brandt, and Gold (1990) studied dissociative experiences in 30 female eating disorder patients, compared to 30 age-matched “normal” women, and found that the patients demonstrated significantly higher levels of dissociative psychopathology than the control subjects. This finding has been replicated by Covino, Jimerson, Wolfe, Franko, and Frankel (1994), who found higher scores on a self-reporting dissociation questionnaire in bulimics, compared to controls. A study by Goldner, Cockhill, Bakan, and Birmingham (1991) corroborates these findings. Significantly higher scores on a dissociation questionnaire were reported in eating-disordered patients compared to age-matched female controls. McCallum, Lock, Kulla, Rorty, and Wetzel (1992) demonstrated in a sample of 38 eating-disordered patients that dissociative symptoms frequently occur in subgroups of eating disorders, particularly those with multiple psychiatric comorbidity. The authors found a 28% rate for dissociative disorders, including a 10% rate for multiple personality disorder (MPD). The presence of dissociative disorder was significantly related to a history of self-harm.

Herzog, Stoley, Carmody, Robbins, and van der Kolk (1993) studied the presence of both sexual abuse and dissociative symptoms in 20 eating disorder patients: 65% of the subjects reported childhood sexual abuse, and those with more comorbidity reported abuse more often. Subjects with a history of abuse had significantly higher scores on a dissociation scale. In another study with a rather small number of patients, Greenes, Fava, Cioffi, and Herzog (1993) assessed dissociative features in bulimics with and without depression and in depressed subjects with and without bulimia. In contrast with earlier findings, an association was found between depression and dissociation, confounding the previously noted relationship between bulimia neivosa and dissociation. Another study in 142 college women by Rosen and Petty (1994) suggested that dissociation might be associated with eating problems and that treatment of eating-disordered individuals should include a component directed toward teaching patients to recognize their ability to dissociate.

A study carried out in Japan by Berger and colleagues (1994) in a sample of 41 eating disorder outpatients found a combined physical and sexual abuse rate of 45% for the total sample. Of these patients 22% fulfilled the criteria for MPD (multiple personality disorder according to DSM-III-R) and 15% showed scores on a dissociation scale that indicate a high likelihood of MPD or posttraumatic stress disorder.

A relationship between dissociative experiences and eating disorders has also been reported by Everill, Waller, and Macdonald (1995). They investigated the links between dissociation and eating pathology in a clinical group of bulimic women and a nonclinical group of female undergraduates. In the nonclinical group, specific dissociative styles were found to be linked with bulimic tendencies. In the eating-disordered group, there was an association between the scores on a dissociation scale and the frequency of binge eating. The authors further concluded that the presence of both dissociation and bulimic symptomatolog...