Altered pain perception and psychosocial features among women with gastrointestinal disorders and history of abuse: a preliminary model.

OBJECTIVES: To evaluate the relationships between sexual/physical abuse, pain perception, environmental events, coping strategies, and psychiatric morbidity in a sample of female patients with painful gastrointestinal disorders. PATIENTS: Fifty paid volunteers from a tertiary care center including 13 patients with gastroesophageal reflux disease (GERD), 26 with noncardiac chest pain (NCCP), and 11 with irritable bowel syndrome (IBS). MEASUREMENTS: (1) Sexual and physical abuse interview questions; (2) Structured psychiatric interview; (3) Self-report questionnaires: demographics, clinical pain measurement, Millon Behavioral Health Inventory, Hassles and Uplifts Scales, Sickness Impact Profile, Life Experiences Survey, Pain Beliefs and Perceptions Inventory, and Coping Strategies Questionnaire; (4) Pain Perception and Sensory Decision Theory tasks. RESULTS: Fifty-six percent of the sample reported a history of sexual/physical abuse. Abuse was significantly more prevalent among patients with GERD (92%) and IBS (82%) compared with those with NCCP (27%). Abused patients, relative to nonabused patients, had significantly lower pain threshold levels in response to finger pressure stimuli and significantly lower cognitive standards for judging stimuli as noxious. Abused patients reported significantly higher levels of functional disability and a significantly greater number of psychiatric disorders, minor daily hassles, and pain syndromes unrelated to gastrointestinal disorders. In addition, abused patients more frequently blamed themselves for their pain and reported significantly greater use of maladaptive pain coping strategies than nonabused patients. CONCLUSION: These data suggest that the relationships between abuse, disability, multiple pain syndromes, and health care seeking behavior are mediated by abnormal pain perception, psychiatric disorders, disruption of physical function, and environmental stressors.

Sexual abuse and incest. What can you do?

The problem of child sexual abuse is of increasing relevance to family physicians. Apart from the need to recognize and manage child victims and their families, it is important to be aware of the incidence and nature of the many sequelae of childhood sexual exploitation. Common signals include physical, psychosomatic, and psychiatric disorders. Some physicians must deal with their own childhood victimization if the best interests of their patients are to be served.

Dissociation, childhood trauma, and the response to fluoxetine in bulimic patients.

Histories of childhood trauma have been reported previously in bulimic subjects but no study to date has assessed how these experiences may affect response to fluoxetine. Thirty outpatient subjects in a placebo-controlled trial of 60 mg of fluoxetine for the treatment of bulimia nervosa completed the Dissociative Experiences Scale and a self-report instrument assessing trauma. Response to treatment was measured with the Hamilton Depression Scale-17 (HAMD-17), the CGI, the PGI, and the change in number of binges per day. Subjects taking fluoxetine with histories of physical abuse showed a significantly greater drop in HAMD-17 scores than those without such histories. No relationship between a reported history of abuse and the response of binging to fluoxetine was found. A history of abuse does not appear to predict the response of binging to fluoxetine but may predict a greater response of nonspecific symptoms like depression.

Sexual abuse histories among treatment-resistant bulimia nervosa patients.

Although cognitive behavior therapy has been found to be an effective treatment for bulimia nervosa, it has been noted that a subset of patients fail to engage in treatment. We 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. Subjects were 464 bulimic women in treatment at a residential facility for women with eating disorders. Of the women with all of the indicators of poor prognosis, approximately 71% reported a history of sexual abuse. Of the women who reported none of the symptoms indicative of poor prognosis, only 15% reported a history of abuse, and none of these women reported recurrent abuse (greater than five times). We discuss the possible connections between previous treatment failures and histories of abuse and discuss the implications for successful case formulation and treatment.

Effects of childhood trauma on psychological functioning in adults sexually abused as children.

Standardized symptom measures were used to determine the effect of childhood trauma experiences on adults sexually victimized as children. One hundred eighty-eight sexually abused individuals were tested for mean scores for depression, self-esteem, general levels of trauma symptoms, sexual dysfunction, posttraumatic stress disorder symptoms, and dissociation. Childhood traumatic experiences (parents fighting, physical abuse by father or by mother, other childhood traumas) of a nonsexual nature correlated with increased symptom levels and accounted for significant changes in percentage of variance ranging from 5.2% (general trauma symptoms) to 12.3% (posttraumatic stress disorder). Even after controlling for nonsexual-abuse trauma, sexual trauma in childhood continued to contribute significantly to increased adult symptom levels. Variables tested included number of perpetrators; incest; age of first abuse; whether force, bribes, or threats were used by the perpetrator; and penetration. The use of force was the single most significant individual sexual abuse variable. Sexual abuse as a whole contributed significantly to all the symptom measures with the most change in variance noted for dissociation (20.5%). Gender contributed significant differences only for sexual dysfunction when men scored significantly worse.

Behavior, family function, school performance, and predictors of persistent disturbance in sexually abused children.

OBJECTIVE: Although sexual abuse is widely considered to have severe sequelae, most studies of children's status after sexual abuse have had major limitations, including retrospective design, small sample sizes, selective enrollment of subjects, no comparison groups, and lack of information about potentially confounding characteristics of studied children. The aim of this study was to clarify the impact of sexual abuse on children's psychological well-being. METHODS: We prospectively studied 154 children who were brought to urban, university-affiliated hospitals for assessment of recently disclosed sexual abuse and compared them with a control group of 53 demographically similar children not known to have been sexually abused. RESULTS: In comparison with the control children, fewer of the sexually abused children had health insurance and more had received psychiatric care unrelated to the sexual abuse. Most initial ratings of behavior, maternal psychiatric status, family function, and school performance were less favorable among the sexually abused than among the control children (P < .05). At follow-up 6 months later, the psychiatric status of the mothers of the abused children apparently improved, but the children's difficulties largely persisted. Baseline characteristics of the abused children significantly or suggestively associated with persisting problematic behavior were older age (P = .04), lower maternal educational attainment (P = .06), poorer maternal psychiatric status (P = .04) and lower family integration (P < .001). These four factors accounted for 31% of the variance in the children's behavior at 6-month follow-up (P < .001). Unexpectedly, characteristics of the children's sexual abuse experiences did not predict their later behavioral status. CONCLUSIONS: These findings suggest that preexisting, long-standing adverse psychosocial circumstances may contribute importantly to persistently problematic behavior and school performance among sexually abused children. The findings also suggest that it is children's preexisting psychosocial circumstances, rather than the abuse, that determine, at least in part, the nature of their functional outcomes.

Sexual abuse and bulimia nervosa: three integrated case control comparisons.

OBJECTIVE: This study had three aims: to determine whether sexual abuse increases the risk of developing bulimia nervosa, to see whether any increase in risk is specific to bulimia nervosa, and to determine whether patients referred for treatment of bulimia nervosa differ from a community group of subjects with bulimia nervosa with respect to their exposure to sexual abuse. METHOD: A case control design with individual matching was used. There were three related case control comparisons. Fifty community-based subjects with bulimia nervosa were compared with 100 community-based comparison subjects without an eating disorder, 50 community-based comparison subjects with other psychiatric disorders, and 50 patients (secondary referrals) with bulimia nervosa. An investigator-based interview was used to assess sexual abuse. RESULTS: Sexual abuse involving physical contact was reported by a minority of the community-based subjects with bulimia nervosa. It was more common among this group than among the normal comparison subjects. There was no difference between the community-based subjects with bulimia nervosa and either the subjects with general psychiatric disorders or the patients with bulimia nervosa. CONCLUSIONS: While the findings indicate that sexual abuse is a risk factor for the development of bulimia nervosa, it does not appear to be specific to bulimia nervosa nor is it relevant to most cases. Sexual abuse appears to be a risk factor for psychiatric disorder in general (including bulimia nervosa) among young adult women. There was no evidence that secondary referrals of bulimia nervosa are biased with respect to sexual abuse.

Relationships between bulimia, childhood sexual abuse, and family environment.

Prior studies investigating the relationship between childhood sexual abuse and bulimia have yielded mixed to weak empirical support for such an association. The current research, utilizing relatively restrictive definitions of abuse and bulimia, obtained significant associations between bulimia, sexual abuse, and a chaotic family environment in female college students. Among abuse victims, severity of abuse was also associated with bulimia. Although some analyses suggested that a chaotic family environment moderated the abuse--bulimia association, sexual abuse, and family environment appeared to combine in an additive manner to increase the probability of bulimia.

Vaginal foreign bodies and child sexual abuse.

OBJECTIVE: To determine whether vaginal foreign bodies (VFBs) in prepubertal girls are associated with sexual abuse and whether evidence exists in earlier reports for such an association. DESIGN: Retrospective case review. SETTING: General pediatric clinic at Duke University Medical Center, Durham, NC. PARTICIPANTS: All 12 girls 10 years of age and under who, between 1985 and 1988, were seen in the general clinic and subsequently found to have VFBs. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Clinic protocol required referral of all children with vaginal bleeding, unusual discharge, or VFBs to the Child Protection Team at the medical center, which also served as a pediatric gynecology consultation service. Records for the 12 girls, whose mean age was 6.3 years, showed 19 visits for single, multiple, or recurrent VFBs. Two girls had concurrent sexually transmitted diseases. Eight met diagnostic criteria for confirmed sexual abuse; three, for suspected abuse; and in one, abuse status was unknown. CONCLUSIONS: Vaginal foreign bodies in young girls may be a previously unrecognized indicator of sexual abuse. Girls with VFBs should be evaluated for possible sexual abuse. Prospective studies on the suggested association between VFBs and sexual abuse need to be conducted.

Substance use, risky behaviors, and victimization among a US national adolescent sample.

Data from the National Adolescent Student Health Survey were used to study the interrelations among substance use, risky (dangerous) behaviors, and victimization among 8th and 10th graders. Pearson correlations indicated significant associations between substance use and both higher levels of risky behaviors (e.g., hitchhiking, going on a blind date) and victimization among adolescents. Regression analyses indicated the potency of risky behaviors as a predictor of victimization for male adolescents, and a significant risky behavior by illicit drug use interaction for female adolescents. Results are discussed with regard to potential short- and long-term health consequences of risky behaviors and violent victimization for psychological development in adolescence and adulthood.