Sexual abuse and body-image distortion in the eating disorders

Sense of Self: Its Place in Personality Disturbance, Psychopathology, and Normal Experience

Sense of self (SOS) is a cornerstone of psychological inquiry and therapy and is a defining feature of a range of psychological conditions including borderline personality disorder, yet it is poorly understood. SOS is that continuous experience of being a complete and authentic person who feels in control of their own activities. It is a part of normal development of the self and, when weakened by trauma or developmental neglect, is a vulnerability for developing many different disorders, including depression and dissociative, personality, and eating disorders. This review aims to provide a working definition and description of SOS and to summarize its transdiagnostic role in contributing to psychological disorders. To achieve this aim, the article encompasses and unites the literature from various theoretical domains including developmental psychology, identity theory, cognitive psychology, personality disorders, and psychodynamic theories. Implications are raised for psychological therapy and research into psychopathology and its underpinnings.

Body image in patients with posttraumatic stress disorder after childhood sexual abuse and co-occurring eating disorder

BACKGROUND

Body image is a multidimensional construct with cognitive-affective, behavioral and perceptive components. Survivors of childhood sexual abuse report a disturbance of the cognitive-affective component of their body image but not of the perceptive component. It has not yet been examined whether and how the behavioral component is affected. Also, it is still unknown whether the disturbances might be due to the influence of co-occurring eating disorders.

SAMPLING AND METHODS

The cognitive-affective and behavioral components of the body image of 84 female participants with posttraumatic stress disorder (PTSD) after childhood sexual abuse (31 with a co-occurring eating disorder) and 53 healthy participants were assessed via the Dresden Body Image Inventory (Dresdner Körperbildfragebogen-35, DKB-35) and the Body Image Avoidance Questionnaire (BIAQ).

RESULTS

PTSD patients reported significantly higher negative scores on all DKB-35 subscales (p < 0.001) and the BIAQ (p = 0.002; p < 0.001). Results remained consistent after accounting for the influence of co-occurring eating disorders (p = 0.021; p = 0.001; p < 0.001).

CONCLUSIONS

Results show for the first time that the behavioral component of the body image is impaired in female patients with PTSD in addition to the cognitive-affective component. This is not solely due to a comorbid eating disorder. The effect of established treatments on the body image of PTSD patients should be evaluated and new treatment modules should be developed and tested, if necessary.

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.

Traumatic experiences in individuals with body dysmorphic disorder

Individuals with body dysmorphic disorder (BDD) are excessively concerned about perceived defects in their appearance (e.g., blemishes on their skin). BDD is a severe mental disorder often associated with increased suicidality as well as significant social and occupational interference (e.g., J Clin Psychiatry 2005;66:717-725). Recently, investigators have begun to explore variables that might function as risk factors in the development of BDD, such as traumatic experiences (e.g., Child Abuse Negl 2006;30:1105-1115). As such, one of the goals of the current study was to examine the role of early-life sexual, physical, or emotional abuse in BDD. Specifically, the Traumatic Stress Institute Life Event Questionnaire (Treat Abuse Today 1992;2:9-11) was used to examine whether individuals with BDD (n = 18) self-reported having experienced more traumatic events than mentally healthy controls (n = 19). The BDD group reported more retrospective experiences of sexual and physical abuse in childhood or adolescence than did healthy controls. Surprisingly, there was no significant group difference in reports of emotional abuse in early life. This study provides preliminary evidence of the importance of examining abuse as a potential risk factor in the development of BDD.

The role of imagery-based techniques in cognitive-behavioural therapy for adults with eating disorders

Disorder-specific and transdiagnostic cognitive-behavioural models and treatments primarily target surface-level maintaining factors in order to effect symptom change. Despite this approach resulting in the most effective evidence-based approach for most eating disordered patients, a significant proportion of sufferers fail to benefit from such treatments. This conclusion suggests that deeper-level causal factors might also need to be addressed in some cases. Theoretical and empirical findings are considered in terms of the clinical applicability of imagery-based techniques and their ability to enhance cognitive-behavioural treatment of the eating disorders. Imagery techniques (particularly, but not only, imagery rescripting) are proposed as a means to enhance current treatments and improve existing outcomes. Potential treatment targets include core beliefs, emotional regulation difficulties and body image disturbance. The existing literature is limited but early indications suggest that imagery rescripting is effective in modifying core beliefs in this population, and that other imagery-based methods are potentially beneficial. Areas for further clinical application and investigation are identified.

Beyond "healthy eating" and "healthy weights": harassment and the health curriculum in middle schools

In this paper we use data from interviews conducted with grades 7 and 8 girls to explore connections between body-based harassment and girls' body modification practices. We discuss how the elementary health curricula fail to consider harassment and other cultural factors that influence the body modification practices and eating patterns of diverse girls. More specifically, we argue that the "healthy eating, healthy weights" approach of the grades 7 and 8 Ontario health curriculum has five limitations: (1) it sends contradictory messages; (2) it increases anxieties about body weight; (3) it ignores the multiple causes of eating problems; (4) it marginalizes issues most relevant to racialized girls; and (5) it ignores dilemmas associated with physical development. We conclude with suggestions for developing a curriculum on body dissatisfaction and eating disorders prevention that considers the various socio-cultural factors influencing the range of body monitoring and modifying practices taken up by girls.

Eating disorders and sexual abuse

This review examines the current debate on the role that sexual and physical abuse may play in predisposing to eating disorders in women. Despite some discordant opinions, clinicians agree that the experience of abuse in early childhood may be important for understanding the complex genesis of the eating disorders of some women. Three groups of studies are presented: those in which no connections emerge between sexual abuse and eating disorders, those in which a strong link is present and those in which the results refer to a multifactorial interpretative model. Some of the main symptoms, such as reactualization of the trauma, dissociation, personality disorders, pathological relationship with food, distortion of body image, suicide attempts and self-inflicted punishment that victims of abuse and eating disordered subjects share are examined.

Relating body image to psychological and sexual functioning in child sexual abuse survivors

Cognitive-affective body image variables and their relation to long-term psychological and sexual functioning were investigated in a community sample of 57 female adult child sexual abuse (CSA) survivors and 47 comparison subjects. The Body-Self Relations Questionnaire and the Body Esteem Scale were administered to assess cognitive-affective body image. Group comparisons indicated that, after controlling for actual weight status, survivors evaluated their health more negatively and reported less body esteem regarding their sexual attractiveness than comparison subjects. Body image variables related to health and sexual attractiveness significantly explained variance on symptom measures that reflect the diverse CSA long-term sequelae. Results suggest the need for careful assessment of body image disturbances and the development of effective interventions targeting body image in the treatment of CSA survivors.

The meaning of body image for women with eating disorders

OBJECTIVE

To propose a theoretical model accounting for the meaning and function of body image disturbances for individuals with eating disorders. This model departs from available conceptualizations of body image focused on attractiveness and emphasizes the role of body image preoccupations in the regulation of self-esteem and affect.

METHOD

This model was developed on the basis of the author's clinical observations and the available empirical research.

RESULTS

Three main functions of body image are described. The first one, "affiliation," consists of using one's appearance in the establishment of interpersonal relationships, both at the level of friendship and romance. The second function, "avoidance," consists of using one's body image to avoid abuse, be it psychological, physical, or sexual. The third function, "expression," consists of using one's body image to communicate to the self and others one's capacity for accomplishment or one's inner feelings of dejection.

CONCLUSION

This model is designed to be a therapeutic tool within body image therapy. Body image therapy can be most effective when focused on the unique meaning of body image for each individual patient.

Disordered eating, weight dissatisfaction and dieting in relation to unwanted childhood sexual experiences in a community sample

A study was conducted to examine the relationships among eating pathology, weight dissatisfaction and dieting, and unwanted sexual experiences in childhood. An unselected community sample of 201 young and 268 middle-aged women were administered questionnaires assessing eating behaviors and attitudes, and past and current sexual abuse. Results showed differential relationships among these factors for the two age cohorts: for young women, past sexual abuse predicted weight dissatisfaction, but not dieting or disordered eating behaviors, whereas for middle-aged women, past abuse was predictive of disordered eating, but not dieting or weight dissatisfaction. Current physical or sexual abuse was also found to be predictive of disordered eating for the young women. These findings underscore the complexity of the relationships among unwanted sexual experiences and eating and weight pathology, and suggest that the timing of sexual abuse, and the age of the woman, are important mediating factors.

Relationship of childhood sexual abuse and eating disorders

OBJECTIVE

To review the literature that has examined the relationship between childhood sexual abuse and the eating disorders.

METHOD

Each of the five authors reviewed all identified empirical studies to be certain that inclusion/exclusion criteria were met. Two teams of raters then independently reviewed each study to determine whether it supported any of a series of six hypotheses that had been tested in this literature.

RESULTS

This review indicates that childhood sexual abuse is a nonspecific risk factor for bulimia nervosa, particularly when there is psychiatric comorbidity. There is some indication that childhood sexual abuse is more strongly associated with bulimic disorders than restricting anorexia, but it does not appear to be associated with severity of the disturbance.

CONCLUSION

Childhood sexual abuse is a risk factor for bulimia nervosa with significant comorbidity. Further study of the nature of this relationship is warranted.

Histories of childhood trauma and complex post-traumatic sequelae in women with eating disorders

The profound self-destructiveness and tenacity of eating disorders found among women abused and neglected in childhood become comprehensible when understood within a complex posttraumatic conceptualization as desperate attempts to regulate overwhelming affective states and construct a coherent sense of self and system of meaning. Trauma leads to the predictable consequences of dysregulation of the arousal system, avoidance, and constriction of affect; coherence of self and world are shattered. Abused patients' childhood experiences teach them that to need is to expose oneself to the pain of abandonment and betrayal at the hands of individuals responsible for their care. Consequently, needs-psychological, physical, and spiritual-come to be perceived as dangerous, and human relationships are simultaneously yearned for and feared. Robbed of the opportunity to develop a cohesive self and a coherent system of meaning and faith to sustain from within, the traumatized eating-disorder patient turns to the culture to tell her who to be and how to live; she learns that to conquer rather than satisfy needs and to be "in control" (an internal state of equanimity manifested externally in a thin body) will bring meaning and purpose. Binge eating, purging, and starving become apt metaphors for the boundless hunger, the wish to fulfill needs together with the wish to rid oneself forever of need, the desire to "purify" the damaged psychic and physical self, and the hope of restoring meaning. The treatment of the traumatized eating disorder patient is complex. Individual therapy provides the opportunity for intensive relational work that begins to restore faith in human connection and that provides a "safe base" from which to examine the trauma and separate past from present. Therapy groups for eating-disordered women and trauma survivors provide relief from isolation, valuable perspectives from others who have "been there," and the opportunity to contribute to others' healing as one heals. Ultimately, these patients must be willing to leave the world of obsession with food and weight, which guarantees safety from interpersonal hurt while it simultaneously guarantees that hope will not be restored. Though reconnecting with humanity carries the risk of further pain, it opens up the opportunity for connection, healing, and growth.