Some AN Patients with Childhood Sexual Abuse May Require Special Treatment Needs

Patients with anorexia nervosa (AN) of the binge-purge subtype and a history of childhood sexual abuse may need more intensive treatment for their eating disorder than patients without a history of sexual abuse. In addition, these patients may require treatment aimed specifically at addressing the effects of sexual abuse. These were two of the findings of a recent study by a team of clinicians in Toronto, Canada (Child Abuse & Neglect 2006; 30:257).

Dr. Jacqueline C. Carter and her colleagues assessed 77 consecutive patients with anorexia nervosa who were admitted to an inpatient eating disorders unit between 2000 and 2005. This is an intensive group therapy program aimed primarily at normalizing eating and restoring body mass index (BMI; kg/m2) to 20. Admissions are voluntary, and patients may leave the program at any time. The staff can also discharge patients when there is lack of progress or with repeated violations of program rules—for example, purging.

The 95 participants were assessed on admission to the unit with the Eating Disorder Examination (EDE), the self-report version of the EDE (EDE-Q4), the Beck Depression Inventory, the Rosenberg Self-esteem Scale, and the Brief Symptom Inventory. Interpersonal function was assessed with the Inventory of Interpersonal Problems, which measures distress from interpersonal sources—its six subscales measure assertiveness, sociability, intimacy, submissiveness, responsibility and control.

Childhood sexual abuse was defined as any unwanted sexual experience involving physical contract, including sexual touching and sexual intercourse that occurred before age 18 and before the onset of the eating disorder.

Nearly half had been abused

Eighteen of the 95 patients were excluded from the study because of abuse after age 18 or because the sexual abuse occurred after their eating disorder developed. Thirty-seven, or 48%, of the remaining 77 patients reported a history of sexual abuse during childhood. Eighty-four percent reported more than one episode of sexual abuse, usually by the same perpetrator, and 16% reported a single episode. The average age at which it occurred was 10.1 years. More than half (19 or 51.4%) were sexually abused by a family member or personal acquaintance; 16.2% by a boyfriend, 18.9% by an immediate family member, 5.4% by a stranger, and 8.1% by a teacher or doctor, for example.

Comorbidity was greater among the abused women

Compared with subjects who did not report a history of sexual abuse during childhood, patients with a history of sexual abuse had greater psychiatric comorbidity, including higher levels of depression and anxiety, lower self-esteem, more interpersonal problems and more severe obsessive-compulsive symptoms. Those with a sexual abuse history had significantly higher mean EDE-Q Global scores, indicating more severe eating disorder psychopathology.

Premature discharge from treatment

Contrary to the authors’ predictions, the mean time of discharge for those with a history of childhood sexual abuse was not significantly different from that for patients without a history of abuse. The proportion of patients dropping out prematurely also did not differ significantly between the group with a history of sexual abuse (43%) and those without such a history (57%).

The impact of AN subtype

Significantly more patients with a history of childhood sexual abuse had the binge-purge subtype of AN (54%), compared with the restricting subtype of AN (46%). Most patients with AN-binge-purge subtype (65%) had a history of childhood abuse, while less than half (37%) of AN-restrictor patients reported such experiences. The binge-purge subgroup terminated earlier and at a faster rate.

Purging more likely among those with a history of abuse

The authors noted that their results support previous research showing that patients with AN who report a history of sexual abuse were more likely to use purging behaviors (such as self-induced vomiting or misuse of laxatives) compared with patients without a history of sexual abuse. One possible explanation is that the effects of childhood sexual abuse may interact with personality characteristics present in AN patients with the binge-purge subtype versus those with the restricting subtype of AN. For example, the tendency of the AN binge-purge type subgroup to show greater mood lability and more impulsive behavior may be intensified by the aftermath of childhood sexual abuse. Because purging behaviors may help modulate negative internal states, individuals with a history of childhood sexual abuse who develop an eating disorder may be more likely to develop purging behaviors, possibly as a way of coping with the negative emotional effects of the abuse. In addition, sexual abuse during childhood may interfere with development of self-regulation and social functioning.

Routine screening for abuse is suggested

According to Dr. Carter and colleagues, it is not clear whether treatment for the abuse should take place before, after, or concurrently with treatment for an eating disorder. Also, since childhood sexual abuse is so common in this population and often is not disclosed by patients, it may be important to routinely screen patients for a history of sexual abuse.