Abstract
Childhood sexual abuse is a prevalent and significant issue in today?s society. This paper will explore general theories regarding the effects childhood sexual abuse has on adolescents and adults; the possible outcomes; and the relationship between sexual abuse, eating disorders, and personality disorders. The following hypotheses will be evaluated by a literature review: childhood sexual abuse is a risk factor for developing an eating disorder in adolescence; children that experience sexual abuse develop maladaptive beliefs or cognitive schemas; and
childhood sexual abuse contributes to the development of personality disorders in adulthood. The supporting factors and summary of an interview conducted with an adult survivor of childhood sexual abuse will also be included.
The Correlation between Childhood Sexual Abuse, Eating and Personality Disorders
According to the American Psychological Association (2005), children and adolescents who have been sexually abused can suffer a range of psychological and behavioral problems, both in the short and long term. Amongst these problems are depression, anxiety, guilt, fear, sexual dysfunction, withdrawal, and acting out. Childhood sexual abuse is a prevalent and significant issue in today?s society and can affect the victims far into adulthood.
The US Department of Health and Human Services (2000) reported that there were 879,000 victims of childhood maltreatment substantiated in 2000. Of those substantiated reports, 10% were sexual abuse cases. Adults survivors of childhood abuse and neglect, when compared to those without the same history, often incur several different types of psychopathology including drug and alcohol disorders, personality disorders, and generalized distress (Horwitz, Widom, McLaughlin, & White, 2001).
This paper will explore general theories regarding the effects childhood sexual abuse has on adolescents and adults; the possible outcomes; and in particular, the relationship between sexual abuse, eating disorders, and personality disorders. It is hypothesized that children who experience sexual abuse are more likely to develop eating disorders in adolescence, and are at risk for developing personality disorders in adulthood if their cognitive schemas and maladaptive beliefs are not addressed in treatment.
A literature review supported the hypothesis that childhood sexual abuse is a risk factor for developing an eating disorder in adolescence. In particular, one article indicated that ?Self-reported childhood sexual abuse was positively associated with all disorders, the highest being seen with bulimia and drug dependence (Henderson, 2000).
According to Wonderlich, Crosby, Mitchell, and Roberts (2000), females that experience childhood sexual abuse are at an increased risk to develop eating disorders during adolescence. Research shows that abused girls tend to be more dissatisfied with their weight resulting in a tendency to be preoccupied with dieting, binging and purging, using laxatives and diuretics (Wonderlich et al., 2000). It is suggested that abused girls might experience elevated levels of emotional distress, possibly linked to the victimization, and an inability to cope; therefore, food restriction and eating disorder behaviors are a method to deal with the trauma (Wonderlich et al., 2000).
Additionally, Stephen Wonderlich (summary of interview on Radio National Encounter, May 11, 2000) postulated that there are three ideas that need to be tested further regarding a person who has been sexually abused that develops an eating disorder. He indicated a sexual abuse victim may take away an extreme shame about their bodies (psychological distortion), and may develop an eating disorder as a way to modify their bodies. A second possible mechanism or avenue by which a victim could go from sexual abuse to eating disorders might be in the form of some generic traumatic response that the person has. It might be actually psycho-biological, with the trauma of sexual abuse being very upsetting to a young child, leaving a permanent impact on their biology, brain, on their entire central nervous system. This impact may lead to other physiological programs that which ultimately lead to eating disorders (Wonderlich, 2000).
A third possibility Wonderlich (2000) reported as a connection between sexual abuse in childhood and eating disorders in adolescence is a ?generic dysregulation phenomenon? in which processes in body and in the mind become deregulated. Food control becomes deregulated, mood control becomes deregulated, relationship control is somewhat deregulated, and the person may engage in a wide array of problem behaviors, all of which is basically predicted by a dysregulation of the central nervous system, the personality, which then ultimately includes eating disorders (Wonderlich, 2000).
Another hypothesis explored is that children who experience sexual abuse develop maladaptive beliefs or cognitive schemas. Several studies (Bernstein, 2002; Trippany, Helm, & Simpson, 2006) indicate that when emotional, physical, or sexual maltreatment occurs in childhood, it can result in distorted, maladaptive beliefs (i.e. cognitive schemas) about the self and others; and form the cognitive and affective core of personality disorders. In particular, early maladaptive schemas (EMS) include: abandonment; emotional deprivation of nurturance, autonomy, and protection; abuse/mistrust; defectiveness/shame; and social isolation (Bernstein, 2002).
When these EMS are triggered, three coping mechanisms are used to manage the potentially disruptive effects of schematic activation: schema surrender, schema avoidance, and schema overcompensation (Bernstein, 2002). For example, the client copes with the defectiveness schema by giving in or surrendering to the unpleasantness of a situation because it is familiar to them. It was apparent throughout the interview conducted for the purpose of this report (see Appendix), that the interviewee?s past experiences and relationships provided the structure for several of these emotional maladaptive schemas.
For example, during the interview, Sarah shared that, ?my father would give me spankings when I misbehaved. I always felt it was my fault, so I would work extra hard to gain his acceptance.? The interviewee?s mother also appeared to be neglectful and reportedly abusive, which potentially fostered lifelong feelings of incompetence and helplessness; resulting in Sarah turning to others to solve problems (surrender coping mechanism); and of feelings of loneliness and neediness (social isolation and emotional deprivation schemas) (Bernstein, 2002).
The sexual abuse that Sarah also endured as a child potentially contributed to the EMS of abuse/mistrust which lends to a self-defeating manner in which her schemas and coping mechanisms play themselves out and confirm the EMS. According to her self-reported history, a typical scenario that portrays her dependency and relationship issues, ?After I left my husband, I tried to develop new friendships, to be more sociable, and to be more independent; however, I felt very lonely. Within a few months of leaving my abusive husband, I was living with another verbally abuse man? (see Appendix). Sarah apparently had a history of feeling lonely and needy (emotional deprivation and social isolation schemas); to deal with these feelings, she sought out a man for committal relationship (overcompensation coping mechanism); these relationships were inevitably emotionally abusive, leaving her feeling used and mistreated; which ultimately leads to her feeling even more deprived, defective, and mistrustful, further reinforcing her maladaptive schemas.
In exploring the hypothesis that childhood sexual abuse contributes to the development of personality disorders in adulthood, the findings in the reviewed literature were confounding. A study conducted by Trippany, Helm, and Simpson (2006) identified a possible misdiagnosis of Borderline Personality Disorder (BPD) when working with adult survivors of childhood sexual abuse. They postulated that the client?s symptoms may be more indicative of a Post Traumatic Stress Disorder diagnosis, and identified that the symptoms may line up with trauma reenactment (Trippany et al., 2006).
It appears that self-harming behaviors, promiscuity, risk taking, and relationship difficulties, often seen in BPD clients, may also appear in survivors as a way of re-living the trauma, similar to an addiction. The self injuring or defeating behaviors could be interpreted as a way to recreate the feelings of rage, shame, or fear from childhood. Additionally, the cycle of self-harm may be a way for a survivor to keep a distance in new relationships (Trippany et al., 2006).
Conversely, Battle, Shea, Johnson, and Yen (2004) emphasized that individuals diagnosed with Borderline Personality Disorder, and that have experienced childhood sexual abuse have, received the most attention of research. Prior to their study, Battle et al. (2004) indicated that no published studies have compared childhood maltreatment experiences of samples from multiple personality disordered groups. Consequently, they examined precursors to several different personality diagnoses. Ironically, the study ultimately concluded that Borderline Personality Disorder was the Axis II diagnosis most strongly association with childhood maltreatment, primarily sexual abuse. Their findings also suggested that Obsessive Compulsive Personality Disorder and Antisocial Personality Disorder had elevated rates of certain forms of childhood maltreatment (Battle et al., 2004).
According to Cohen, Crawford, Johnson, and Kasen (2005), childhood sexual abuse appears to be a precursor or prospective risk factor in the various types of personality disorders. In particular, they indicated that Cluster A personality disorders (paranoid, schizoid, and Schizotypal), were increasingly diagnosed in adults that had a history of childhood sexual abuse. In adults that had experienced verbal abuse, paranoid personality disorder specifically appeared more frequently, according to their longitudinal study (Cohen et. al, 2005).
Investigating the Cluster B personality disorders (borderline, histrionic, and narcissistic ? antisocial was excluded due to the age of their cohort), Cohen et al (2005) substantiated that in the community sample for their study, there was a significant link to childhood abuse, with elevated symptoms of borderline personality disorder in early adulthood predicted by official records of sexual abuse.
Interestingly, the conclusion of Cohen et al?s study (2005) reported the disclaimer that while childhood trauma increases the risk of developing a personality disorder, the trauma does not account for all cases of personality disorder. Likewise, not all children who have experienced childhood sexual abuse will develop a personality disorder. Additionally, they concluded that there may be interplay between environmental influences and genetic factors in the formation of personality disorders. It is imperative for treatment that discrimination is made between the two when investigating the origins of personality disorder, as well as, investigating outcomes of childhood trauma.
During the interview (see Appendix), Sarah disclosed that she was a victim of childhood sexual abuse, and also diagnosed by her Clinical Psychologist as an adult with Dependent Personality Disorder (Cluster C personality disorder). According to the DSM-IV TR (APA, 2000), Dependent Personality Disorder must be distinguished from dependencies arising as a consequence of Axis I disorders and as a result of general medical conditions. Sarah?s dependency issues reportedly had an early onset, chronic course, and illustrative pattern behavior that does not occur exclusively during periods of depression, but rather concurrent to dysthymia.
Sarah?s relationships, various behavior patterns, and coping mechanisms appear to be consistent with the predominant features of Dependent Personality Disorder: submissive, reactive, and clinging behavior; fear of abandonment; strong need for reassurance; feelings of inadequacy, etc. Sarah did not report diagnosis of any other personality disorders and does not appear to meet the differential diagnosis of Borderline Personality Disorder (which appears to be the most predominant personality disorder in adult survivors). By the information gathered in the interview, Sarah reacts to her fear of abandonment by seeking a replacement relationship, rather than the rage typically seen in Borderline Personality Disorder at the termination of a relationship. Additionally, according to information gathered in the interview (see Appendix), Sarah?s dependency issues did not formulate as a direct result of any childhood illnesses or medical conditions.
According to Eskedal and Demetri (2006), it is important to detect and properly diagnose personality disorders because they are typified by an enduring pattern of thinking, feeling, and behaving that is relatively stable over the life cycle, beginning in adolescence or early adulthood and continuing on throughout the life cycle. Over time, this maladaptive lifestyle places the individual at odds with his or her social and cultural environment, leading to distress and/or impairment (Eskedal & Demetri, 2006).
Implications to many studies includes the fact that the sample is typically compiled of personality disordered patients which may over-report experiences of childhood maltreatment to elicit sympathy, justify symptoms, or may under-report experiences due to shame or failure to recall negative childhood events. The majority of research conducted on child victimization outcomes rely upon recall and retrospective reporting, which affects the reliability of information. Furthermore, it is reportedly challenging to exclude environmental influences as confounding variables on the development of psychopathology. Research has shown that childhood victimization is oftentimes combined with other stressors such as poverty, unemployment, parental alcohol and drug problems, and inadequate family function (Horwitz et al., 2001).
In identifying a treatment plan for adult survivors of childhood sexual abuse, a cognitive behavioral approach may help them become aware of how their dysfunctional attitudes and automatic thoughts are causing unhappiness or impairing their physical wellness. They could benefit from schema change methods, including cognitive restructuring, to help alter the distorted way they views themselves, the world, and the future (Bernstein, 2002). This could be combined with behavioral activities to foster better coping abilities. The therapist?s ability to provide empathy and compassion would be crucial to counter feelings of shame and deprivation for survivors, and they could benefit from limited re-parenting, an active directive approach in which the therapist attempts to provide some of the warmth, guidance, and firm yet empathic limit setting that the patient may have lacked as a child (Bernstein, 2002).
In conclusion, continued research on the effects childhood sexual abuse has on the development of eating and personality disorders is fundamental to future generations. Early detection of childhood sexual abuse is imperative to the treatment and prognosis of adult survivors. Society education and intervention is paramount in the prevention of childhood victimization resulting in later psychopathologic outcomes. It is imperative to investigate other life course events that occur when looking at the way early experiences and traumas affect later psychopathology and mental health wellness. Lastly, it is important for future studies to not only focus on the negative outcomes that result from childhood maltreatment, but also the protective factors that may serve as interventions, such as having a positive relationship with parents, peers, or other adults, to buffer the damaging effects, and overall focus on improving parenting abilities, reducing risk factors for pathology, and to improving preventative resources.
References
American Psychological Association (2005). Understanding childhood sexual abuse: education, prevention, and recovery. Retrieved May 18, 2006, from http://www.apa.org/releases/sexabuse/effects.html.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision, DSM-IV-TR. Washington DC: American Psychiatric Association.
Battle, C.L., Shea, M.T., Johnson, D.M., Yen, S., et al.. (2004). Childhood maltreatment association with adult personality disorders: Findings from the collaborative longitudinal personality disorders study. Journal of Personality Disorders, 18, 193-212.
Bernstein, D.P. (2002). Cognitive therapy of personality disorders in patients with histories of emotional abuse or neglect. Psychiatric Annals, 32, 618-632.
Cohen, P., Crawford, T.N., Johnson, J.G., & Kasen, S. (2005). The children in the community study of developmental course of personality disorder. Journal of Personality Disorders, 19, 466-487.
Eskedal, G.A., Demetri, J.M. (2006). Etiology and treatment of cluster c personality disorders. Journal of Mental Health Counseling, 28, 1-18.
Horwitz, A., Widom, C., McLaughlin, J., & White, H. (2001) The impact of childhood abuse and neglect on adult mental health: a prospective study. Journal of Health and Social Behavior, 42, 184-201.
Trippany, R.L., Helm, H.M., & Simpson, L. (2006). Trauma reenactment: rethinking borderline personality disorder with diagnosing sexual abuse survivors. Journal of mental health counseling, 28, 95-111.
U.S. Department of Health and Human Services (2000). Sexual Abuse Statistics. Retrieved May 21, 2006 from http://www.prevent-abuse-now.com/stats.htm#Substantiated.
Wonderlich, S.A. (2000). The body and the self: eating disorders and sexual abuse. Retrieved May 21, 2006 from http://www.abc.net.au/rn/relig/enc/stories/s208692.htm.
Wonderlich, S.A., Crosby, R.D., Mitchell, J.E., Roberts, J.A. (2000). Relationship of childhood sexual abuse and eating disturbance in children. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1277-1283.
Maybe not a good topic to discuss on a forum...
I would think it could get interesting, especially if someone was abused as a child and they were willing to explore their emotions about it with you.
Hmmm...that would be a touch too personal on the forum.
I guess this is more of an informational thread than a discussion one...thanks for commenting though, Daisy!
Haven't said anything about your thread up to now, sunny, but I wanted to say that I have read it all, and find it very interesting.
Please keep posting whatever you want. I, for one, am very interested and am spending many hours thinking about your posts.
Thanks for the twinge on the intellectual side. I'm learning. 8) 8) 8)
Sunny I must follow FTW's lead here and let you know I too have read every line. I'm glad he open the door for me to walk through.
This was a hard subject to comment on, years ago I took my step grandaughter out of her home in Ohio and brought her back to Indiana with me. I knew something was terrible wrong, I knew it because of her actions. I was right, she was 4 years old at the time. Thank God she trusted me because telling me about video's her father made her watch was enough to get him away from her. I will not explain the other things that had happen to her, but I kept her with me until she was 9. Counciling was a must to help make her mentally healthy. I highly applaud you in your decison to help the meek who do not know how to help themselves.
If we as adults would just listen......truely listen to a child, the smallest comment can tell the big picture!
May God Bless you Sunny, we need more protectors like you in this world. :smitten:
I value your comments, observations & disclosure, FCM and FTW! I've had reservations ever since I posted of my papers...I'm glad someone found interest in them. :smile: