The author reviews the psychodynamics of eating disorder behaviors in women with childhood sexual abuse histories, with a focus on anorexia, bingeing, purging, and overeating. The various defenses and behaviors interact with each other through numerous different feedback loops. The same behavior can have multiple defensive functions and the same defensive function can be served by different behaviors. None of the behaviors is specific to childhood sexual abuse, but the abuse history modifies the content, heightens the intensity of the feelings being defended against, and should be taken into account in the therapy. Several examples of therapeutic strategies are also provided.
KEYWORDS: sexual abuse survivors; eating disorders; behavior; psychodynamics
PSYCHODYNAMICS OF EATING DISORDER BEHAVIOR IN SEXUAL ABUSE SURVIVORS
My goal in this paper is to describe the psychodynamics of eating disorder behaviors in women with childhood sexual abuse histories. Most, if not all, of these dynamics are equally relevant for understanding men with severe body image distortions, eating disorders, and sexual abuse histories (Feldman & Meyer, 2007). I will not attempt to review the literature comprehensively because this is a clinical summary of my experience and understanding as a psychotherapist, which is summarized in a series of books (Ross, 1994; 1995, 1997; 2004; 2007; Ross and Halpern, in press).
I first began to study eating disorders in 1984 as a psychiatry resident in a half-time, six-month rotation in an eating disorders program. Since 1991, 1 have been operating an inpatient trauma program that has admitted thousands of women with childhood sexual abuse histories: of these, slightly fewer than 40% have an eating disorder as classically defined by DSM (Ellason and Ross, 1996). Of the remainder, many have pathological eating patterns that could be classified as an eating disorder not otherwise specified. These include extreme overeating with morbid obesity, phobic avoidance of certain foods based on childhood sexual abuse, and extremely unhealthy diets with normal weight.
As reported throughout the literature, only a subset of individuals with eating disorders reports a history of childhood sexual abuse (Costin, 2007; Feldman & Meyer, 2007; Schwartz and Cohen, 1996; Vanderlinden, 1993); the same psychodynamics operate in people with eating disorders but no sexual abuse histories. Nothing in my analysis is unique or specific to sexual abuse. Childhood sexual abuse rarely, if ever, occurs in isolation and is almost always accompanied by varying combinations of emotional, physical and verbal abuse, family violence, loss of primary caretakers, and failures of bonding, nurturing, and attachment by the parents. A variety of forms of trauma are likely relevant to the understanding and treatment of eating disorders in women (Mangweth-Matzek, Rupp, Hausman, Kemmler, & Biebl, 2007; Striegel-Moore, Dohn, Kraemer, Schreiber, Taylor, & Daniels, 2007; Smyth, Heron, Wonderlich, Crosby, & Thompson, 2008; Wade, Gillespie, & Martin, 2007) and men (Feldman & Meyer, 2007). Although I am focusing on childhood sexual abuse in my analysis, these other forms of conflict also contribute to the cognitive errors, conflicts and defensive functions of eating disorder behavior.
The relationship between trauma and eating disorders was the subject of a recent special issue of the International Journal of Eating Disorders (Levitt & Sansone, 2007). The authors of papers in that issue discussed epidemiology, diagnosis and assessment (Brewerton, 2007; Briere & Scott, 2007; Clae & Vandereycken, 2007; Waller, Corstorphine & Mountford, 2007; Sansone & Sansone, 2007) and treatment (Berrtett, Hartman, O'Grady & Richards, 2007; Levitt, 2007). All authors commenting on the relationship between trauma and eating disorders agree that it is complex and that no form of abuse is a specific risk factor for eating disorders (Baker, Mazzeo & Kendler, 2007; Bardone-Cone, Maldonado, Crosby, Mitchell, Wonderlich, Joiner, Crow, Peterson, Klein & Grange, 2008; Calam & Slade, 1989; Miller & McCluskey-Fawcett, 1993; Sansone & Schumacher, 2008; Steiger & Zankor, 1990; Zlotnick, Hohlstein, Shea, Pearlstein, Recupero & Bidadi, 1996). …