Medical and Psychiatric Symptoms in Women with Childhood Sexual Abuse EDWARD A. WALKER, MD, WAYNE J. KATON, MD, JANET HANSOM, MD, JANE HARROP-GRIFFITHS, MBBS, LOUISE HOLM, MD, MICHAEL L. JONES, MD, LEE HICKOK, MD, AND RON P. JEMELKA, PHD Although there is increasing awareness of the short-term psychological and social adaptations to childhood sexual abuse, little is known about the long-term effects of such abuse, particularly its effect on subsequent medical utilization and the experience and reporting of physical symptoms. We re-analyzed data from a previous study of 100 women scheduled for diagnostic laparoscopy (50 for chronic pain, 50 for tubal ligation or infertility evaluation) who received structured, physician-administered psychiatric and sexual abuse interviews. Women were regrouped by severity of childhood sexual abuse, and we compared the groups with respect to lifetime psychiatric diagnoses and medically unexplained symptom patterns. Unadjusted odds ratios showed that risk for lifetime diagnoses of major depression, panic disorder, phobia, somatization disorder and drug abuse, and current diagnoses of major depression and somatoform pain disorder were significantly higher in the severely abused group compared with women with no abuse or less severe abuse. Logistic regression analysis demonstrated that number of somatization symptoms, lifetime panic disorder and drug dependence were predictive of a prior history of severe childhood sexual abuse. Psychiatric disorders and medical symptoms, particularly chronic pelvic pain, are common in women with histories of severe childhood sexual abuse. Clinicians should inquire about childhood sexual and physical abuse experiences in patients with multiple medical and psychiatric symptoms, particularly patients with chronic pelvic pain. Key words: sexual abuse; chronic pelvic pain; medical symptoms.
INTRODUCTION
Over the last decade there has been an increasing awareness of the high prevalence of childhood sexual abuse in the general community and its impact on the psychosocial functioning of adult women.
From the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington (E.A.W., W.J.K., R.P.J.). Address reprint requests to: Dr. Edward A. Walker, Department of Psychiatry and Behavioral Sciences, University of Washington RP-10, Seattle WA 98195. Received for publication March 18, 1992; revision received August 3, 1992
658 0033-3174/92/5406-0658S03 00/0 Copyright © 1992 by ihe American Psycho
Although recent research has focused on short-term psychological and social adaptations to this trauma, surprisingly little is known about the long-term effects of such abuse, particularly its effect on subsequent medical utilization and the experience and reporting of physical symptoms. Several retrospective investigations have suggested an association between childhood sexual abuse and the later development of high medical utilization and multiple medical complaints (1-6), particularly chronic pelvic pain (6-9). The association between chronic pelvic pain and childhood sexual abuse remains controversial, however, since one study (10) Psychosomatic Medicine 54:658-664 (1992)
SEQUELAE OF CHILDHOOD SEXUAL ABUSE
found an association with physical but not compared with women without prior sesexual abuse. Unfortunately, most of vere childhood sexual abuse. these studies have been difficult to interpret due to methodological limitations such as small numbers of subjects, lack of METHOD control groups, the use of no-validated sexual abuse questionnaires and nonIn our prior study (11) we selected a sequential structured medical, psychiatric, or sexual sample of patients from the laparoscopy schedules abuse interviews. at our University Hospital, an urban OB/GYN priWe recently completed a study compar- vate practice, or Group Health Cooperative (a local ing the psychiatric and developmental health maintenance organization). The subjects histories of 50 women laparoscoped for were women who had either medically unexplained chronic pelvic pain for at least 6 months (N = 50), chronic pelvic pain and 50 women lapa- or were being laparoscoped for tubal ligation (N = roscoped for non-painful gynecological 32) or infertility evaluation (N = 18). None of the conditions (11). When compared with the women in the comparison group reported pelvic pain non-pain group, the women with chronic complaints prior to surgery or at the time of the interview. Interviews were completed within pelvic pain had significantly higher prev- study 20 months of the date of surgery. Approximately alences of current and lifetime depres- 75% of the women approached for the study agreed sion, somatization disorder, drug abuse to participate. and phobia, and significantly higher rates After obtaining informed consent we interviewed of medically unexplained symptoms the patients using the NIMH Diagnostic Interview Schedule (DIS) Version III-A. This is a structured across many organ systems despite no difinterview that makes valid and reliable ferences in objective laparoscopic find- psychiatric DSM-III diagnoses, and is widely used in psychiatric ings. The prevalence of childhood sexual epidemiology (12). We used an abridged version that abuse was significantly higher in the pain included the diagnoses most commonly found in group, and nearly all the severely abused primary care such as somatization disorder, panic, phobia, major depression, and alcohol and drug women had chronic pelvic pain. abuse. Interviewers are required to probe each posThe large number of subjects (N = 100) itive symptom, and to rate whether the symptom led in our study and the fact that they all had to medical consultation or impairment of life activistructured, physician-administered inter- ties, was due to alcohol or substance abuse, a mediside effect, or was the result of stress or views as well as very intensive medical cation psychiatric disorder. evaluations (including physical and lapaThe interviewers (J.H., L.H., M.J., and J.H.-G.) roscopic examinations) suggested to us were trained and supervised in the use of the DIS that a re-analysis of the patients' sexual by the senior psychiatrist (W.K.) and were blind to abuse histories might shed further light the indication for laparoscopy. Ten percent of the on the association between sexual abuse interviews were independently scored by a another (E.W.) with 100% agreement between and subsequent somatization. This report psychiatrist the psychiatrist and the four interviewers with reis a re-examination of our data from that spect to the patients' psychiatric disorders. The DIS prior study. We hypothesized that women section on major depression was changed to inquire with histories of severe childhood sexual more accurately about current symptoms of major (13). During the interview we inquired abuse would have significantly higher depression about current (1 month) and lifetime diagnoses for prevalences of lifetime psychiatric disor- the psychiatric disorders, and, in order to determine ders and a higher mean number of medi- whether subjects met criteria for more than one cally unexplained physical symptoms psychiatric diagnosis, we scored the DIS to allow the Psychosomatic Medicine 54:658-664 (1992)
659
E. A. WALKER TABLE 1. Odds Ratios of Current and Lifetime Psychiatric Diagnoses in Women with and without Severe Childhood Sexual Abuse Histories
Current diagnoses Major depression Chronic pelvic pain Lifetime diagnoses Major depression Panic Phobia Somatization D/O Alcohol abuse Drug abuse Functional dyspareunia Inhibited sexual desire Inhibited orgasm
Severe Abuse (N = 14) N (%)
Nonsevere or No Abuse (N = 86) N (%)
Odds Ratio
95% Confidence Interval
5(36) 12(86)
9(10) 2(14)
4.8 7.6
1.3-17.3 1.6-36.0
12(86) 5(36) 8(57) 5(36) 5(36) 9(64) 6(43) 4(29) 3(21)
31 (36) 1 (D 15(17) 2 (2) 21 (24) 20(23) 20(23) 14(16) 11 (13)
10.6 47.2 6.3 23.3 1.7 5.9 2.5 2.1 1.9
2.2-50.7 5.0-450.0 1.9-20.9 4.0-138.1 0.5-5.7 1.8-19.8 0.8-8.0 0.6-7.5 0.4-7.7
maximum number of valid DSM-III psychiatric diagnoses with no exclusion criteria. We then interviewed the patients using a structured family history interview (14) and a 14-question structured sexual assault instrument previously used in large community epidemiologic studies (15). Women were characterized as having no abuse, less severe childhood abuse (exhibitionism, aborted attempts before age 14), or more severe childhood abuse (incest, rape, oral contact, or repeated fondling before age 14). For the purpose of this analysis, we pooled the 50 women reporting pain with the 50 who did not report pain and examined the lifetime psychiatric diagnoses and somatization patterns of women with and without histories of severe childhood sexual abuse. For clinical usefulness we first computed unadjusted odds ratios with 95% confidence intervals for selected psychiatric diagnoses. We then attempted to control more carefully for confounding and interactions between the variables by calculating a logistic regression analysis using severe childhood abuse as a dependent variable. As independent variables we used lifetime diagnoses of major depression, panic disorder, drug and alcohol dependence, chronic pain, mean number of somatization symptoms, mean number of psychiatric diagnoses, age, marital status, and socioeconomic status. We also computed interaction terms including lifetime depression by all other variables, and age by all other variables.
660
RESULTS Of the 100 women in the study 56 (56%) reported no childhood sexual abuse, 30 (30%) reported less severe abuse, and 14 (14%) reported more severe abuse. There were no significant differences between the no abuse and less severe abuse groups on any of the demographic or psychiatric independent variables with the exception of number of medically unexplained somatization symptoms (no abuse 3.4 ± 4.2; less severe 5.7 ± 3.7; t = 2.39; df = 84; p < 0.02), so we combined them into a single group for the purposes of this analysis. For clinical usefulness we computed unadjusted odds ratios and 95% confidence intervals for several selected psychiatric diagnoses comparing women with and without histories of severe childhood sexual abuse (Table 1). The risk for lifetime diagnoses of major depression, panic disorder, phobia, somatization disorder and drug abuse, and current diagnoses of major depression and somatoPsychosomatic Medicine 54:658-664 (1992)
SEQUELAE OF C H I L D H O O D SEXUAL ABUSE
form pain disorder was significantly higher in the severe abuse group. A logistic regression approach to control for confounding showed that main predictors of a history of severe sexual abuse were the number of medically unexplained symptoms, and lifetime histories of drug abuse and panic disorder (Table 2). Chronic pain history and socioeconomic factors were not significantly associated. The model yielded a sensitivity of 36%, a specificity of 99%, and a positive predictive value of 83%. We also calculated the positive predictive value of a history of severe childhood sexual abuse for the later development of chronic pelvic pain by identifying patients with both disorders. Twelve of the 14 women with severe childhood abuse also had chronic pelvic pain yielding a positive predictive value of 86%, with a specificity of 96% and a sensitivity of 24%. In addition to the high frequency of childhood sexual abuse many of the subjects also reported abuse as adults (after age 14). Of the 100 patients in the study, 61% reported no adult sexual abuse, 11% less severe abuse, and 28% more severe forms of abuse after the age of 14. There was a significant correlation between severe childhood abuse and subsequent se-
vere forms of adult sexual abuse (r = 0.46, p < 0.01), and the positive predictive value of severe childhood abuse for later adult sexual abuse was 79%.
DISCUSSION The women in this study who experienced less severe forms of childhood sexual abuse were not significantly different from those who had experienced no abuse. However, when compared with women who reported a history of less severe or no sexual abuse, the women in this study with severe abuse were significantly more likely to have multiple medically unexplained physical symptoms and lifetime histories of drug abuse and panic disorder. In addition, computation of unadjusted odds ratios suggests that these women with severe childhood abuse are significantly more likely to have several other psychiatric disorders as well. Differences between the odds ratios and the logistic regression procedure are due to the fact that the logistic regression removed the influence of variables highly correlated with the variables entered into the regression equation. Thus, although it
TABLE 2. Logistic Regression Analysis of Socioeconomic and Psychiatric Variables in Women with and without Histories of Severe Childhood Sexual Abuse
Intercept # Medically unexplained symptoms Lifetime panic disorder Drug and alcohol dependence
Beta
SE
Wald t
Odds
95% Confidence Interval
-3.8593 1.9542
0.8033 0.8522
23.1 5.3
7.1
1.33-37.51
2.7469 1.3618
1.2192 0.7225
5.1 3.6
15.6 3.9
1.43-170.12 0.95-16 09
The following variables made nonsignificant contributions to the logistic regression: lifetime depression, chronic pain, number of psychiatric diagnoses, age, marital status, socioeconomic status.
Psychosomatic Medicine 54:658-664 (1992)
661
E. A. WALKER is clinically useful to know that women with severe abuse have a 10-fold risk for lifetime major depression, the significant correlation of major depression with somatization removes major depression from the final regression equation due to the magnitude of the effect provided by somatization. Recently, several studies have suggested a possible association between childhood sexual abuse and the subsequent development of medically unexplained physical symptoms (1-6), particularly chronic pelvic pain (6, 7, 16, 17). Rapkin et al. (10) showed that physical but not sexual abuse was more prominent in 31 women with chronic pelvic pain compared with 142 women with chronic pain in other locations and 32 pain-free controls. While these studies suggest that early sexual abuse may play a role in the subsequent development of high medical utilization, unexplained physical complaints- and chronic pelvic pain, several are methodologically limited by their absence of controls and small sample size (5-7), and for failure to meet the current methodologic standards for psychiatric and sexual abuse research with respect to the use of validated interview instruments (1-4, 6, 8, 10, 16). The use of selfreport questionnaires and interviews of untested reliability and validity have been shown to reduce the accuracy of sexual abuse reporting (18). Despite the limitations of these earlier reports, the present study confirms the observations of an association between childhood sexual abuse and subsequent medical symptoms by using a larger sample, a comparison group without history of sexual abuse, and physician-administered, validated, structured interviews for the medical, psychiatric, and sexual abuse histories. Care should be taken, 662
however, in generalizing these findings beyond this study since the selection of this sample from a medical clinic laparoscopy schedule was to test another hypothesis. Nevertheless, the sample was sequential and non-biased, and we believe that the results of this analysis suggest that further study of this association is warranted. Does early childhood sexual abuse predispose a woman to develop subsequent somatization and chronic pelvic pain? Sexual and physical abuse are frequently markers for serious family distress and the failure of parents to provide an adequate, predictable, and protective environment for children. The study of Rapkin et al. (10) demonstrated that physical abuse is common in patients with chronic pelvic pain, and Drossman et al. (3) found in his sample of female patients with gastrointestinal (GI) diagnoses that all but one of the women who were sexually abused were physically abused as well. Gold (19) has shown in a community sample that depression, sexual dysfunction, and social problems are long-term psychological sequelae of early sexual abuse. The severity of these disabilities was most strongly associated with an attributional style of learned helplessness or an expectation of having little or no control over the environment. This suggests that chronic, severe abuse (emotional, physical, or sexual), and a highly insecure, unpredictable family life are likely to result in the development of multiple maladaptive responses including increased medical utilization and somatization. Somatization is highly correlated with personal psychological distress, the psychological trait of neuroticism and a tendency to have an external locus of control (20). Thus, patients with somatization often perceive that they have little control Psychosomatic Medicine 54:658-664 (1992)
SEQUELAE OF CHILDHOOD SEXUAL ABUSE
over their world and that their lives are and 13.0 visits to outpatient clinics. Total directed by powerful external forces (or health care charges over 1 year averaged people). Somatization may provide pa- $4,700 in 1980 dollars, or nine times the tients who have been victims of unpre- U.S. per capita personal health care exdictable early environments and a sense penditure. Laparoscopy alone costs apof personal powerlessness with a safe way proximately $2500 and carries a risk of of describing their chronic distress, in- iatrogenic injury. The findings of this creased support from physicians and fam- study imply the need for studies of psyily and a way of leveraging interpersonal chological interventions in patients with histories of sexual abuse in an attempt to relationships. The high correlation between child- decrease distress, functional disability, sohood and adult sexual abuse suggests that matization, and high medical utilization. the impact of early traumatic experiences If these intervention strategies are succan be long lasting. Adults who have been cessful they are likely to lead to cost offset physically and sexually victimized as effects due to the high cost of these pachildren are at increased risk for high tients to the medical system. levels of psychological distress, dissociaThe presence of high rates of childhood tive episodes, post-traumatic stress disor- sexual abuse in women with chronic pelder and somatization. Early victimization vic pain suggests that inquiry into the may cause people to react to similar dan- psychosocial functioning of these patients gerous adult situations with dissociative is an important part of a comprehensive coping mechanisms that interfere with biopsychosocial evaluation of this disorthe ability to recognize and withdraw der. Integration of psychosocial assessfrom potential harm. Although the asso- ment early in the diagnostic evaluation ciation between childhood and adult vic- may assist the practitioner in formulating timization has long been clinically appre- a treatment plan that takes into account ciated, more research is necessary to de- not only the physical causes of pain but fine the mechanisms by which these early emotional and environmental factors that traumatic experiences can lead to pat- can sustain pain behavior. Management terns of recurrent victimization. of somatization can lead to cost-effective The increased psychological distress, care plans that reduce both inappropriate somatization, and high medical utiliza- utilization of medical care and long-term tion found in survivors of childhood sex- physical and emotional disability. ual abuse also lead to increased medical cost. Smith et al. (21] showed that over a This study was performed in coopera1-year period patients with somatization tion with the Center for Health Studies, disorder average 7.6 stays in the hospital Group Health Cooperative ofPuget Sound.
REFERENCES
1. Rimsza ME, Berg RA, Locke C: Sexual abuse: Somatic and emotional reactions. Child Abuse Negl 12:201-208, 1988
Psychosomatic Medicine 54:658-664 (1992)
663
E. A. WALKER 2. Briere J, Runtz M: Symptomatology associated with childhood sexual victimization in a nonclinical adult sample. Child Abuse Negl 12:51-59, 1988 3. Drossman DA, Leserman ), Nachman G, et al: Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Ann Intern Med 113:828-833, 1990 4. Morrison J: Childhood sexual histories of women with somatization disorder. Am J Psychiatry 146:239241, 1989 5. Arnold RP, Rogers D, Cook DA: Medical problems of adults who were sexually abused in childhood. Br Med J 300:705-708, 1990 6. Cunningham J, Pearce T, Pearce P: Childhood sexual abuse and medical complaints in adult women. J Interpersonal Violence 3:131-144, 1988 7. Gross R|, Doerr H, Caldirola D, et al: Borderline syndrome and incest in chronic pelvic pain patients. Int J Psychiatry Med 10:79-96, 1980-81 8. Reiter RC, Gambone JC: Demographic and historic variables in women with idiopathic chronic pelvic pain. Obstet Gynecol 75:428-432, 1990 9. Walker EA, Katon WJ, Harrop-Griffiths J, et al: Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. Am ) Psychiatry 145:75-80, 1988 10. Rapkin AJ, Kames LD, Darke LL, et al: History of physical and sexual abuse in women with chronic pelvic pain. Obstet Gynecol 76:92-96, 1990 11. Walker EA, Katon WJ, Hansom J, et al: Psychiatric diagnoses and childhood sexual abuse in women with chronic pelvic pain, submitted 12. Robins LN, Helzer JE, Croughan J, et al: National Institute of Health Diagnostic Interview Schedule. Arch Gen Psychiatry 38:381-389,1981 13. Von Korff M, Anthony JC: The NIMH diagnostic interview schedule modified to record current mental status. J Affect Disord 4:365-371, 1982 14. Andreasen NC, Endicott JE, Spitzer RL, et al: The family history method using diagnostic criteria: reliability and validity. Arch Gen Psychiatry 34:1229-1235,1977 15. Russell DEH: The Secret Trauma: Incest in the Lives of Girls and Women. New York, Basic Books, 1986 16. Wood DP. Wiesner MG, Reiter RC: Psychogenic pelvic pain: Diagnosis and management. Clin Obstet Gynecol 33:179-195, 1990 17. Reiter RC, Shakerin LR, Gambone JC, Milburn AK: Correlation between sexual abuse and somatization in women with somatic and nonsomatic chronic pelvic pain. Am J Obstet Gynecol 165:104-109,1991 18. Peters SD, Wyatt GE, Finkelhor D: Prevalence. In Finkelhor D. (ed), A Sourcebook on Child Sexual Abuse. Beverly Hills, Sage Publications, Inc. 1986; 15-59 19. Gold E: Long-term effects of sexual victimization in childhood. An attributional approach. J Consult Clin Psychol 54:471-475, 1986 20. Pennebaker JW: The psychology of physical symptoms. New York, Springer Verlag, 1982 21. Smith GR, Monson RA, Ray DC: Patients with multiple unexplained symptoms. Arch Int Med 146:6972, 1986
664
Psychosomatic Medicine 54:658-664 (1992)
INTRODUCTION
Over the last decade there has been an increasing awareness of the high prevalence of childhood sexual abuse in the general community and its impact on the psychosocial functioning of adult women.
From the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington (E.A.W., W.J.K., R.P.J.). Address reprint requests to: Dr. Edward A. Walker, Department of Psychiatry and Behavioral Sciences, University of Washington RP-10, Seattle WA 98195. Received for publication March 18, 1992; revision received August 3, 1992
658 0033-3174/92/5406-0658S03 00/0 Copyright © 1992 by ihe American Psycho
Although recent research has focused on short-term psychological and social adaptations to this trauma, surprisingly little is known about the long-term effects of such abuse, particularly its effect on subsequent medical utilization and the experience and reporting of physical symptoms. Several retrospective investigations have suggested an association between childhood sexual abuse and the later development of high medical utilization and multiple medical complaints (1-6), particularly chronic pelvic pain (6-9). The association between chronic pelvic pain and childhood sexual abuse remains controversial, however, since one study (10) Psychosomatic Medicine 54:658-664 (1992)
SEQUELAE OF CHILDHOOD SEXUAL ABUSE
found an association with physical but not compared with women without prior sesexual abuse. Unfortunately, most of vere childhood sexual abuse. these studies have been difficult to interpret due to methodological limitations such as small numbers of subjects, lack of METHOD control groups, the use of no-validated sexual abuse questionnaires and nonIn our prior study (11) we selected a sequential structured medical, psychiatric, or sexual sample of patients from the laparoscopy schedules abuse interviews. at our University Hospital, an urban OB/GYN priWe recently completed a study compar- vate practice, or Group Health Cooperative (a local ing the psychiatric and developmental health maintenance organization). The subjects histories of 50 women laparoscoped for were women who had either medically unexplained chronic pelvic pain for at least 6 months (N = 50), chronic pelvic pain and 50 women lapa- or were being laparoscoped for tubal ligation (N = roscoped for non-painful gynecological 32) or infertility evaluation (N = 18). None of the conditions (11). When compared with the women in the comparison group reported pelvic pain non-pain group, the women with chronic complaints prior to surgery or at the time of the interview. Interviews were completed within pelvic pain had significantly higher prev- study 20 months of the date of surgery. Approximately alences of current and lifetime depres- 75% of the women approached for the study agreed sion, somatization disorder, drug abuse to participate. and phobia, and significantly higher rates After obtaining informed consent we interviewed of medically unexplained symptoms the patients using the NIMH Diagnostic Interview Schedule (DIS) Version III-A. This is a structured across many organ systems despite no difinterview that makes valid and reliable ferences in objective laparoscopic find- psychiatric DSM-III diagnoses, and is widely used in psychiatric ings. The prevalence of childhood sexual epidemiology (12). We used an abridged version that abuse was significantly higher in the pain included the diagnoses most commonly found in group, and nearly all the severely abused primary care such as somatization disorder, panic, phobia, major depression, and alcohol and drug women had chronic pelvic pain. abuse. Interviewers are required to probe each posThe large number of subjects (N = 100) itive symptom, and to rate whether the symptom led in our study and the fact that they all had to medical consultation or impairment of life activistructured, physician-administered inter- ties, was due to alcohol or substance abuse, a mediside effect, or was the result of stress or views as well as very intensive medical cation psychiatric disorder. evaluations (including physical and lapaThe interviewers (J.H., L.H., M.J., and J.H.-G.) roscopic examinations) suggested to us were trained and supervised in the use of the DIS that a re-analysis of the patients' sexual by the senior psychiatrist (W.K.) and were blind to abuse histories might shed further light the indication for laparoscopy. Ten percent of the on the association between sexual abuse interviews were independently scored by a another (E.W.) with 100% agreement between and subsequent somatization. This report psychiatrist the psychiatrist and the four interviewers with reis a re-examination of our data from that spect to the patients' psychiatric disorders. The DIS prior study. We hypothesized that women section on major depression was changed to inquire with histories of severe childhood sexual more accurately about current symptoms of major (13). During the interview we inquired abuse would have significantly higher depression about current (1 month) and lifetime diagnoses for prevalences of lifetime psychiatric disor- the psychiatric disorders, and, in order to determine ders and a higher mean number of medi- whether subjects met criteria for more than one cally unexplained physical symptoms psychiatric diagnosis, we scored the DIS to allow the Psychosomatic Medicine 54:658-664 (1992)
659
E. A. WALKER TABLE 1. Odds Ratios of Current and Lifetime Psychiatric Diagnoses in Women with and without Severe Childhood Sexual Abuse Histories
Current diagnoses Major depression Chronic pelvic pain Lifetime diagnoses Major depression Panic Phobia Somatization D/O Alcohol abuse Drug abuse Functional dyspareunia Inhibited sexual desire Inhibited orgasm
Severe Abuse (N = 14) N (%)
Nonsevere or No Abuse (N = 86) N (%)
Odds Ratio
95% Confidence Interval
5(36) 12(86)
9(10) 2(14)
4.8 7.6
1.3-17.3 1.6-36.0
12(86) 5(36) 8(57) 5(36) 5(36) 9(64) 6(43) 4(29) 3(21)
31 (36) 1 (D 15(17) 2 (2) 21 (24) 20(23) 20(23) 14(16) 11 (13)
10.6 47.2 6.3 23.3 1.7 5.9 2.5 2.1 1.9
2.2-50.7 5.0-450.0 1.9-20.9 4.0-138.1 0.5-5.7 1.8-19.8 0.8-8.0 0.6-7.5 0.4-7.7
maximum number of valid DSM-III psychiatric diagnoses with no exclusion criteria. We then interviewed the patients using a structured family history interview (14) and a 14-question structured sexual assault instrument previously used in large community epidemiologic studies (15). Women were characterized as having no abuse, less severe childhood abuse (exhibitionism, aborted attempts before age 14), or more severe childhood abuse (incest, rape, oral contact, or repeated fondling before age 14). For the purpose of this analysis, we pooled the 50 women reporting pain with the 50 who did not report pain and examined the lifetime psychiatric diagnoses and somatization patterns of women with and without histories of severe childhood sexual abuse. For clinical usefulness we first computed unadjusted odds ratios with 95% confidence intervals for selected psychiatric diagnoses. We then attempted to control more carefully for confounding and interactions between the variables by calculating a logistic regression analysis using severe childhood abuse as a dependent variable. As independent variables we used lifetime diagnoses of major depression, panic disorder, drug and alcohol dependence, chronic pain, mean number of somatization symptoms, mean number of psychiatric diagnoses, age, marital status, and socioeconomic status. We also computed interaction terms including lifetime depression by all other variables, and age by all other variables.
660
RESULTS Of the 100 women in the study 56 (56%) reported no childhood sexual abuse, 30 (30%) reported less severe abuse, and 14 (14%) reported more severe abuse. There were no significant differences between the no abuse and less severe abuse groups on any of the demographic or psychiatric independent variables with the exception of number of medically unexplained somatization symptoms (no abuse 3.4 ± 4.2; less severe 5.7 ± 3.7; t = 2.39; df = 84; p < 0.02), so we combined them into a single group for the purposes of this analysis. For clinical usefulness we computed unadjusted odds ratios and 95% confidence intervals for several selected psychiatric diagnoses comparing women with and without histories of severe childhood sexual abuse (Table 1). The risk for lifetime diagnoses of major depression, panic disorder, phobia, somatization disorder and drug abuse, and current diagnoses of major depression and somatoPsychosomatic Medicine 54:658-664 (1992)
SEQUELAE OF C H I L D H O O D SEXUAL ABUSE
form pain disorder was significantly higher in the severe abuse group. A logistic regression approach to control for confounding showed that main predictors of a history of severe sexual abuse were the number of medically unexplained symptoms, and lifetime histories of drug abuse and panic disorder (Table 2). Chronic pain history and socioeconomic factors were not significantly associated. The model yielded a sensitivity of 36%, a specificity of 99%, and a positive predictive value of 83%. We also calculated the positive predictive value of a history of severe childhood sexual abuse for the later development of chronic pelvic pain by identifying patients with both disorders. Twelve of the 14 women with severe childhood abuse also had chronic pelvic pain yielding a positive predictive value of 86%, with a specificity of 96% and a sensitivity of 24%. In addition to the high frequency of childhood sexual abuse many of the subjects also reported abuse as adults (after age 14). Of the 100 patients in the study, 61% reported no adult sexual abuse, 11% less severe abuse, and 28% more severe forms of abuse after the age of 14. There was a significant correlation between severe childhood abuse and subsequent se-
vere forms of adult sexual abuse (r = 0.46, p < 0.01), and the positive predictive value of severe childhood abuse for later adult sexual abuse was 79%.
DISCUSSION The women in this study who experienced less severe forms of childhood sexual abuse were not significantly different from those who had experienced no abuse. However, when compared with women who reported a history of less severe or no sexual abuse, the women in this study with severe abuse were significantly more likely to have multiple medically unexplained physical symptoms and lifetime histories of drug abuse and panic disorder. In addition, computation of unadjusted odds ratios suggests that these women with severe childhood abuse are significantly more likely to have several other psychiatric disorders as well. Differences between the odds ratios and the logistic regression procedure are due to the fact that the logistic regression removed the influence of variables highly correlated with the variables entered into the regression equation. Thus, although it
TABLE 2. Logistic Regression Analysis of Socioeconomic and Psychiatric Variables in Women with and without Histories of Severe Childhood Sexual Abuse
Intercept # Medically unexplained symptoms Lifetime panic disorder Drug and alcohol dependence
Beta
SE
Wald t
Odds
95% Confidence Interval
-3.8593 1.9542
0.8033 0.8522
23.1 5.3
7.1
1.33-37.51
2.7469 1.3618
1.2192 0.7225
5.1 3.6
15.6 3.9
1.43-170.12 0.95-16 09
The following variables made nonsignificant contributions to the logistic regression: lifetime depression, chronic pain, number of psychiatric diagnoses, age, marital status, socioeconomic status.
Psychosomatic Medicine 54:658-664 (1992)
661
E. A. WALKER is clinically useful to know that women with severe abuse have a 10-fold risk for lifetime major depression, the significant correlation of major depression with somatization removes major depression from the final regression equation due to the magnitude of the effect provided by somatization. Recently, several studies have suggested a possible association between childhood sexual abuse and the subsequent development of medically unexplained physical symptoms (1-6), particularly chronic pelvic pain (6, 7, 16, 17). Rapkin et al. (10) showed that physical but not sexual abuse was more prominent in 31 women with chronic pelvic pain compared with 142 women with chronic pain in other locations and 32 pain-free controls. While these studies suggest that early sexual abuse may play a role in the subsequent development of high medical utilization, unexplained physical complaints- and chronic pelvic pain, several are methodologically limited by their absence of controls and small sample size (5-7), and for failure to meet the current methodologic standards for psychiatric and sexual abuse research with respect to the use of validated interview instruments (1-4, 6, 8, 10, 16). The use of selfreport questionnaires and interviews of untested reliability and validity have been shown to reduce the accuracy of sexual abuse reporting (18). Despite the limitations of these earlier reports, the present study confirms the observations of an association between childhood sexual abuse and subsequent medical symptoms by using a larger sample, a comparison group without history of sexual abuse, and physician-administered, validated, structured interviews for the medical, psychiatric, and sexual abuse histories. Care should be taken, 662
however, in generalizing these findings beyond this study since the selection of this sample from a medical clinic laparoscopy schedule was to test another hypothesis. Nevertheless, the sample was sequential and non-biased, and we believe that the results of this analysis suggest that further study of this association is warranted. Does early childhood sexual abuse predispose a woman to develop subsequent somatization and chronic pelvic pain? Sexual and physical abuse are frequently markers for serious family distress and the failure of parents to provide an adequate, predictable, and protective environment for children. The study of Rapkin et al. (10) demonstrated that physical abuse is common in patients with chronic pelvic pain, and Drossman et al. (3) found in his sample of female patients with gastrointestinal (GI) diagnoses that all but one of the women who were sexually abused were physically abused as well. Gold (19) has shown in a community sample that depression, sexual dysfunction, and social problems are long-term psychological sequelae of early sexual abuse. The severity of these disabilities was most strongly associated with an attributional style of learned helplessness or an expectation of having little or no control over the environment. This suggests that chronic, severe abuse (emotional, physical, or sexual), and a highly insecure, unpredictable family life are likely to result in the development of multiple maladaptive responses including increased medical utilization and somatization. Somatization is highly correlated with personal psychological distress, the psychological trait of neuroticism and a tendency to have an external locus of control (20). Thus, patients with somatization often perceive that they have little control Psychosomatic Medicine 54:658-664 (1992)
SEQUELAE OF CHILDHOOD SEXUAL ABUSE
over their world and that their lives are and 13.0 visits to outpatient clinics. Total directed by powerful external forces (or health care charges over 1 year averaged people). Somatization may provide pa- $4,700 in 1980 dollars, or nine times the tients who have been victims of unpre- U.S. per capita personal health care exdictable early environments and a sense penditure. Laparoscopy alone costs apof personal powerlessness with a safe way proximately $2500 and carries a risk of of describing their chronic distress, in- iatrogenic injury. The findings of this creased support from physicians and fam- study imply the need for studies of psyily and a way of leveraging interpersonal chological interventions in patients with histories of sexual abuse in an attempt to relationships. The high correlation between child- decrease distress, functional disability, sohood and adult sexual abuse suggests that matization, and high medical utilization. the impact of early traumatic experiences If these intervention strategies are succan be long lasting. Adults who have been cessful they are likely to lead to cost offset physically and sexually victimized as effects due to the high cost of these pachildren are at increased risk for high tients to the medical system. levels of psychological distress, dissociaThe presence of high rates of childhood tive episodes, post-traumatic stress disor- sexual abuse in women with chronic pelder and somatization. Early victimization vic pain suggests that inquiry into the may cause people to react to similar dan- psychosocial functioning of these patients gerous adult situations with dissociative is an important part of a comprehensive coping mechanisms that interfere with biopsychosocial evaluation of this disorthe ability to recognize and withdraw der. Integration of psychosocial assessfrom potential harm. Although the asso- ment early in the diagnostic evaluation ciation between childhood and adult vic- may assist the practitioner in formulating timization has long been clinically appre- a treatment plan that takes into account ciated, more research is necessary to de- not only the physical causes of pain but fine the mechanisms by which these early emotional and environmental factors that traumatic experiences can lead to pat- can sustain pain behavior. Management terns of recurrent victimization. of somatization can lead to cost-effective The increased psychological distress, care plans that reduce both inappropriate somatization, and high medical utiliza- utilization of medical care and long-term tion found in survivors of childhood sex- physical and emotional disability. ual abuse also lead to increased medical cost. Smith et al. (21] showed that over a This study was performed in coopera1-year period patients with somatization tion with the Center for Health Studies, disorder average 7.6 stays in the hospital Group Health Cooperative ofPuget Sound.
REFERENCES
1. Rimsza ME, Berg RA, Locke C: Sexual abuse: Somatic and emotional reactions. Child Abuse Negl 12:201-208, 1988
Psychosomatic Medicine 54:658-664 (1992)
663
E. A. WALKER 2. Briere J, Runtz M: Symptomatology associated with childhood sexual victimization in a nonclinical adult sample. Child Abuse Negl 12:51-59, 1988 3. Drossman DA, Leserman ), Nachman G, et al: Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Ann Intern Med 113:828-833, 1990 4. Morrison J: Childhood sexual histories of women with somatization disorder. Am J Psychiatry 146:239241, 1989 5. Arnold RP, Rogers D, Cook DA: Medical problems of adults who were sexually abused in childhood. Br Med J 300:705-708, 1990 6. Cunningham J, Pearce T, Pearce P: Childhood sexual abuse and medical complaints in adult women. J Interpersonal Violence 3:131-144, 1988 7. Gross R|, Doerr H, Caldirola D, et al: Borderline syndrome and incest in chronic pelvic pain patients. Int J Psychiatry Med 10:79-96, 1980-81 8. Reiter RC, Gambone JC: Demographic and historic variables in women with idiopathic chronic pelvic pain. Obstet Gynecol 75:428-432, 1990 9. Walker EA, Katon WJ, Harrop-Griffiths J, et al: Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. Am ) Psychiatry 145:75-80, 1988 10. Rapkin AJ, Kames LD, Darke LL, et al: History of physical and sexual abuse in women with chronic pelvic pain. Obstet Gynecol 76:92-96, 1990 11. Walker EA, Katon WJ, Hansom J, et al: Psychiatric diagnoses and childhood sexual abuse in women with chronic pelvic pain, submitted 12. Robins LN, Helzer JE, Croughan J, et al: National Institute of Health Diagnostic Interview Schedule. Arch Gen Psychiatry 38:381-389,1981 13. Von Korff M, Anthony JC: The NIMH diagnostic interview schedule modified to record current mental status. J Affect Disord 4:365-371, 1982 14. Andreasen NC, Endicott JE, Spitzer RL, et al: The family history method using diagnostic criteria: reliability and validity. Arch Gen Psychiatry 34:1229-1235,1977 15. Russell DEH: The Secret Trauma: Incest in the Lives of Girls and Women. New York, Basic Books, 1986 16. Wood DP. Wiesner MG, Reiter RC: Psychogenic pelvic pain: Diagnosis and management. Clin Obstet Gynecol 33:179-195, 1990 17. Reiter RC, Shakerin LR, Gambone JC, Milburn AK: Correlation between sexual abuse and somatization in women with somatic and nonsomatic chronic pelvic pain. Am J Obstet Gynecol 165:104-109,1991 18. Peters SD, Wyatt GE, Finkelhor D: Prevalence. In Finkelhor D. (ed), A Sourcebook on Child Sexual Abuse. Beverly Hills, Sage Publications, Inc. 1986; 15-59 19. Gold E: Long-term effects of sexual victimization in childhood. An attributional approach. J Consult Clin Psychol 54:471-475, 1986 20. Pennebaker JW: The psychology of physical symptoms. New York, Springer Verlag, 1982 21. Smith GR, Monson RA, Ray DC: Patients with multiple unexplained symptoms. Arch Int Med 146:6972, 1986
664
Psychosomatic Medicine 54:658-664 (1992)
