Dissociation,Abuse and the Eating Disorders: Evidence from an Australian Population

Abstract

Objective: Anumber of European and Northern American studies have investigated a possible association between dissociative phenomena, eating disorders, child sexual abuse and self-mutilation. However, there has been little confirmation from other countries and cultures, and the Australian experience of these interrelationships has not previously been studied.

Method: Dissociative symptomatology and self-reported history of abusive experiences, physical and sexual, were retrospectively studied in a sample of Australian eating disordered patients using a self-report measure, the Dissociation Questionnaire (DIS-Q).

Results: As hypothesised, dissociative symptoms were particularly frequent in those who reported child and adult sexual abuse and in those who self-mutilated. A correlation between multiple forms of abuse and higher dissociation scores was only partially upheld.

Conclusions: Interrelationships between victimisation and dissociation are discussed within the context of current knowledge in the field, and brief suggestions for therapeutic strategies are offered.

A possible role for dissociation, either as an aetiological factor or an epiphenomenon in the dieting disorders, has been developed from earlier work in the 1980s revealing higher hypnotic capacity in bulimic patients compared to their anorexic counterparts, both restrictive and purging [1–2]. As an outgrowth of this, anecdotal reports emerged recommending the use of hypnotherapeutic techniques in the management of eating disorders, particularly for bulimia nervosa [3–4].

More recently, various authors commented that the binge-purge cycle of some bulimic patients occurs during a dissociated state or actually serves to create a dissociated state [5–7]. In addition, possible interrelationships between self-destructive behaviour, dissociation, abnormal eating and borderline personality disorder have also been described in the literature, raising questions about whether dissociation might be the common pathway in which intolerable affects are translated into clinical symptomatology [8–10].

In one such model [7], binge-eating behaviour is thought to represent a form of auto-hypnosis in which intense narrowing of focus and heightened concentration on the task of eating induces numbing and relieves the rising tension and dysphoric affects so often described prior to bingeing. Purging then both ablates the negative consequence of feared weight gain and itself provides a sense of soothing, cleansing and relief.

The potential defensive functions of dissociation in dealing with trauma-related dysphoric affects have been expanded in a number of well-designed studies which offer support for a relationship between dissociation, eating dysfunction and a history of child sexual abuse [5], [6], [8], [9] or child physical abuse [8],[11]. Dissociation has also been linked to the actual frequency of bingeing [9] and unhealthy eating attitudes in non-clinical populations [12].

Studies thus far have generally used the widely validated Dissociative Experiences Scale (DES) [13] and most samples are limited to Northern American and British populations. More recently, Vanderlinden, Van Dyck, Vandereycken and Vertommen developed a self-report instrument for use in European populations [14] and demonstrated significantly higher scores on the Dissociation Questionnaire (DIS-Q) for eating disordered patients compared to normal controls [15]. In a subsequent sample [16], these authors found that around 12% of eating disordered patients achieved similar scores to patients with dissociative disorders, compared to only 1% of a general population control group.

Working in the setting of a specialised eating disorders unit, we have also noted a clinical association between a self-reported history of abuse, eating dysfunction, dissociative symptoms and self-mutilation. We hypothesised that self-reported physical and sexual victimisation would be positively correlated with dissociative phenomena as measured by the DIS-Q, not previously used in an Australian population to our knowledge. Along with these better documented connections, we chose to also focus our study on child physical and adult sexual abuse, abuse types which have been less well described in this population.

Even less emphasis has been placed on those victims who have suffered multiple forms of abuse, thought to be a more usual situation than occurrences of one abuse type alone [17],[18]. In this regard, little is understood about the effect that such ‘multiabuse’ might have on dissociation. Given our clinical impression of these patients as being more severely affected in terms of dissociative psychopathology, we postulated that there might be an additive effect with higher total dissociation scores for increasing numbers of abuse types.

Method

Participants and the procedure

Details of this larger study of abusive experiences in patients with eating disorders have been described elsewhere [19]. Briefly, the eating disordered sample was drawn from a specialised inpatient program in a University of Sydney-associated private psychiatric hospital. Consecutively admitted patients over the age of 18 years with anorexia or bulimia nervosa (DSM-III-R) were included, as well as those missing one criteria but clinically diagnosed with a dieting disorder of either type (eating disorder not otherwise specified). Those with an eating problem secondary to another major psychiatric disorder (e.g. schizophrenia or organic brain disease) were excluded. Underweight anorexics were first re-fed to their goal weight range and those maintaining weight were examined towards the end of their hospital admission.

Procedure involved subjects completing a package of self-report questionnaires introduced by a covering letter which noted that the study involved questions regarding ‘traumatic experiences’ as well as more general questions regarding eating behaviours. Approval for the study was obtained from the hospital ethics committee. Thirty-eight of 40 suitable inpatients agreed to enter the study, giving a participation rate of 95%.

In addition, patients admitted since the unit opened in November 1990 (in fact ‘ex’ patients rather than all being current outpatients) were also surveyed by mail. As many as could be contacted were telephoned to ask for oral consent. Of 185 past patients to the unit (over 18 years of age), 30 patients were uncontactable, 27 refused involvement before knowing the study topic and 49 subjects did not return the questionnaires despite mailed reminders. These three subsets did not differ from the responders on demographic date, diagnosis or illness characteristics such as body mass index (BMI) or number of previous admissions. A chart review for all such subjects revealed a relevant history of childhood sexual abuse in around 30%. Overall 79 (43%) of the potential past patient group participated.

Measures

Finkelhor Sexual Life Events Inventory (SLEI) [20]

Used in a number of studies of sexual abuse and eating disorders [21–23], the SLEI is a self-report inventory focusing on sexual experiences in childhood and unwanted experiences in adulthood. By using the originator's definitions, a history of childhood sexual abuse (CSA) included any sexual experience aged 15 or younger with someone at least 5 years older, or if the age gap was less, when experiences were rated as negative, unwanted or forced. Adult sexual abuse (ASA) was defined as any unwanted sexual experience above the age of 16 years. As there are no established criteria for the physical violence aspect of the scale [Finkehlor D: personal communication], we defined child physical abuse (CPA) as, at minimum, ‘hitting really hard, kicking, punching, stabbing or throwing someone down’ whether administered as discipline or not, at least 10 times yearly at age 12.

Dissociation Questionnaire (DIS-Q) [15]

Drawing on previously developed measures of dissociation, this 63-item, self-report inventory was designed for use in both clinical and non-clinical populations as a screening measure rather than a diagnostic instrument. Reliability and validity data have been described by its authors [15]. The DIS-Q gives a total scale score and four subscales: (i) identity confusion and alteration (referring to derealisation, depersonalisation and dissociated alter personalities); (ii) loss of control (i.e. impulsiveness); (iii) amnesia (referring to experiences of memory lacunae); and (iv) absorption (referring to experiences of enhanced concentration). Scores are all average scores (i.e. the total sum divided by the number of items).

Methods

Demographics

A total of 117 patients, 38 inpatients and 79 outpatients, formed the eating disordered sample. One each of the two groups were male and the remainder of the total sample, female.

The age range for the total sample was 18–47 years. The mean was 25.7 years (SD = 6.6) for the inpatients and 24.2 years (SD = 6.7) for the outpatient group. No significant differences in age, marital status or education were found between inpatients and outpatients, with a majority being single (76% and 68%, respectively, p > 0.05) and having received some kind of tertiary education (84% and 74%, respectively, p > 0.05).

Prevalence rates

Around 45% (n = 17) of the inpatients reported CSA, 34% CPA (n = 13) and 26% ASA(n = 10). For outpatients, these figures were 51% (n = 40), 16% (n = 13) and 30% (n = 24), respectively. Comparison revealed no significant differences in prevalence between inpatient and outpatient groups for CSA; however, for CPA, a significantly higher prevalence rate was found for inpatients versus outpatients (X ² = 5.1, df = 1, p < 0.03). For ASA, there were no significant differences between the groups.

Of the 75 abused eating-disorder patients, 45 subjects (60%) had experienced one abuse type only, 12 had experienced both CSA and ASA (16%), one subject reported CPA and CSA (1%), seven subjects reported CPA and CSA(9%) and 10 reported all three types of abuse (13%). Overall, 30 (40%) of abused eating-disorder subjects described more than one type of abuse. No significant differences were found between in- and outpatient groups with respect to combinations of abuse (p > 0.05).

Dissociation scores

In general, the mean scores for the total and four subscales of the DIS-Q were comparable to those in eating disordered samples described by Vanderlinden's group [16]. Details are listed in Table 1.

Table 1.

Dissociation Questionnaire (DIS-Q) scores for eating-disorder patients

No significant differences were found between inpatient versus outpatient groups on either the total or subscale scores with the following results combining the two groups, divided into abused versus non-abused for each of the three abuse types. A series of one-way analyses of variance (ANOVA) were then performed to study possible correlations between abuse status and dissociation scores. For the total score average, highly significant correlations were found between both sexual abuse categories and higher scores on the DIS-Q (F_1,110 = 16.07, p < 0.0002) for CSA and (F_1,110 = 14.39, p < 0.0004) for ASA with CPAjust missing significance (F_1,110 = 3.78, p < 0.06). For the four subscales, correlations between DIS-Q scores and both CSA and ASA were also highly significant. For subjects experiencing CPA, only the identity confusion subscale reached significance. These findings are outlined in Table 2.

Table 2.

Dissociation Questionnaire (DIS-Q) scores for reported abuse status in eating-disorder patients

Combinations of abuse

For the DIS-Q total scale score and all subscales, excepting loss of control, those who had suffered either one, two or three types of abuse had significantly higher mean scores compared to those rated as ‘no abuse’ using a series of modified LSD (Bonferroni) tests at the 0.05 level of significance. Significantly higher mean scores were found for those reporting all three abuse types compared to those reporting only one type (but not three vs two types) of abuse for the total score and for the amnesia, identity-confusion and absorption subscales. No such difference was found in this regard for the loss of control subscale. For all parameters but the identity-confusion subscale, a finding of significantly higher scores was found for those reporting all three abuse types compared to those reporting only one type of abuse. Details are listed in Table 3.

Table 3.

Dissociation Questionnaire (DIS-Q) scores and combinations of abuse

Diagnosis and dissociation scores

Eating disordered subjects were diagnosed according to DSM-III-R criteria and further categorised as anorexia nervosa (BMI less than 17.5), restrictive subtype (n = 41), those with both anorexia and bulimia (n = 19), normal weight bulimia (n = 43), and eating disorder not otherwise specified (EDNOS) (n = 11). Diagnostic reliability was determined by retrospective chart review. Three anonymous subjects were unable to be classified.

Regarding diagnostic subtype, findings are reported for the in- and outpatient groups collapsed together (no significant differences were found between the groups), comparing the abused group versus the non-abused subjects. A Chi-squared analysis revealed no significant association between the four subtypes of eating disorder and the three abuse types (p > 0.05).

No subtype of diagnosis was associated with higher scores for the total scale score or for any of the subscales of the DIS-Q excepting that for loss of control which was higher for those with anorexia/bulimia, compared to those with restrictive anorexia (p = 0.04). Intermediate scores were found for normal weight bulimia and EDNOS. Details are outlined in Table 4.

Table 4.

Diagnostic subtypes and Dissociation Questionnaire (DIS-Q) scores

Self-harm and dissociation

A history of self-mutilation was defined as deliberate acts of self-harm such as cutting, burning or hitting oneself, but without suicidal intent. This feature, as assessed by clinical questioning and chart review, was significantly associated with higher DIS-Q total scores (F_1,112 = 8.3, p < 0.006) and this trend was also present for the subscales of amnesia (F_1,112 = 10.1, p < 0.003), loss of control (F_1,112 = 8.6, p < 0.005), identity confusion (F_1,112 = 5.04, p < 0.004) and absorption (F_1,112 = 6.6, p < 0.02). Self-harm status was uncertain for five subjects who were excluded from this analysis.

Furthermore, while self-harm was not associated with ASA (p > 0.05), a significant correlation was found with CPA (χ² = 4.9, df = 1, p < 0.04) and CSA (χ² = 5.12, df = 1, p < 0.03).

Discussion

Our findings confirm that symptomatic dissociation is common in eating disordered patients and more specifically in those who report a history of sexual abuse, both child and adult, rather than child physical abuse.

Vanderlinden and colleagues [16] were surprised by high amnesia scores on the DIS-Q for physical abuse and query whether this abuse type is dissociated to a greater extent than other traumatic experiences. In contrast, we found a much higher prevalence rate for CPA and high scores only for the subscale of absorption, arguably a less pathological aspect of dissociation and one which occurs frequently in the normal population [15].

Even less interest has been directed towards those who have experienced adult sexual abuse. Highly significant findings for this group also, suggest that although dissociation may well be a sensitive marker for a trauma history, it may not differentiate between different types of abuse. Why adult sufferers should experience such high scores is not so surprising, given that evidence of this coping mechanism has been well described after traumatic events (e.g. in rape victims) [24–26]. Alternatively, a significant number of subjects had experienced multiple forms of abuse which might be adding their own contributions to these scores. Unfortunately, small numbers in this survey preclude more accurate statistical evaluation at this point.

That no significant difference was found for dissociative scores between diagnostic groups was a surprising finding, given a number of reports indicating higher scores for bulimic patients, particularly for those who purge and atypical patients [16],[23]. Only the ‘loss of control’ subscale correlated with a mixed diagnosis of anorexia/bulimia, a finding which could be justified on clinical grounds. However, our findings are similar to those of Oppenheimer et al. [21] and Hall et al. [26], who found no such association.

Our hypothesis that combinations of abuse types would elevate dissociative scores was partly supported. Although there was no linear or direct correlation with increased scores, there did appear to be a general trend towards multiple forms of abuse increasing DIS-Q scores. Replication with larger numbers might clarify the role of multiple forms of abuse and neglect in this regard; studying such combinations is an area often hampered by the difficulties in classifying individuals in a more complicated, but undoubtedly more realistic fashion.

That the behavioural disturbance of self-mutilation was so significantly correlated with both total and subscale scores of the DIS-Q suggests that this instrument may be a valuable screen for those at risk of self-harm. Given that our classification was based on simple clinical ratings, such a finding further supports the importance of this increasingly recognised association.

That the inpatient and outpatient patient groups were not significantly different on most measures, including those of the DIS-Q, is an interesting finding given that the latter group had been discharged at varying times over the last 2 years. Although aware that this might make any comparison difficult [Vanderlinden J: personal communication], we did find much more in the way of similarities than might be expected for a currently versus previously hospitalised population. However, recovery from eating disorders takes several years on average [27], so that this group's scores in terms of eating dysfunction, and possibly other parameters, may ‘move’ quite slowly towards improvement. Alternatively, dissociation may represent a trait rather than a state phenomenon in eating disordered patients.

By using the cut-off of 2.9 for the total score, suggested by the authors to signify a likely dissociative disorder, 13 eating-disorder patients (11%) fell into this category. Until larger numbers are studied, this difference cannot be evaluated statistically, nonetheless, this figure is remarkably concordant with that found by Vanderlinden's group [16]. Using a structured clinical interview, McCallum et al. [8] found an even higher incidence of dissociative disorders (29%) in a sample of 38 women with eating disorders. In our survey, two of these high scoring subjects met DSM-III-R criteria for dissociative identity disorder and a further three met criteria for dissociative disorder not otherwise specified. Overall, our results tend to confirm the findings of our Northern Hemisphere counterparts and like them, we would suggest the first step must be accurate diagnosis of pathological dissociation. In this regard, the DIS-Q was a useful screen. Once recognised, the patient can be educated about their own defensive use of dissociation, its origin as an adaptive, ‘survival’ mechanism and its evolution into a pervasive and dysfunctional way of coping with trauma. As noted by Levin and Spauster [28], failure to address the dissociative pathology as well as the abuse issues may lead to a treatment impasse. These patients might then be viewed as recalcitrant and difficult to treat, precisely because ‘fogging’, ‘clouding’ or lack of emotional presence would be likely to inhibit new learning. Various expressive, hypnotic and cognitive—behavioural techniques, used for the more general management of sexual abuse can be tailored to fit with that for both the eating disorder and dissociative diagnoses [28]. Not infrequently, we have found that disclosure, or discussion of known abuse, triggers overwhelming affects or dissociative ‘numbing’; either may be maladaptively acted out in cutting, burning or other self-harming behaviour. Our own experience is that working on both issues concurrently, especially when a patient is underweight or malnourished, may overload existing defence mechanisms and exacerbate more primitive dissociative ones [29]. Pacing this work and respecting the individual's own protective mechanisms is paramount in the healing process. Patients can be taught so-called ‘grounding’ techniques by learning to recognise early signs of dissociation such as visual field constriction, fogginess and difficulty attending to current stimuli. Awareness of decreased attention and ‘forgetting’ in both individual and group sessions can then be addressed and interpreted to patients, ideally with a follow through effect on changes to abnormal eating behaviours, improved awareness of bodily sensations such as hunger and satiation and to a better sense of connectedness between body and self.

Conclusions

In conclusion, anorexia and bulimia may become a positively reinforcing defensive pseudo-solution, with dissociation as one potentially maladaptive coping mechanism. Recognition of the potential role of dissociation as a mediating factor between abuse and eating disorder will hopefully lead to treating both eating disorder and pathological dissociation to better outcomes.

Footnotes

Acknowledgements

This research was initially supported by a Grant-in-Aid from the Board of Research, Royal Australian and New Zealand College of Psychiatrists (RANZCP) and subsequently by a New South Wales Institute of Psychiatry Fellowship. A draft of this paper was presented at the 33rd RANZCP Annual Conference, Melbourne 1998

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