Article                                                                             Table of Contents                     ...
Douglas A. Drossman, MD; Nicholas J. Talley, MD; Jane Leserman, PhD; Kevin W. Olden, MD; andMarcelo A. Barreiro, MD, MSc15...
Methods                                                                                Top                                ...
There is evidence that more persons report abuse when definitions include questions based onbehavior (for example, "Has an...
experiences. Investigators should recognize that concurrent psychosocial difficulties affect reportingtendencies.Relations...
victims were compared with the group that had not been abused, significant differences were noted forreports of gastrointe...
The frequency of sexual abuse was greater in patients with functional lower gastrointestinal tractdisorders than in those ...
sexually abused had an increased risk (odds ratio) for the irritable bowel syndrome of 1.9 (CI, 1.2 to3.0) and a risk of 1...
significantly higher in persons with a history of any type of abuse (odds ratio, 1.4 [CI, 1.0 to 2.0]),sexual abuse (odds ...
Psychophysiologic effects: Psychological distress can, through the central nervous system-entericnervous system [53] or au...
Risk Factors for Abuse History among Patients with GastrointestinalIllnessSeveral clinical features increase the likelihoo...
is disproportionate to the clinical data, seeks to validate disease (often excluding a role forpsychological factors), pla...
improves the response rate and preserves the therapeutic relationship and the patients right not todisclose this informati...
The Role of the Mental Health ConsultantWe recognize that addressing the psychological difficulties patients have in copin...
Because many patients consider mental health referral a rejection by the medical physician, their careis best managed by a...
If local organizations are not available, several national organizations can provide information andreferrals for physicia...
References                                                                               Top                              ...
15. Joachim G, Milne B. Inflammatory bowel disease: effects on lifestyle. J Adv Nurs. 1987;12:483-7.16. Briere J, Runtz M....
32. Leroi AM, Bernier C, Watier A, et al. Animus, sexual abuse and functional lower gastrointestinaltract disorders. Gastr...
50. Miller BA, Downs WR, Gondoli DM. The role of childhood sexual abuse in the development ofalcoholism in women. Violence...
69. Toner BB, Koyama E, Garfinkel PE, Jeejeebhoy KN, Gasbarro I. Social desirability and irritablebowel syndrome. Int J Ps...
90. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV.4th ed. Washington, D.C...
This article has been cited by other articles:       U. Pikarinen, T. Saisto, B. Schei, K. Swahnberg, and E. Halmesmaki   ...
[Abstract] [Full Text] [PDF]Y Ringel, W E Whitehead, B B Toner, N E Diamant, Y Hu, H Jia, S IBangdiwala, and D A DrossmanS...
[Abstract] [Full Text] [PDF]A. E. WALLER, S. L. MARTIN, and M. L. ORNSTEINHealth Related Surveillance Data on Violence Aga...
Article                                                                             Table of Contents                     ...
1.1Sexual and Physical Abuse and Gastrointestinal Illness: Review and        Recommendations Douglas A. Drossman, MD; Nich...
medical and psychiatric illness, the data for gastrointestinal clinical populations are limited and will notbe discussed.M...
The Operational DefinitionThere is evidence that more persons report abuse when definitions include questions based onbeha...
Gastro-intestinal illness review, Drossman
Gastro-intestinal illness review, Drossman
Gastro-intestinal illness review, Drossman
Gastro-intestinal illness review, Drossman
Gastro-intestinal illness review, Drossman
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Gastro-intestinal illness review, Drossman
Gastro-intestinal illness review, Drossman
Gastro-intestinal illness review, Drossman
Gastro-intestinal illness review, Drossman
Gastro-intestinal illness review, Drossman
Gastro-intestinal illness review, Drossman
Gastro-intestinal illness review, Drossman
Gastro-intestinal illness review, Drossman
Gastro-intestinal illness review, Drossman
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Gastro-intestinal illness review, Drossman

  1. 1. Article Table of Contents Abstract of this article Advertisement Figures/Tables List Related articles in Annals Articles citing this article Services Send comment/rapid response letter Notify a friend about this article Alert me when this article is cited Add to Personal Archive Download to Citation Manager ACP Search PubMed Articles in PubMed by Author: Drossman, D. A. Barreiro, M. A. Related Articles in PubMed PubMed Citation PubMed Search Annals: Advanced search Home | Current Issue | In the Clinic | Past Issues | Search | Collections| CME | PDA Services | Subscribe | Contact Us | Help | ACP OnlineREVIEW1.Sexual and Physical Abuse and GastrointestinalIllness: Review and Recommendations
  2. 2. Douglas A. Drossman, MD; Nicholas J. Talley, MD; Jane Leserman, PhD; Kevin W. Olden, MD; andMarcelo A. Barreiro, MD, MSc15 November 1995 | Volume 123 Issue 10 | Pages 782-794Objectives: To summarize the existing data on abuse history and gastrointestinal illness, suggest aconceptual scheme to explain these associations, suggest ways to identify patients at risk, and provideinformation about mental health referral.Data Sources: Review of the pertinent literature by clinicians and investigators at referral centers whoare involved in the care of patients with complex gastrointestinal illness and who have experience inthe diagnosis and care of patients with abuse history in these settings.Study Selection: All research articles and observational data that addressed abuse history ingastroenterologic settings. Articles were identified through a MEDLINE search.Data Extraction: Independent extraction by multiple observers.Data Synthesis: On the basis of literature review and consensus, it was determined that abusehistory is associated with gastrointestinal illness and psychological disturbance; appears more oftenamong women, patients with functional gastrointestinal disorders, and patients seen in referralsettings; is not usually known by the physician; and is associated with poorer adjustment to illness andadverse health outcome.Although the mechanisms for this association are unknown, psychological factors (somatization,response bias, reinforcement of abnormal illness behavior) and physiologic factors (psychophysiologicresponse, enhanced visceral sensitivity) probably contribute. On the basis of these data,recommendations are made on how to identify patients at risk, how to obtain this information, and, ifneeded, how to make appropriate referrals.Conclusions: The authors agree with existing data on the association between abuse history andgastrointestinal illness. Physicians should ask patients with severe or refractory illness about abusehistory. Appropriate referral to a mental health professional may improve the clinical outcome.In recent years, the lay media and the scientific community have addressed the frequency of sexualand physical abuse in U.S. society. Psychologists and psychiatrists now recognize several psychiatricsyndromes (for example, somatization disorder, severe depression, post-traumatic stress disorder, thedissociative disorders, borderline personality disorder, and multiple personality disorder) asconsequences of abuse [1, 2]. However, only in the last few years has attention turned to the physicalconcomitants of sexual and physical abuse, that is, their association with certain medical disordersand their effect on health care [3-7].Of recent interest is the growing evidence that a history of sexual and physical abuse is associatedwith gastrointestinal illness [8]. Is this association unique to patients with gastrointestinal disorders, oris it part of a more generalized association between abuse history and somatization and reporting ofsymptoms? If a relation does exist, what are the possible reasons for it? Finally, what is the cliniciansrole in eliciting this type of history and in responding to patient disclosure? To answer these questions,a working team sponsored by the Functional Brain-Gut Research Group of the AmericanGastroenterology Association was formed. Our goals were 1) to review existing data on the relationbetween abuse history and gastrointestinal illness, 2) to discuss possible reasons for this association,3) to offer suggestions for identifying patients at risk and sensitively eliciting a history, and 4) toprovide information on how mental health professionals and patient support groups can be accessed.Although other forms of trauma, such as emotional abuse and neglect, may also be associated withmedical and psychiatric illness, the data for gastrointestinal clinical populations are limited and will notbe discussed.
  3. 3. Methods Top MethodsEach member of the working team was assigned a topic by the primary Conclusionauthor. He or she then did a MEDLINE search on that topic and submitted Author & Article Infoit to the primary author, who integrated the material into a manuscript that Referenceswas then resubmitted to the working team and revised. The final documentwas agreed on by consensus.Clinical and Epidemiologic AssociationsMethodologic Considerations in Evaluating Studies of AbuseReportingThe widely differing estimates of the prevalence of abuse (6% to 62%) in the United States [9] resultfrom the varying definitions and methods used to assess abuse history. Furthermore, police recordsand confirmation with family or acquaintances grossly underestimate the frequency of abuse, leavingno gold standard of validation. For clinicians, merely the disclosure of this information is consideredtruthful unless proven otherwise. However, to evaluate epidemiologic estimates of abuse history inclinical or population-based studies, clinicians and investigators must consider several factors.Changing Societal Values about Definitions of AbuseNumerous studies have suggested that the number of reports of sexual and physical abuse is highand may be increasing. In a review comparing the frequency of sexual abuse reported in the UnitedStates from the 1940s to the late 1970s, Leventhal [10] concluded that the frequency of these reportshas increased (from 24% to 48% by the broad definition of abuse and from 12% to 28% by the narrowdefinition). The increase relates in part to changing societal values: The disclosure of an abusiveexperience is now encouraged and supported, whereas it was previously considered secretive andshameful. For example, society now considers date rape to be a form of sexual abuse. Thirty or 40years ago, however, this experience may not have been defined as such, and victims may have beenmore reluctant to report it to officials. Investigators therefore must consider that the frequency ofabuse reports are higher in areas where there is increased public attention to these events.Interview versus QuestionnaireSome evidence suggests that interview methods may yield more reports of abuse than questionnaires[9, 11]. This theory is difficult to assess because most studies that use interviews also use morequestions and specific activity-based questions that are known to increase abuse reporting. A carefullyadministered interview in a supportive environment may be the best way to identify a history of abuse[11], but this theory has yet to be tested adequately.The Operational Definition
  4. 4. There is evidence that more persons report abuse when definitions include questions based onbehavior (for example, "Has anyone ever touched the sex organs of your body when you did not wantthis?") rather than general or emotionally charged questions (for example, "Have you ever beensexually abused or molested?") [9, 12, 13]. Furthermore, a broader definition of abuse that includesmany types of forced or unwanted sexual encounters (such as noncontact abuse or fondling) results inhigher estimates of abuse prevalence. Noncontact sexual abuse includes unsolicited sexual advancesor encounters with exhibitionists during childhood [9]. Noncontact experiences include attempted orthreatened rape or sexual touching in which force is used but sexual contact does not occur (such aswhen the victim escapes). Contact abuse can include both touch experiences (that is, being fondled orbeing made to touch the perpetrator) and penetration (that is, vaginal sex, anal sex, or oral sex [14,15]).Similarly, physical abuse is identified by several variables: being assaulted or attacked with a weapon,beaten up, hit with a fist or object, kicked, bit, burned, slapped, or threatened with a weapon. Becausethe life-threat associated with these experiences can differ, investigators can use groupings ofphysical abuse experiences [in descending order of threat]: 1) being assaulted or attacked with aweapon [such as a gun or knife]; 2) being attacked without a weapon but with the intent to kill; 3) beingbeaten up, hit with a fist or object, kicked, bit, burned, or slapped by another without intent to kill; 4)being threatened with a weapon but not actually attacked; or 5) being threatened with harm but withouta weapon or threat to life [16, 17].The degree of coercion indicated in the question can affect estimates of the prevalence of abuse.Some investigators consider any unwanted sexual experiences to be abuse [18]. Others define abusemore rigorously as using force or threatening harm to engage in sexual acts [19-21]. Because abusedpersons are more likely to acknowledge abuse using the first definition and because questionnairesmay tend to underestimate abuse [12], defining abuse as unwanted sexual experiences may be amore sensitive measure. However, with interviews, defining abuse in terms of force or threat of harmmay be more valid because the nature of the abuse can be further clarified.Many researchers stipulate that there be a 5-year age difference between the perpetrator and a child[9] so that the possibility of consensual sexual activity with peers can be eliminated. However, thisdefinition may exclude abusive encounters with peers or siblings. We believe that by stipulating"unwanted or forced" sexual experience in the definition, the requirement of a 5-year difference in ageis unnecessary. Estimates of childhood sexual abuse have also varied because different age criteriahave been used to define childhood. The definition of childhood has ranged from 13 to 18 years, withsome studies not defining what is meant by "child." Age 14 years has recently been used as a cut-offfor child and adult sexual abuse [22, 23].Nature of the Setting and Patient SampleThe clinical setting in which the information is obtained may be as important as the type of questionsasked. Studies done in referral practices (such as pain centers or academic practices) yield muchhigher response rates than those done in primary care or nonclinical settings. Similarly, patientsseeing mental health professionals for emotional difficulties may be more likely to report abusiveexperiences than patients attending medical practices [24]. Furthermore, the prevalence of abusetends to be higher in younger samples and perhaps among persons in certain regional areas (forexample, urban compared with rural) [13, 25]. Investigators should also consider that the positivepredictive value of a screening evaluation will probably be greater in clinical settings in which theprevalence is high than in nonclinical settings in which the prevalence is low.The Psychosocial Profile of the PatientPatients with certain psychiatric disorders (such as somatization disorder) or personality disorders(such as borderline personality disorder) may set low thresholds for reporting medical or psychologicalsymptoms. These patients might therefore overinterpret and over-report previous experiences asabuse. In contrast, patients with dissociation disorders who may not recall these experiences, or thosewho harbor intense feelings of shame or guilt, are less likely to report a history of abuse. Finally,patients who are experiencing ongoing abuse, but who have limited social support or poorly developedcoping skills or who fear retribution from the perpetrator, are much less likely to report these
  5. 5. experiences. Investigators should recognize that concurrent psychosocial difficulties affect reportingtendencies.Relationship with the InterviewerFinally, persons may be more likely to disclose sensitive information when confidentiality is assuredand when the interviewer or test administrator can effectively communicate trust and support [11]. Theperson doing this assessment should be adequately trained to address the patients emotionalresponse, and mental health resources should be made available if needed.Abuse History and Gastrointestinal SymptomsThe epidemiologic investigation of abuse history is still in the early stage of its development, andadditional work is needed to standardize the assessment of a history of sexual and physical abuse.When interview methods are not feasible, a standardized questionnaire may be helpful as a screeninginstrument, particularly when it is administered in a trusting and relaxed environment. Given thesecaveats, the following is a review of existing studies about the relation between abuse history andgastrointestinal symptoms.Frequency of Gastrointestinal Symptoms among Sexually Abused PatientsIn a review of the psychological and medical consequences of abuse in victimized female children,Bachmann and colleagues [26] found that a prominent theme was the development of psychologicaland physical symptoms, particularly of the gastrointestinal and genitourinary tract. For example,Rimsza and colleagues [27] did a chart review and telephone interview of the mothers of 72 femalechildren and adolescents who had experienced forced sexual activity with an adult, comparing thefrequency of behavioral and physical problems with the frequency in a matched control group of 26children. The investigators found that the abused group reported significantly more physical symptoms(P < 0.01) and that the duration of abuse affected symptom reporting (P < 0.005), specifically thereporting of gastrointestinal (P < 0.01) and genitourinary (P < 0.01) symptoms. Seventy-one percent ofchildren who were abused for more than 24 months reported gastrointestinal symptoms.Felice and colleagues [28] described the development and progression of reports of physicalsymptoms in a chart study of a cohort of 25 female adolescent rape victims who were followed in arehabilitation program. Phobias developed in approximately half of the rape victims soon after therape, and this led to a period of denial and loss of interest in the treatment program. Years later, manyof the victims returned for medical treatment with "psychosomatic" symptoms of abdominal pain,headaches, and dizzy spells, and they did not report an association between the physical symptomsand the previous rape. This observation suggests that for some patients, physical symptoms tend toemerge when recollection of the abusive experience diminishes. Although these two studies werelimited in the rigor with which the outcome measures were assessed, the validity of the abuse historywas assured, and the findings are consistent with those of retrospective studies.Similar associations were found in studies of adults who had been sexually abused as children. In ahealth maintenance organization (HMO) clinic study, Felitti [3] identified 131 adult patients whoacknowledged a history of abuse (abuse had occurred an average of 30 years earlier) from aquestionnaire (specifically, from the answer to the question "Have you ever been raped or molested?")and compared the frequency of current somatic symptoms with the frequency in a matched cliniccontrol group. The group with an abuse history described a higher frequency of depressive symptoms(83% compared with 32%, respectively; P < 0.001); the next most common symptom wasgastrointestinal problems (64% compared with 39%; P < 0.01), followed by headaches (45%compared with 25%; P < 0.05). In another study, Lechner and colleagues [29] administered aquestionnaire to a consecutive sample of adult female patients seen in the waiting room of a familypractice clinic. A positive response to the screening question "As a child 16 years of age or younger,were you ever a victim of sexual abuse... (with a person more than two years older)?" was obtained in26% of the sample and led to a series of more detailed questions on sexual abuse. After this, thepatients were asked questions about respiratory, cardiovascular, gastrointestinal, musculoskeletal,gynecologic, and otorhinolaryngologic symptoms, as well as mental health treatment. When abuse
  6. 6. victims were compared with the group that had not been abused, significant differences were noted forreports of gastrointestinal (30.1% compared with 10.9%; P < 0.001), respiratory (15.4% compared with6.2%; P < 0.002), and neurologic (7.4% compared with 2.1%; P < 0.01) symptoms. Abuse history wasalso associated with more mental health treatment (60% compared with 28%; P < 0.001). Althoughthese two studies identified abuse victims through self-reports, the findings indicate that female victimsof early abuse are more likely than others to have physical (and, in particular, gastrointestinal)symptoms later in life.Prevalence of Abuse History in Gastrointestinal PracticesA high frequency of reports of sexual and physical abuse in a cohort of gastrointestinal patients wasfirst described in 1990 [22]. The investigators evaluated a consecutive sample of women referred tothe University of North Carolina gastroenterology practice over 2 months. The women were asked tocomplete a self-report screening questionnaire of sexual and physical abuse history Appendix 1 thatwas derived from previous studies [16, 18] and that contained the criteria noted above. Thisquestionnaire was later validated against a detailed psychological interview [11]. Forty-four percent ofthe 206 patients studied reported a history of sexual or physical abuse in childhood or later in life.Furthermore, sexual abuse was strongly associated with physical abuse, and child abuse was stronglyassociated with history of abuse in adults. In addition, patients with functional gastrointestinaldisorders reported more abuse (Table 1). For example, the frequency of rape or incest was 31% forpatients who had functional gastrointestinal disorders (for example, the irritable bowel syndrome,functional dyspepsia, constipation, chronic abdominal pain) compared with 18% for those with organicdisorders (for example, acid-peptic disease, inflammatory bowel disease, liver disease) (odds ratio,2.08 [95% CI, 1.03 to 4.21]). In general, this history of abuse was concealed; the history of only 17% ofthe abuse victims was known to their physicians, and 30% of the victims had not previously disclosedthis history to anyone. The findings also suggest that a standardized and confidential screeningquestionnaire can identify abuse history with reasonable sensitivity. View this Table 5. Self-Report Screening Questionnaire of Sexual and table: Physical Abuse History [in this window] [in a new window] View this Table 1. History of Abuse in 206 Female Outpatients with table: Functional or Organic Diagnoses* [in this window] [in a new window]It is important to determine the generalizability of these findings to other clinical settings. Talley andcolleagues [30] used the same self-report questionnaire to identify abuse and found a frequency of30% among a consecutive sample of 68 men and 149 women seen at the Mayo Clinic (compared witha frequency of 44% among only female patients at the University of North Carolina). Patients whoreported sexual abuse history were 2.8 times more likely to have a functional bowel disorder, a findingsimilar to that of the previous study. In a study of female patients referred to the University of Alabamafor investigation of esophageal disorders (a more select patient sample) in which the samequestionnaire was used, the frequency of abuse history was 56% [31]. Abuse frequencies amongpatients with different functional gastrointestinal disorders have been compared in only one study [32].
  7. 7. The frequency of sexual abuse was greater in patients with functional lower gastrointestinal tractdisorders than in those with functional upper gastrointestinal tract disorders. Abused patients weremore likely to report constipation, diarrhea, or animus (pelvic-floor dyssynergia) [32].The high frequency of these abuse reports may be related to the selective nature of the study sample(patients with gastrointestinal symptoms seen at referral centers). This finding is supported by thefindings of Longstreth and Wolde-Tsadik [33], who evaluated 1264 persons presenting for a periodichealth examination at an HMO. Using the same screening questionnaire as in the previous studiesAppendix 1, these investigators found lower rates of abuse reports. Women had a higher frequency ofsexual abuse history (19%) than men (5.7%; P < 0.001). Twenty percent of this sample met criteria formoderate or severe irritable bowel syndrome, and these patients were compared with the women whodid not have bowel symptoms (Table 2). The investigators found that unwanted sexual intercoursewas reported by 5.2% of patients without the irritable bowel syndrome, 9.6% of those with less severesymptoms of the syndrome, and 22.2% of those with severe symptoms (Table 2). These data can becompared to the 31% frequency of abuse in patients with the irritable bowel syndrome who werereferred to the University of North Carolina gastroenterology clinic Table 1 [22]. As shown in Figure 1,the frequency of abuse history progressively increases in relation to the presence of the syndrome(compared with patients with no bowel symptoms), its severity (mild or severe), and the clinicalpopulation (HMO compared with referral center). View this Table 2. Childhood Abuse in 1264 Patients Presenting for a table: Periodic Health Examination* [in this window] [in a new window] Figure 1. Comparison of frequencies of sexual abuse history (for sexual exposure, contact abuse, and rape or incest) among health maintenance organization (HMO) members without bowel symptoms, with mild irritable View larger version (46K): bowel syndrome (IBS), or severe irritable [in this window] bowel syndrome and patients seen at a [in a new window] university referral gastroenterology clinic [22, 33]. The progressive increase in frequency supports a relation of abuse history with the irritable bowel syndrome, its severity, and primary care compared with referral status. UNC equals University of North Carolina, Chapel Hill, North Carolina. (Reproduced with permission [7]).Only one population-based study has been reported [34]. A self-report questionnaire that included theprevious questions about abuse Table 5 was mailed to a random sample of 919 persons in OlmstedCounty, Minnesota (age range, 30 to 49 years). Twenty-six percent of the population reported someform of abuse in the past (age-adjusted prevalence was 41% for women and 11% for men), and mostin this sample (22%) reported sexual abuse. In addition, sexual abuse history was associated withfunctional gastrointestinal symptoms. When compared with normal persons, patients who were
  8. 8. sexually abused had an increased risk (odds ratio) for the irritable bowel syndrome of 1.9 (CI, 1.2 to3.0) and a risk of 1.9 (CI, 1.3 to 2.9) for functional dyspepsia.Relation between Abuse History and Psychiatric DisturbanceA history of physical or sexual abuse during childhood is associated with psychiatric disturbances. In asurvey of a nonclinical population (278 women attending a university), 15% reported having hadunwanted sexual contact with a substantially older person before they had reached the age of 15years [35]. Using a modified version of the Hopkins Symptom Checklist, the investigators found thatthe affected persons had significantly higher levels of dissociation (P < 0.009), somatization (P <0.03), anxiety (P < 0.03), and depression (P < 0.05) than the women who were not abused. Similarly,a higher frequency of psychiatric diagnoses was reported among clinical patients with gastrointestinaldisorders who reported abuse history. Walker and colleagues [36] evaluated a cohort of patients withthe irritable bowel syndrome and inflammatory bowel disease using a 14-item questionnaire [37] thatascertained sexual abuse history, the severity of the abuse, and the victims relationship with theperpetrator. Patients who had been severely abused were more likely than those with no history ofabuse or those with a history of less severe abuse to have several lifetime DSM-III (Diagnostic andStatistical Manual, Third Edition) diagnoses: phobia (67% compared with 26% [odds ratio, 5.6; CI, 1.2to 26.7]), panic disorder (44% compared with 11% [odds ratio, 6.8; CI, 1.3 to 36.7]), somatizationdisorder (56% compared with 11% [odds ratio, 10.6; CI, 2.0 to 56.7]), alcohol abuse (44% comparedwith 13% [odds ratio, 5.3; CI, 1.0 to 26.7]), functional dyspareunia (78% compared with 21% [oddsratio, 13.1; CI, 2.3 to 75.9]), and major depression (78% compared with 34% [odds ratio, 6.7; CI, 1.2 to27.2]).Dissociation, which is commonly seen in persons who have been abused [38], may allow the patientto psychosocially adapt to the experience. In these patients, the "depersonalization" and "blanking out"occur as painful memories materialize and help the patient to avoid reexperiencing emotional trauma.This process can range from isolated, brief flashbacks and nightmares to amnesia or full-blownmaladaptive personality styles. Patients with dissociation tend to frequently and persistently reportphysical symptoms [39]. As previously observed by Felice and colleagues [28], dissociation andphysical symptoms may be a late outcome that occurs when the emotional trauma from childhoodabuse is "forgotten." Dissociation and somatization may also be associated with other psychiatricdiagnoses such as multiple-personality disorder and borderline-personality disorder [40], or it mayexist as a behavior pattern independent of other psychiatric diagnosis among patients withgastrointestinal or other medical diagnoses.Relation between Abuse History and Other Medical DiagnosesSeveral studies have shown that abuse history is independently associated with certain other(nongastrointestinal) medical syndromes [7] and is strongly associated with increased symptomreporting (for example, somatization) in general [41-43]. At referral centers, diagnoses frequentlyassociated with abuse history include chronic pain (such as pelvic pain [44-46], headache [47], andback and myofascial pain [48]) and eating disorders, particularly bulimia nervosa [49], morbid obesity[3], and alcohol and drug abuse [50, 51]. Abuse history probably has a general effect on increasedsymptom reporting and a poorer adjustment to illness. Well-designed epidemiologic studies areneeded to determine whether the putative preferential association of abuse history withgastrointestinal illness is valid or whether these observations are related to the greater attentionrecently given to gastrointestinal disorders.Relation between Abuse History and Health StatusThe relation between abuse history and poor health status has implications for treatment. In theUniversity of North Carolina study of gastroenterology patients [22], those with an abuse history weremore likely than those without an abuse history to report pelvic pain (16% compared with 6% [oddsratio, 4.05; CI, 1.41 to 11.69]), multiple somatic symptoms (7.1 ± 0.28 symptoms compared with 5.8 ±0.25 symptoms; P = 0.001) and more lifetime surgeries (2.8 ± 1.10 surgeries compared with 2.0 ± 1.09surgeries; P = 0.009). Similar findings were found in an HMO study [33], in which abuse history wassignificantly associated with at least one nongastrointestinal symptom (P = 0.016) and at least onesurgery (P = 0.034). Finally, in the population-based study [34], the odds of visiting a physician were
  9. 9. significantly higher in persons with a history of any type of abuse (odds ratio, 1.4 [CI, 1.0 to 2.0]),sexual abuse (odds ratio, 1.5 [CI, 1.0 to 2.2]), and emotional or verbal abuse (odds ratio, 1.8 [CI, 1.1 to3.0]), but not for those with a history of physical abuse alone. Therefore, regardless of practice type ordiagnosis, abuse history is associated with poor adjustment to illness and adverse clinical outcomes,including an increased amount of health-care seeking and a greater risk for surgical procedures.Summary of Clinical DataWe obtained the following information from our review of the literature: 1) Abuse history, psychiatricdisturbance, and medical symptoms are significantly associated; 2) the apparent preferentialassociation of abuse history with gastrointestinal symptoms requires epidemiologic confirmation; 3)abuse history is more commonly reported by women; 4) abuse history is more frequent in referralpractices than in primary care; 5) patients with functional gastroenterologic disorders report abusemore frequently than patients with organic disorders; 6) abuse history is associated with an increasedtendency to seek health care and poorer health status [psychological dysfunction, symptom reporting,more frequent surgery]; and 7) the patients physicians are usually unaware of the history of abuse.A Conceptual ModelWe propose a conceptual model to explain the relation between abuse history and psychosocialdisturbance, gastrointestinal illness, and health care utilization (Figure 2). Additional studies areneeded to confirm the effect of the contributing factors. Figure 2. Conceptual scheme for relation of abuse history to psychosocial disturbance, gastrointestinal illness, and health care utilization. View larger version (28K): [in this window] [in a new window]1. Abuse can be a traumatic event that has long-lasting psychosocial consequences. Abusiveexperiences may produce long-standing symptoms of psychological distress and may predisposepatients to psychiatric diagnoses (for example, post-traumatic stress disorder; anxiety; and depressive,somatoform, or personality disorders [39, 41, 43, 45, 52]). Furthermore, abusive experiences are oftenpart of and contribute to a milieu of poor social support and the development of ineffective copingstrategies [5, 31].2. Susceptibility to gastrointestinal illness in combination with psychological disturbances may mediatethe development or exacerbation of gastrointestinal symptoms. Psychological distress generallylowers symptom threshold, thereby increasing the number and severity of symptoms reported formany medical conditions. However, the functional gastrointestinal disorders are so common that manysusceptible persons may develop gastrointestinal symptoms. This may occur through any of severalplausible mechanisms [8]:
  10. 10. Psychophysiologic effects: Psychological distress can, through the central nervous system-entericnervous system [53] or autonomic pathways [54], produce exaggerated intestinal motility [55] andabdominal discomfort [56]; this occurs to a greater degree in persons with functional bowel disorders[57-59].Enhanced visceral sensitivity: Prolonged visceral stimulation from injury or inflammation evokes theactivity of previously unresponsive silent nociceptors that, along with other sensory afferents, amplifyperipheral input to the central nervous system to produce persistent pain even after peripheral afferentactivity decreases [60, 61]. For example, repetitive noxious distention of the colon in humans producesa progressive increase in pain scores and an increased area of referred sensation to the abdomen[62]. Therefore, traumatic stimulation of the vagina or anus in children may lead to neural changes [63]that down-regulate the sensation thresholds of visceral nociceptors, thereby increasing perception ofabdominal or pelvic pain or other bowel symptoms [8, 61].Psychodynamic effects: Young children who have been sexually abused often believe that their sexualorgans are dirty or bad; this can lead to feelings of guilt and shame. The psychological distressengendered by these feelings may be expiated through physical pain or suffering [64, 65]. Thelocation of the pain in the abdomen, pelvis, or genitourinary area is logical to the psyche because thisarea represents the "bad" or offending part of the body that is to be punished.Response bias: Patients with gastrointestinal disorders and abuse histories have significantly lowerpain thresholds than normal persons, and this relates in part to the psychological tendency to set lowstandards for judging stimuli as painful (response bias) [31].Psychiatric comorbid conditions: Patients with functional gastrointestinal disorders who are seen inmedical centers have a high frequency of psychiatric comorbid conditions [66, 67] and are likely tocommunicate psychological distress through physical symptoms. Furthermore, they may notacknowledge a relation between psychological difficulties and their symptoms [68, 69], whichreinforces their belief that they have a serious medical disorder.Early-life reinforcement of illness behavior: Increased attention paid to reports of illness early in lifemay lead to reinforcement of illness behaviors [70-72] and the seeking of health care.3. Gastrointestinal symptoms, combined with existing psychosocial difficulties, amplify the symptomexperience and lead to health-care seeking, refractoriness, and, ultimately, referral [73-75]. Continuedreferral is reinforced because the health care system provides only incomplete relief of somaticsymptoms, a socially acceptable and secure social support system, an idealized "parental" figure(physician) to take responsibility for "cure," and possible reinforcement of pain and suffering throughsubmission to unneeded diagnostic and therapeutic procedures.4. A "vicious cycle" of psychological difficulties, increased symptom severity caused by refractorysymptoms, and health-care seeking is perpetuated. Refractory symptoms amplify psychologicaldisturbance, which in turn worsens symptoms and illness behavior. The cycle continues when thephysician does not consider the psychosocial determinants of these disorders and responds to thepatients distress by administering unneeded testing or treatments.Obtaining an Abuse HistoryBecause abuse history may adversely affect illness outcome [22, 33, 76], it is important to elicit ahistory of abuse among patients at high risk and to initiate appropriate referral with the hope that theclinical condition improves. The clinician should consider several factors in deciding when and how toaddress this issue [77].
  11. 11. Risk Factors for Abuse History among Patients with GastrointestinalIllnessSeveral clinical features increase the likelihood that a person has been abused (Table 4). View this table: Table 4. Factors Suggesting a History of Abuse [in this window] [in a new window] View this Table 3. Association of Abuse with Functional Bowel Disorders table: in a Random Sample of 870 Olmsted County, Minnesota, [in this window] Residents Aged 30 to 49 Years* [in a new window]Psychological IssuesPatients with abuse histories have been violated in ways that erode their sense of trust in others,particularly if they depend on the perpetrator as a source of support. This may lead to a cycle ofhelplessness and lack of control over the actions in their life, which fosters dependence on thosewhom they cannot trust. If these experiences occur early in life, the child cannot discriminate right fromwrong or personal responsibility from the responsibility of others. This may lead to a pervasive andunjustified sense of shame and guilt: They may blame themselves for actions they did not initiate. Inclinical practice, patients demonstrate these difficulties by 1) distrusting physicians but feelingdependent on them for attention and security; 2) harboring unrealistic (magical) expectations for cureand overtly delegating decisions to physicians while engaging in passive conflicts over control [78]; 3)submitting to unneeded or painful procedures, which may expiate feelings of guilt; or 4) contributing tointerpersonal difficulties that lead to anger or rejection by physicians, which in turn reinforces feelingsof worthlessness and poor self-esteem. Such difficulties can only be ameliorated when the bases forthese behaviors are understood.Medical and Psychiatric DisordersCertain medical and psychiatric disorders are strongly associated with a history of abuse. Medicaldisorders include chronic pain [48, 79]; severe constipation [80], particularly pelvic dyssynergia(obstructive defecation); the eating disorders [49]; morbid obesity [3]; unexplained vomiting; andsexual dysfunction [46, 81]. Several psychiatric disorders may develop concurrently: the somatoformdisorders [39, 41, 43], the dissociation disorders and multiple-personality disorder [4, 82], post-traumatic stress disorder [83], and severe depression or panic disorder [39].Illness-Related BehaviorsIllness behavior defines the degree to which symptoms are reported (its frequency, severity, andqualitative description), the manner in which it is communicated (with a stoic, suffering, or help-seekingdemeanor), and its clinical effects (self-care, narcotic use, disability, health care utilization) [84]. Whenthe physician observes that the patients behavior surpasses the usual range of expectation, theillness behavior is considered abnormal [85]. This often occurs when the patient displays disability that
  12. 12. is disproportionate to the clinical data, seeks to validate disease (often excluding a role forpsychological factors), places responsibility for the treatment with the physician, and avoids health-promoting behaviors.Patients with abuse histories may also have difficulties with certain procedures (such as rectal orpelvic examination and endoscopies), and patients may show "borderline" behaviors, such as formingintense and chaotic emotional attachments with physicians, "splitting" the health care team by playingone person against another, or being unable to accept the uncertainties of medical care by demandingdiagnostic procedures or treatments for "cure."Unwanted OutcomesInevitably, the above features lead to unwanted effects. Patients may undergo multiple diagnosticprocedures, treatments, and surgeries [86]; abuse alcohol, medications, and other substances [7];seek disability and litigation; and overuse health care services [22, 33, 76].When To Inquire about an Abuse HistoryPhysicians should inquire about a history of abuse when the clinical data are suggestive Table 4 andthe information will help improve the patients outcome. When the symptoms are refractory anddisabling and an abuse history is suspected, determining current or previous abuse is importantbecause the physician can then refer the patient to a mental health professional. The mental healthspecialist in turn can address and alleviate the psychological encumbrances of the experience orexperiences. The patients risk for becoming significantly distressed from discussing theseexperiences is low [22]. In an ongoing study by one of the authors (DD) that involves intensiveinterviews of more than 100 patients with abuse history, the ability to discuss the abuse history wasconsidered beneficial or at least not harmful to the patient in almost all cases. Only 3 patients requiredimmediate additional counseling.Physicians should also inquire about an abuse history if they believe they can discuss the topic.Certainly, physicians may feel uncomfortable addressing these issues or may be unable to take thetime to allow adequate discussion of the patients thoughts or feelings. In these situations, it isunderstandable and appropriate to defer the inquiry or to refer the patient to a mental health colleague(see below).When eliciting an abuse history, physicians should ensure that resources for referral are available.Obtaining this history is only the first step in what may be a long treatment process to help the patientwork through the thoughts and feelings of the abuse experience. The physician should therefore beprepared to provide additional counseling services.How To Ask about an Abuse HistoryThe history should be obtained in a clinical setting that is free from interruption and after the physicianestablishes rapport and mutual trust with the patient. We recommend that, rather than directly askthese questions, the physician follow the patients lead and look for an opportunity to address theissue of abuse [87]. If the patient refers to an experience suggestive of abuse (for example, "Thingswere pretty horrible then ..."), then the physician should encourage the patient to elaborate. If thepatient does not volunteer this information, the physician should provide further opportunity: "Is thereanything else you would like to discuss that you think is important?" If the information is still notforthcoming, the physician can ask if any experiences not yet discussed have been particularly painfulor difficult. Finally, if the physician is still concerned that the patient has been abused, he or she canask about it more directly: "As you may know, its not uncommon these days for persons to have beenemotionally, physically, or sexually victimized at some time in their life and this can affect how peoplemanage with their medical condition. Has this ever happened to you?" This approach communicatesthat the patient is not alone with this type of experience. It also allows the patient to definevictimization in personal terms, and the physician can clarify the responses. Although a more directinquiry has also been recommended, we believe our approach reduces the pressure to disclose. This
  13. 13. improves the response rate and preserves the therapeutic relationship and the patients right not todisclose this information if feeling unable or unwilling.It is important to observe the manner in which the information is presented. If the patient denies thishistory but the nonverbal response is incongruent, the physician should register the information forfuture inquiry and say no more. If the patient acknowledges a history of abuse, the physician shouldremain nonjudgmental and encourage the patient to continue. Obtaining the details of the experienceor experience is not as important as being supportive and empathic, an approach that allows thepatients to express previously suppressed thoughts and feelings in his or her own way. Inquiring aboutthis information in a supportive manner may be therapeutic. The information will not be disclosed if thepatient cannot or is unwilling to do so.After the history is obtained, the physician needs to monitor the patients comfort level and decidewhether to continue. Gentle encouragement provides the opportunity for the patient to say more.Periods of silence must be permitted so the patient can collect thoughts and feelings in order tocoherently present them. Some emotional distress is expected and should be permitted. However, ifthe patient begins to change or evade the topic, turn away with arms folded, or present emotion-ladeninformation in a disaffected or emotionally incongruent manner, the physician should end thediscussion but provide the option to discuss this issue again in the future. The question items listed inAppendix, although developed primarily for research, can also be used by clinicians to determine theseverity of abuse.How To Make a ReferralReferral to a mental health professional should be consistent with the patients needs andexpectations. If the patient freely and congruently discloses the abuse experience, the physicianshould acknowledge that he or she has shared some very important, private, and meaningfulexperience and that these experiences have clearly affected the patients feelings and ability to copewith the illness. For these reasons, it may be helpful to seek further psychological treatment.In some cases, patients believe they have come to a physician for a medical problem and may besurprised or feel ashamed about discussing their emotional experiences. They may question therelevance of these experiences to the medical condition. In this case, the physician needs to help thepatient accept the importance of referral. The physician can first acknowledge that sharing importantpersonal information must have been difficult for the patient and that the physician will be available inthe future if the patient wishes to discuss it further. The physician can also address the difficulties thepatient has had with the illness and can refer to statements of feeling depressed, despondent, orunable to cope with the illness. The physician can then use the patients comments to emphasize theimportance of the mental health professional in helping him or her to reverse the vicious cycle ofcontinued symptoms and psychological distress. Finally, the physician could mention thatimprovement in psychological distress can increase tolerance of pain and provide an overall betteradjustment to medical illness. Because of feelings of shame or of an inability to deal with the emotionsgenerated, the patient may be reluctant to see a mental health consultant. In this situation, thephysician must accept the patients wishes, continue in the care, and suggest that the topic can alwaysbe discussed again in the future. In all cases, the physician should maintain continuity of care. To referthe patient to a mental health professional and then remove oneself from the treatment would beviewed by the patient as a rejection.If the patient is willing to be referred, a telephone call or letter should precede the visit, with an offermade to maintain ongoing communication. The type of mental health professional (such aspsychiatrist, psychologist, or psychiatric social worker) is not as important as choosing someone whohas experience in working with abused patients. Peer support groups or group therapy with otherabused patients can also be recommended because they may accelerate the patients ability tocommunicate shameful thoughts to an understanding and supportive audience.
  14. 14. The Role of the Mental Health ConsultantWe recognize that addressing the psychological difficulties patients have in coping with chronic painand illness can be intimidating for the nonpsychiatric physician. Distressed patients who aredemanding, not well understood by their physicians, and refractory to treatment produce frustration,despair, and, at times, hostility on the part of the treating physician [78, 88, 89]. Frequently, however,these are the patients in whom a history of abuse is likely, and a physicians reluctance to inquireabout this sensitive and emotion-laden topic is understandable. Nevertheless, ignoring this importanthistory only further hampers the clinical progress of the patient and the physician-patient relationship.When an abuse history is suspected to contribute to refractory illness, the medical physician maychoose to defer exploration of psychological issues and recommend consultation with a mental healthprofessional. This person can provide specialty care and also serve as an additional source of clinicalsupport and emotional validation.The mental health consultant can provide several services.1. Identify psychological comorbid conditions. The mental health consultant can confirm whether amajor psychological disturbance is present, and this may lead to specific forms ofpsychopharmacologic or psychological treatment. In a clinical interview, the consultant may screen forpsychiatric diagnoses by using standardized criteria (Diagnostic and Statistical Manual, Fourth Edition[DSM-IV]) [90] or by administering validated questionnaires to identify certain psychological features.Some questionnaires, such as the Spielberger Anxiety State-Trait measure [91], the Beck DepressionInventory [92], the Sheehan panic disorder questionnaire [93], and the Eating Disorders Attitudes Test[94], can be administered by the mental health consultant or even the medical physicians at the time ofthe patients visit. More comprehensive personality and symptom inventories such as the MinnesotaMultiphasic Personality Inventory [95] and the Hopkins Symptom Checklist 90 (SCL-90) [96] givecomplex information that is usually obtained by psychologists or psychiatrists.2. Identify a history of abuse. The mental health consultant can confirm the physicians findings ofabuse history or can independently identify its existence. He or she will then determine with the patientwhether additional treatment is needed. This is usually done if the abuse history is contributing to pooradjustment to illness or to significant psychological distress. The consultant might also determine thatthe abuse history does not require further action (for example, if the patient has previously sought helpor has adjusted psychologically to the experience).3. Decide on psychopharmacologic treatment. The psychiatric consultant determines whether apsychopharmacologic agent would be helpful either as primary treatment or as ancillary topsychological care. The consultant also considers factors such as the patients medical condition,concurrent medications, and the nature of the psychological problem to decide on the best medicationchoice and dosage.4. Initiate concurrent psychological treatment. When needed, the mental health consultant can eitherpersonally initiate or implement referral for psychological treatment along with the medical care. Thegoal of therapy is to encourage the patient to accept the reality of the abuse experience and exploreand revise maladaptive thoughts and feelings. For example, patients abused early in life frequentlyfeel responsible for the events, and this leads to pervasive feelings of guilt and shame. Clinicalsymptoms usually improve and self-esteem is usually heightened when patients can separatethemselves from the experience and redirect the responsibility to the perpetrator. Including apsychopharmacologic agent in addition to the psychological care may be helpful [97].5. Assume primary responsibility for the patients care. In some circumstances, the psychologicaldifficulties will be so great that the mental health consultant will take the primary role in the care of thepatient either through psychiatric hospitalization or outpatient therapy. However, the medical physicianshould still continue treatment, albeit less frequently, to monitor the patients medical symptoms.
  15. 15. Because many patients consider mental health referral a rejection by the medical physician, their careis best managed by a combined medical and psychological approach [98, 99].Patient Support GroupsVictims of abuse may find it difficult to communicate with physicians because of shame or becausetheir trust in authority has been eroded. Referral to a patient support group (see Appendix 2) may helpby promoting helpful exchanges among persons with similar experiences. Patients withgastrointestinal disorders are particularly stigmatized because, aside from their emotional difficulties,they have embarrassing and socially unacceptable physical symptoms. View this Table 6. National Resources for Victims of Abuse and Persons table: with Gastrointestinal Disorders [in this window] [in a new window]Many communities have mental health resources that either have or are willing to establish a patientsupport group led by an experienced group facilitator. Patient support groups can help patients adjustto and gain control over chronic illness or the effects of abuse. Certain medical support groups (forexample, the International Foundation for Bowel Dysfunction and the Crohns and Colitis Foundationof America) organize local groups to address the personal experiences of having specificgastrointestinal disorders (the irritable bowel syndrome, ulcerative colitis, and Crohn disease). Theycan also provide referrals for persons who want to work primarily on issues related to abuse.Physicians who are unfamiliar with their local support network can access them through several entrypoints:1. Self-help groups for crime victims or victims assistance organizations. Most communities have alocal crime victims assistance resource. These agencies provide free counseling, support, and referralfor victims. They are usually familiar with issues relating to post-traumatic stress disorder, spousalabuse, and adult survivors of child sexual abuse.2. Womens health centers. Independent or hospital-based womens centers that focus on womenshealth issues exist in most communities and either sponsor or provide referral to ongoing supportgroups.3. Womens shelters. Most communities have shelters to which abused persons can go 24 hours aday. Persons working in these shelters also have access to ongoing support groups.4. Young Womens Christian Association (YWCA) and Young Womens Hebrew Association (YWHA).Part of the national mandate of the YWCA and YWHA is to promote womens health. Although not alllocal YWCAs or YWHAs are active in this area, in many communities they provide a valuable resourceand can refer patients to other peer or professional support systems active in womens mental healthissues.
  16. 16. If local organizations are not available, several national organizations can provide information andreferrals for physicians or their patients. Their addresses and telephone numbers are listed inAppendix 2.ConclusionWe agree that a history of abuse is associated with certain chronic medical Topconditions, particularly in women seen at referral centers and those seen Methodsfor functional gastrointestinal disorders. Additional studies are needed to Conclusiondetermine the degree to which abuse history has general as opposed to Author & Article Infodisease-specific effects on symptom reporting. Finally, a history of abuse is Referencesassociated with poorer health status. For this reason, we recommend thatphysicians become aware of the many risk factors among patients withchronic or severe refractory symptoms, and, when these symptoms are present, that they inquireabout a history of sexual or physical abuse. If abuse has occurred, we believe that appropriate referralto a mental health professional may help alleviate psychological distress and symptom severity andpossibly improve the outcome.Dr. Talley: University of Sydney, Clinical Sciences Building, Nepean Hospital, Box 63, Penrith, NewSouth Wales 2751, Australia.Dr. Leserman: University of North Carolina, Department of Psychiatry, CB #7160, Chapel Hill, NC27599-7160.Dr. Olden: 1 Shrader Street, Suite 550, San Francisco, CA 94117.Dr. Barreiro: United Medical Associates, 1159 Vestal Avenue, Binghamton, NY 13903.Author and Article InformationFrom the University of North Carolina, Chapel Hill, North Carolina; theUniversity of Sydney, Sydney, Australia; University of California, San TopFrancisco, San Francisco, California; and United Medical Associates, MethodsBinghamton, New York. ConclusionAcknowledgments: The authors thank Drs. William Whitehead, Robert Author & Article InfoSandler, Ed Walker, and Wayne Katon for their critical review of the Referencesmanuscript.Grant Support: By the Functional Brain-Gut Research Group of theAmerican Gastroenterological Association.Requests for Reprints: Douglas A. Drossman, MD, Division of Digestive Diseases, 420 Burnett-Womack Building, CB #7080, University of North Carolina, Chapel Hill, NC 27599-7080.Current Author Addresses: Dr. Drossman: Division of Digestive Diseases, 420 Burnett-WomackBuilding, CB #7080, University of North Carolina, Chapel Hill, NC 27599-7080.
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  27. 27. 1.1Sexual and Physical Abuse and Gastrointestinal Illness: Review and Recommendations Douglas A. Drossman, MD; Nicholas J. Talley, MD; Jane Leserman, PhD; Kevin W. Olden, MD; andMarcelo A. Barreiro, MD, MSc15 November 1995 | Volume 123 Issue 10 | Pages 782-794Objectives: To summarize the existing data on abuse history and gastrointestinal illness, suggest aconceptual scheme to explain these associations, suggest ways to identify patients at risk, and provideinformation about mental health referral.Data Sources: Review of the pertinent literature by clinicians and investigators at referral centers whoare involved in the care of patients with complex gastrointestinal illness and who have experience inthe diagnosis and care of patients with abuse history in these settings.Study Selection: All research articles and observational data that addressed abuse history ingastroenterologic settings. Articles were identified through a MEDLINE search.Data Extraction: Independent extraction by multiple observers.Data Synthesis: On the basis of literature review and consensus, it was determined that abusehistory is associated with gastrointestinal illness and psychological disturbance; appears more oftenamong women, patients with functional gastrointestinal disorders, and patients seen in referralsettings; is not usually known by the physician; and is associated with poorer adjustment to illness andadverse health outcome.Although the mechanisms for this association are unknown, psychological factors (somatization,response bias, reinforcement of abnormal illness behavior) and physiologic factors (psychophysiologicresponse, enhanced visceral sensitivity) probably contribute. On the basis of these data,recommendations are made on how to identify patients at risk, how to obtain this information, and, ifneeded, how to make appropriate referrals.Conclusions: The authors agree with existing data on the association between abuse history andgastrointestinal illness. Physicians should ask patients with severe or refractory illness about abusehistory. Appropriate referral to a mental health professional may improve the clinical outcome.In recent years, the lay media and the scientific community have addressed the frequency of sexualand physical abuse in U.S. society. Psychologists and psychiatrists now recognize several psychiatricsyndromes (for example, somatization disorder, severe depression, post-traumatic stress disorder, thedissociative disorders, borderline personality disorder, and multiple personality disorder) asconsequences of abuse [1, 2]. However, only in the last few years has attention turned to the physicalconcomitants of sexual and physical abuse, that is, their association with certain medical disordersand their effect on health care [3-7].Of recent interest is the growing evidence that a history of sexual and physical abuse is associatedwith gastrointestinal illness [8]. Is this association unique to patients with gastrointestinal disorders, oris it part of a more generalized association between abuse history and somatization and reporting ofsymptoms? If a relation does exist, what are the possible reasons for it? Finally, what is the cliniciansrole in eliciting this type of history and in responding to patient disclosure? To answer these questions,a working team sponsored by the Functional Brain-Gut Research Group of the AmericanGastroenterology Association was formed. Our goals were 1) to review existing data on the relationbetween abuse history and gastrointestinal illness, 2) to discuss possible reasons for this association,3) to offer suggestions for identifying patients at risk and sensitively eliciting a history, and 4) toprovide information on how mental health professionals and patient support groups can be accessed.Although other forms of trauma, such as emotional abuse and neglect, may also be associated with
  28. 28. medical and psychiatric illness, the data for gastrointestinal clinical populations are limited and will notbe discussed.Methods Top MethodsEach member of the working team was assigned a topic by the primary Conclusionauthor. He or she then did a MEDLINE search on that topic and submitted Author & Article Infoit to the primary author, who integrated the material into a manuscript that Referenceswas then resubmitted to the working team and revised. The final documentwas agreed on by consensus.Clinical and Epidemiologic AssociationsMethodologic Considerations in Evaluating Studies of AbuseReportingThe widely differing estimates of the prevalence of abuse (6% to 62%) in the United States [9] resultfrom the varying definitions and methods used to assess abuse history. Furthermore, police recordsand confirmation with family or acquaintances grossly underestimate the frequency of abuse, leavingno gold standard of validation. For clinicians, merely the disclosure of this information is consideredtruthful unless proven otherwise. However, to evaluate epidemiologic estimates of abuse history inclinical or population-based studies, clinicians and investigators must consider several factors.Changing Societal Values about Definitions of AbuseNumerous studies have suggested that the number of reports of sexual and physical abuse is highand may be increasing. In a review comparing the frequency of sexual abuse reported in the UnitedStates from the 1940s to the late 1970s, Leventhal [10] concluded that the frequency of these reportshas increased (from 24% to 48% by the broad definition of abuse and from 12% to 28% by the narrowdefinition). The increase relates in part to changing societal values: The disclosure of an abusiveexperience is now encouraged and supported, whereas it was previously considered secretive andshameful. For example, society now considers date rape to be a form of sexual abuse. Thirty or 40years ago, however, this experience may not have been defined as such, and victims may have beenmore reluctant to report it to officials. Investigators therefore must consider that the frequency ofabuse reports are higher in areas where there is increased public attention to these events.Interview versus QuestionnaireSome evidence suggests that interview methods may yield more reports of abuse than questionnaires[9, 11]. This theory is difficult to assess because most studies that use interviews also use morequestions and specific activity-based questions that are known to increase abuse reporting. A carefullyadministered interview in a supportive environment may be the best way to identify a history of abuse[11], but this theory has yet to be tested adequately.
  29. 29. The Operational DefinitionThere is evidence that more persons report abuse when definitions include questions based onbehavior (for example, "Has anyone ever touched the sex organs of your body when you did not wantthis?") rather than general or emotionally charged questions (for example, "Have you ever beensexually abused or molested?") [9, 12, 13]. Furthermore, a broader definition of abuse that includesmany types of forced or unwanted sexual encounters (such as noncontact abuse or fondling) results inhigher estimates of abuse prevalence. Noncontact sexual abuse includes unsolicited sexual advancesor encounters with exhibitionists during childhood [9]. Noncontact experiences include attempted orthreatened rape or sexual touching in which force is used but sexual contact does not occur (such aswhen the victim escapes). Contact abuse can include both touch experiences (that is, being fondled orbeing made to touch the perpetrator) and penetration (that is, vaginal sex, anal sex, or oral sex [14,15]).Similarly, physical abuse is identified by several variables: being assaulted or attacked with a weapon,beaten up, hit with a fist or object, kicked, bit, burned, slapped, or threatened with a weapon. Becausethe life-threat associated with these experiences can differ, investigators can use groupings ofphysical abuse experiences [in descending order of threat]: 1) being assaulted or attacked with aweapon [such as a gun or knife]; 2) being attacked without a weapon but with the intent to kill; 3) beingbeaten up, hit with a fist or object, kicked, bit, burned, or slapped by another without intent to kill; 4)being threatened with a weapon but not actually attacked; or 5) being threatened with harm but withouta weapon or threat to life [16, 17].The degree of coercion indicated in the question can affect estimates of the prevalence of abuse.Some investigators consider any unwanted sexual experiences to be abuse [18]. Others define abusemore rigorously as using force or threatening harm to engage in sexual acts [19-21]. Because abusedpersons are more likely to acknowledge abuse using the first definition and because questionnairesmay tend to underestimate abuse [12], defining abuse as unwanted sexual experiences may be amore sensitive measure. However, with interviews, defining abuse in terms of force or threat of harmmay be more valid because the nature of the abuse can be further clarified.Many researchers stipulate that there be a 5-year age difference between the perpetrator and a child[9] so that the possibility of consensual sexual activity with peers can be eliminated. However, thisdefinition may exclude abusive encounters with peers or siblings. We believe that by stipulating"unwanted or forced" sexual experience in the definition, the requirement of a 5-year difference in ageis unnecessary. Estimates of childhood sexual abuse have also varied because different age criteriahave been used to define childhood. The definition of childhood has ranged from 13 to 18 years, withsome studies not defining what is meant by "child." Age 14 years has recently been used as a cut-offfor child and adult sexual abuse [22, 23].Nature of the Setting and Patient SampleThe clinical setting in which the information is obtained may be as important as the type of questionsasked. Studies done in referral practices (such as pain centers or academic practices) yield muchhigher response rates than those done in primary care or nonclinical settings. Similarly, patientsseeing mental health professionals for emotional difficulties may be more likely to report abusiveexperiences than patients attending medical practices [24]. Furthermore, the prevalence of abusetends to be higher in younger samples and perhaps among persons in certain regional areas (forexample, urban compared with rural) [13, 25]. Investigators should also consider that the positivepredictive value of a screening evaluation will probably be greater in clinical settings in which theprevalence is high than in nonclinical settings in which the prevalence is low.The Psychosocial Profile of the PatientPatients with certain psychiatric disorders (such as somatization disorder) or personality disorders(such as borderline personality disorder) may set low thresholds for reporting medical or psychologicalsymptoms. These patients might therefore overinterpret and over-report previous experiences asabuse. In contrast, patients with dissociation disorders who may not recall these experiences, or those

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