Jane Leserman

Sexual and physical abuse in women with functional or organic gastrointestinal disorders

STUDY OBJECTIVES To determine the prevalence of a history of sexual and physical abuse in women seen in a referral-based gastroenterology practice, to determine whether patients with functional gastrointestinal disorders report greater frequencies of abuse than do patients with organic gastrointestinal diseases, and to determine whether a history of abuse is associated with more symptom reporting and health care utilization. DESIGN A consecutive sample of women seen in a university-based gastroenterology practice over a 2-month period was asked to complete a brief questionnaire. MEASUREMENTS The self-administered questionnaire requested information about demographics, symptoms, health care utilization, and history of abuse. Physicians indicated the primary diagnosis for each patient and whether she had ever discussed having been sexually or physically abused. RESULTS Of 206 patients, 89 (44%) reported a history of sexual or physical abuse in childhood or later in life; all but 1 of the physically abused patients had been sexually abused. Almost one third of the abused patients had never discussed their experiences with anyone; only 17% had informed their doctors. Patients with functional disorders were more likely than those with organic disease diagnoses to report a history of forced intercourse (odds ratio, 2.08; 95% CI, 1.03 to 4.21) and frequent physical abuse (odds ratio, 11.39; CI, 2.22 to 58.48), chronic or recurrent abdominal pain (odds ratio, 2.06; CI, 1.03 to 4.12), and more lifetime surgeries (2.7 compared with 2.0 surgeries; P less than 0.03). Abused patients were more likely than nonabused patients to report pelvic pain (odds ratio, 4.05; CI, 1.41 to 11.69), multiple somatic symptoms (7.1 compared with 5.8 symptoms; P less than 0.001), and more lifetime surgeries (2.8 compared with 2.0 surgeries; P less than 0.01). CONCLUSIONS We found that a history of sexual and physical abuse is a frequent, yet hidden, experience in women seen in referral-based gastroenterology practice and is particularly common in those with functional gastrointestinal disorders. A history of abuse, regardless of diagnosis, is associated with greater risk for symptom reporting and lifetime surgeries.

Mood Disorders in the Medically Ill: Scientific Review and Recommendations

OBJECTIVE The purpose of this review is to assess the relationship between mood disorders and development, course, and associated morbidity and mortality of selected medical illnesses, review evidence for treatment, and determine needs in clinical practice and research. DATA SOURCES Data were culled from the 2002 Depression and Bipolar Support Alliance Conference proceedings and a literature review addressing prevalence, risk factors, diagnosis, and treatment. This review also considered the experience of primary and specialty care providers, policy analysts, and patient advocates. The review and recommendations reflect the expert opinion of the authors. STUDY SELECTION/DATA EXTRACTION Reviews of epidemiology and mechanistic studies were included, as were open-label and randomized, controlled trials on treatment of depression in patients with medical comorbidities. Data on study design, population, and results were extracted for review of evidence that includes tables of prevalence and pharmacological treatment. The effect of depression and bipolar disorder on selected medical comorbidities was assessed, and recommendations for practice, research, and policy were developed. CONCLUSIONS A growing body of evidence suggests that biological mechanisms underlie a bidirectional link between mood disorders and many medical illnesses. In addition, there is evidence to suggest that mood disorders affect the course of medical illnesses. Further prospective studies are warranted.

Sexual and physical abuse history in gastroenterology practice: how types of abuse impact health status.

Objective There is an increasing amount of literature pointing to a relationship between sexual and/or physical abuse history and poor health status, although few studies provide evidence concerning which aspects of abuse may impact on health. In female patients with gastrointestinal (GI) disorders, the present study examined the effects on health status of: 1) history of sexual abuse and physical abuse, 2) invasiveness or seriousness of sexual abuse and physical abuse, and 3) age at first sexual and physical abuse. Method: The sample included 239 female patients from a referral gastroenterology clinic who were interviewed to assess sexual and physical abuse history. Results: We found the following: 1) 66.5% of patients experienced some type of sexual and/or physical abuse; 2) women with sexual abuse history had more pain, non-GI somatic symptoms, bed disability days, lifetime surgeries, psychological distress, and functional disability compared to those without sexual abuse; 3) women with physical abuse also had worse health outcome on most health status indicators; 4) rape (intercourse) and life-threatening physical abuse seem to have worse health effects than less serious physical violence, and sexual abuse involving attempts and touch; and 5) those with first abuse in childhood did not appear to differ on health from those whose first abuse was as adults. Conclusions: The authors conclude that asking about abuse should be integrated into history taking within referral-based gastroenterology practices.

Progression to AIDS: the effects of stress, depressive symptoms, and social support.

OBJECTIVE We examined the effects of stress, depressive symptoms, and social support on the progression of HIV infection. METHODS Eighty-two HIV-infected gay men without symptoms or AIDS at baseline were followed up every 6 months for up to 5.5 years. Men were recruited from rural and urban areas in North Carolina as part of the Coping in Health and Illness Project. Disease progression was defined using criteria for AIDS (CD4+ lymphocyte count of <200/microl and/or an AIDS-indicator condition). RESULTS We used Cox regression models with time-dependent covariates, adjusting for age, education, race, baseline CD4+ count, tobacco use, and number of antiretroviral medications. Faster progression to AIDS was associated with more cumulative stressful life events (p = .002), more cumulative depressive symptoms (p = .008), and less cumulative social support (p = .0002). When all three variables were analyzed together, stress and social support remained significant in the model. At 5.5 years, the probability of getting AIDS was about two to three times as high among those above the median on stress or below the median on social support compared with those below the median on stress or above the median on support, respectively. CONCLUSIONS These data are among the first to demonstrate that more stress and less social support may accelerate the course of HIV disease progression. Additional study will be necessary to elucidate the mechanisms that underlie these relationships and to determine whether interventions that address stress and social support can alter the course of HIV infection.

Role of Depression, Stress, and Trauma in HIV Disease Progression

Despite advances in HIV treatment, there continues to be great variability in the progression of this disease. This paper reviews the evidence that depression, stressful life events, and trauma account for some of the variation in HIV disease course. Longitudinal studies both before and after the advent of highly active antiretroviral therapies (HAART) are reviewed. To ensure a complete review, PubMed was searched for all English language articles from January 1990 to July 2007. We found substantial and consistent evidence that chronic depression, stressful events, and trauma may negatively affect HIV disease progression in terms of decreases in CD4 T lymphocytes, increases in viral load, and greater risk for clinical decline and mortality. More research is warranted to investigate biological and behavioral mediators of these psychoimmune relationships, and the types of interventions that might mitigate the negative health impact of chronic depression and trauma. Given the high rates of depression and past trauma in persons living with HIV/AIDS, it is important for healthcare providers to address these problems as part of standard HIV care.

Sexual and Physical Abuse and Gastrointestinal Illness: Review and Recommendations

Although the mechanisms for this association are unknown, psychological factors (somatization, response bias, reinforcement of abnormal illness behavior) and physiologic factors (psychophysiologic response, 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, if needed, how to make appropriate referrals. Conclusions: The authors agree with existing data on the association between abuse history and gastrointestinal illness. Physicians should ask patients with severe or refractory illness about abuse history. 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 sexual and physical abuse in U.S. society. Psychologists and psychiatrists now recognize several psychiatric syndromes (for example, somatization disorder, severe depression, post-traumatic stress disorder, the dissociative disorders, borderline personality disorder, and multiple personality disorder) as consequences of abuse [1, 2]. However, only in the last few years has attention turned to the physical concomitants of sexual and physical abuse, that is, their association with certain medical disorders and their effect on health care [3-7]. Of recent interest is the growing evidence that a history of sexual and physical abuse is associated with gastrointestinal illness [8]. Is this association unique to patients with gastrointestinal disorders, or is it part of a more generalized association between abuse history and somatization and reporting of symptoms? If a relation does exist, what are the possible reasons for it? Finally, what is the clinicians role 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 American Gastroenterology Association was formed. Our goals were 1) to review existing data on the relation between 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) to provide 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 medical and psychiatric illness, the data for gastrointestinal clinical populations are limited and will not be discussed. Methods Each member of the working team was assigned a topic by the primary author. He or she then did a MEDLINE search on that topic and submitted it to the primary author, who integrated the material into a manuscript that was then resubmitted to the working team and revised. The final document was agreed on by consensus. Clinical and Epidemiologic Associations Methodologic Considerations in Evaluating Studies of Abuse Reporting The widely differing estimates of the prevalence of abuse (6% to 62%) in the United States [9] result from the varying definitions and methods used to assess abuse history. Furthermore, police records and confirmation with family or acquaintances grossly underestimate the frequency of abuse, leaving no gold standard of validation. For clinicians, merely the disclosure of this information is considered truthful unless proven otherwise. However, to evaluate epidemiologic estimates of abuse history in clinical or population-based studies, clinicians and investigators must consider several factors. Changing Societal Values about Definitions of Abuse Numerous studies have suggested that the number of reports of sexual and physical abuse is high and may be increasing. In a review comparing the frequency of sexual abuse reported in the United States from the 1940s to the late 1970s, Leventhal [10] concluded that the frequency of these reports has increased (from 24% to 48% by the broad definition of abuse and from 12% to 28% by the narrow definition). The increase relates in part to changing societal values: The disclosure of an abusive experience is now encouraged and supported, whereas it was previously considered secretive and shameful. For example, society now considers date rape to be a form of sexual abuse. Thirty or 40 years ago, however, this experience may not have been defined as such, and victims may have been more reluctant to report it to officials. Investigators therefore must consider that the frequency of abuse reports are higher in areas where there is increased public attention to these events. Interview versus Questionnaire Some 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 more questions and specific activity-based questions that are known to increase abuse reporting. A carefully administered 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 There is evidence that more persons report abuse when definitions include questions based on behavior (for example, Has anyone ever touched the sex organs of your body when you did not want this?) rather than general or emotionally charged questions (for example, Have you ever been sexually abused or molested?) [9, 12, 13]. Furthermore, a broader definition of abuse that includes many types of forced or unwanted sexual encounters (such as noncontact abuse or fondling) results in higher estimates of abuse prevalence. Noncontact sexual abuse includes unsolicited sexual advances or encounters with exhibitionists during childhood [9]. Noncontact experiences include attempted or threatened rape or sexual touching in which force is used but sexual contact does not occur (such as when the victim escapes). Contact abuse can include both touch experiences (that is, being fondled or being 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. Because the life-threat associated with these experiences can differ, investigators can use groupings of physical abuse experiences [in descending order of threat]: 1) being assaulted or attacked with a weapon [such as a gun or knife]; 2) being attacked without a weapon but with the intent to kill; 3) being beaten 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 without a 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 abuse more rigorously as using force or threatening harm to engage in sexual acts [19-21]. Because abused persons are more likely to acknowledge abuse using the first definition and because questionnaires may tend to underestimate abuse [12], defining abuse as unwanted sexual experiences may be a more sensitive measure. However, with interviews, defining abuse in terms of force or threat of harm may 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, this definition 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 age is unnecessary. Estimates of childhood sexual abuse have also varied because different age criteria have been used to define childhood. The definition of childhood has ranged from 13 to 18 years, with some studies not defining what is meant by child. Age 14 years has recently been used as a cut-off for child and adult sexual abuse [22, 23]. Nature of the Setting and Patient Sample The clinical setting in which the information is obtained may be as important as the type of questions asked. Studies done in referral practices (such as pain centers or academic practices) yield much higher response rates than those done in primary care or nonclinical settings. Similarly, patients seeing mental health professionals for emotional difficulties may be more likely to report abusive experiences than patients attending medical practices [24]. Furthermore, the prevalence of abuse tends to be higher in younger samples and perhaps among persons in certain regional areas (for example, urban compared with rural) [13, 25]. Investigators should also consider that the positive predictive value of a screening evaluation will probably be greater in clinical settings in which the prevalence is high than in nonclinical settings in which the prevalence is low. The Psychosocial Profile of the Patient Patients with certain psychiatric disorders (such as somatization disorder) or personality disorders (such as borderline personality disorder) may set low thresholds for reporting medical or psychological symptoms. These patients might therefore overinterpret and over-report previous experiences as abuse. In contrast, patients with dissociation disorders who may not recall these experiences, or those who 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 developed coping skills or who fear retribution from the perpetrator, are much less likely to repo

Impact of Sexual and Physical Abuse Dimensions on Health Status: Development of an Abuse Severity Measure

Objective Despite the abundant literature showing a relationship of sexual and/or physical abuse history with poor health status, few studies provide evidence about with dimensions of abuse may have a worse impact on health. In female patients with gastrointestinal (GI) disorders, the present study aims to identify which dimensions of abuse history (eg, number of perpetrators, injury) might predict poor current health status, in order to develop an empirically based severity of abuse measure. Methods Of a sample of 239 female patients from a referral gastroenterology clinic, this paper primarily focuses on 121 women with a past history of contact sexual abuse (N = 99), and/or life threatening physical abuse (N = 68). Results Among those with a sexual abuse history, 24% of current health status was explained by serious injury during abuse (p =.0006), victimization by multiple perpetrators (p =.03), and being raped (p =.09). Among the physically abused, rape (in addition to life threat) (p =.0001), and multiple life-threatening incidents (p =.002) explained 39% of the variance in overall health. Among the women with a sexual and/or physical abuse history, the experience of rape, serious injury during sexual abuse, and multiple life-threatening incidents explained one fourth of the variance in current health status. Based on these three dimensions of abuse, we created an abuse severity measure which explained about one fourth of the variance in health status among the subgroup with abuse history, and among the entire clinic sample. Conclusions Given the high prevalence of abuse in referral practice, and the potential health impact of previous abuse, it is important that history taking include details concerning the abuse experience. The severity of abuse measure developed in this paper should prove useful for both research and clinical practice.

Health Outcomes and a New Index of Spiritual Experience

Clinical observations suggesting a relationship between spiritual experiences, life purpose and satisfaction, and improvements in physical health led to the development of an Index of Core Spiritual Experience (INSPIRIT). Data from 83 medical outpatients showed the INSPIRIT to have a strong degree of internal reliability and concurrent validity. Multiple regression analyses showed the INSPIRIT to be associated with: (1) increased life purpose and satisfaction, a health-promoting attitude; and (2) decreased frequency of medical symptoms.

The Rating Form of IBD Patient Concerns: A new measure of health status

&NA; Health status assessment for persons with chronic illness includes not only symptoms, but also an appraisal of the psychosocial concomitants of illness. In this national study of persons with inflammatory bowel disease (IBD), we standardized a disease‐specific 25‐item measure of perceived health status: the Rating Form of IBD Patient Concerns (RFIPC). Factor analysis yielded four indices: a) impact of disease (e.g., being a burden, loss of energy, loss of bowel control); b) sexual intimacy; c) complications of disease (e.g., developing cancer, having surgery, dying early); and d) body stigma (e.g., feeling dirty or smelly). A higher level of IBD concerns was associated with greater disease severity, female gender, and lower educational status. When controlling for these factors, as well as disease type and age, we found that concerns about: a) impact of disease was positively associated with poorer perception of health and well‐being, greater psychological distress (SCL‐90), and poorer daily function (Sickness Impact Profile) (p less than 0.0001); b) sexual intimacy was related to poorer psychologic function (p less than 0.01); and c) complications of disease was related to several measures of poorer daily function (p less than 0.0001 to 0.01). This standardized measure of the worries and concerns of persons with IBD may be used in clinical care and research to evaluate the effects of interventions on IBD patient outcomes.

Progression to AIDS, a clinical AIDS condition and mortality: psychosocial and physiological predictors.

BACKGROUND The primary aim of this study is to examine prospectively the association of stressful life events, social support, depressive symptoms, anger, serum cortisol and lymphocyte subsets with changes in multiple measures of human immunodeficiency virus (HIV) disease progression. METHODS Ninety-six HIV-infected gay men without symptoms or anti-retroviral medication use at baseline were studied every 6 months for up to 9 years. Disease progression was defined in three ways using the Centers for Disease Control (CDC) classifications (e.g. AIDS, clinical AIDS condition and mortality). Cox regression models with time-dependent covariates were used, adjusting for control variables (e.g. race, age, baseline, CD4 T cells and viral load, number of anti-retroviral medications). RESULTS Higher cumulative average stressful life events and lower cumulative average social support predicted faster progression to both the CDC AIDS classification and a clinical AIDS condition. Higher anger scores and CD8 T cells were associated with faster progression to AIDS, and depressive symptoms were associated with faster development of an AIDS clinical condition. Higher levels of serum cortisol predicted all three measures of disease progression. CONCLUSIONS These results suggest that stressful life events, dysphoric mood and limited social support are associated with more rapid clinical progression in HIV infection, with serum cortisol also exerting an independent effect on disease progression.