Medically-Unexplained Symptoms in CSA Survivors

1. Medically-Unexplained Symptoms in CSA Survivors Dr Sarah Nelson Dr Julie Taylor Prof Norma Baldwin University of Dundee

2. MUS in Sexual Abuse Survivors • A review of the research literature on MUS in people with sexual abuse histories and mental health symptoms • National Programme for Improving Mental Health and Wellbeing: Small Projects Initiative 2006

3. MUS in Sexual Abuse Survivors:Wider health issues in CSA • Injuries and infections from the assaults themselves • Effects of pregnancy, abortions etc at early age • Escaping abuse: many risks to health on streets • Physical health effects of psychol. effects, e.g. eating disorders, depression, self-injury

4. MUS in Sexual Abuse Survivors: Wider health issues in CSA 2 • Effects of misusing drink/drugs to cope with trauma • Fear and avoidance of health & dental checks • Side-effects of prolonged psychiatric medication • Survivors at higher risk for medically-explained conditions like diabetes, heart disease

5. MUS in Sexual Abuse Survivors: Main types of MUS • Irritable bowel syndrome & other GI complaints • Chronic pelvic pain/severe premenstrual pain • Fibromyalgia & other chronic pain • Respiratory conditions, wheezing, throat problems • Non-epileptic seizures • Chronic fatigue • Symptoms across several organ systems

6. MUS in Sexual Abuse Survivors: Aims of the study • To find out how CSA survivors with MUS and mental health issues have been identified and sampled; the key findings of research literature; theories used to explain inter-connections; any interventions and treatments for the CSA group; gaps in knowledge or understanding which require further research… • ………And to make recommendations!

7. MUS in Sexual Abuse Survivors: Methodology of the review • Electronic searches of medical, psychiatric and social work databases from 1990: quantitative or qualitative studies • Studies had to refer to CSA, MUS and mental health issues • Included review and discussion papers for theory section • Hand –searches plus SN’s prior knowledge of issue • Consultation with experts

8. MUS in Sexual Abuse Survivors: Key review findings • 96 studies retrieved + 27 reviews or discussion papers: overwhelmingly a medical literature • Main recruitment was from “tertiary care” clinics • CSA survivors were main focus in only 9 studies – instead, people with certain symptoms were main focus • Only three qualitative studies and three on males: only one intervention identified for this specific group • Most researchers were medical specialists not experts in CSA: few collaborations with CSA services or support agencies

9. MUS in Sexual Abuse Survivors: Key review findings 2 • Most papers confirm people with CSA are at higher risk for MUS, especially for GI and chronic pain; • The more serious the abuse, more serious the impact on MUS, disability, sick days and healthcare use; • Childhood physical abuse and adult physical assaults also significant influences on MUS; • Recomms. for general good practice include detailed history-taking, respectful listening, referral for psychol therapy.

10. MUS in Sexual Abuse Survivors: Theories of the links • Somatisation: emotional stress translates into bodily symptoms • Severe trauma causes changes in central nervous system increasing vulnerability to pain and infections (neurobiol. research) • Dissociative re-enactments and “body memories” occur

11. MUS in Sexual Abuse Survivors: Theories of the links 2 • Depression/anxiety lead people to amplify their physical symptoms • Injury and infection through assaults directly influence symptoms, especially chronic pain

12. MUS and Sexual Abuse Survivors: Problems of existing research “An overriding concern with testing which risk factors contribute to which outcomes has produced a repetitive (and competitive) body of case control studies, which have failed to identify helpful interventions for sexually abused people with MUS”

13. MUS and Sexual Abuse Survivors: Problems of existing research 2 • Discrete variables used don’t match survivors’ experience, whose forms of abuse & neglect are often interlinked • Key concept, somatisation problematic & poorly defined • Very little collaboration with specialists in CSA • Voices of survivors themselves rarely heard • Lack of ethical safeguards or support for abused people filling in intrusive questionnaires

14. MUS and Sexual Abuse Survivors: Problems about “somatisation” • Term is variously defined, or left undefined • Prone to gender biases - most “somatisers” (“heartsink patients”? ) are women • Ignores other possible explanations plus possibility that a medical condition may be inadequately diagnosed • No convincing proof that the process even exists!

15. MUS and Sexual Abuse Survivors: Recomms for research • CSA survivors must be primary focus of research • Needs to be geared to exploring causes and relieving suffering • Needs open mind, free of value judgments re. “somatisation” • Medical specialists need to collaborate with CSA specialists in design and interpretation of studies

16. MUS and Sexual Abuse Survivors: Recomms for research 2 • Need qualitative research with adult survivors with MUS, to explore health history, abuse history, experiences of health system, and interconnections • Studies of male survivors with MUS • Case histories, exploring medical records and attitudes of clinicians

17. MUS and Sexual Abuse Survivors: Recomms for research 3 • Research into direct physical effects of violence and injury, and into “body memories”, including collaboration with torture research experts • Collaborative research with vol. sector support agencies • Prospective studies with children & young people whose abuse has been documented

18. MUS and Sexual Abuse Survivors: What can new research achieve? • Would help in design of good-practice interview schedules for MUS patients • Would increase respect and dignity of CSA survivors • Would inform design of therapeutic interventions which could be piloted and evaluated • Would increase informed knowledge, understanding of causes, and long-term research collaboration

19. MUS and Sexual Abuse Survivors • “Er - that’s it!”