Trauma and multi-impulsivity in the eating disorders

Abstract

Background

Multiple impulsive behaviours are common in the eating disorders, and multi-impulsive patients appear to do more poorly in treatment. However, comparatively little is known about the origins of multi-impulsivity in such cases. This study addresses the links between reported childhood trauma and multi-impulsivity in the eating disorders, examining whether specific types of trauma are predictive of specific impulsive behaviours in this population.

Method

The sample consisted of 102 individuals who met strict criteria for an eating disorder, and who were interviewed regarding trauma history and comorbid impulsive behaviours.

Results

Any reported history of childhood trauma was associated with a higher number of impulsive behaviours and with the presence of multi-impulsivity. Childhood sexual abuse was particularly important, and was associated with self-cutting, alcohol abuse, and substance abuse (amphetamines, cocaine, cannabis and ‘other substances’, including ketamine and benzodiazepines).

Discussion

These findings indicate the importance of considering the psychological consequences of trauma during both assessment and treatment of the eating disorders. In particular, eating-disordered women who report a history of childhood sexual abuse should be examined for a pattern of comorbid impulsive behaviours.

Introduction

A large body of evidence exists to suggest that comorbid patterns of impulsivity are common in the eating disorders, and that some patients experience multi-impulsivity (Lacey & Evans, 1986). Fahy and Eisler (1993) and Lacey and Read (1993) categorize the multi-impulsive group as having bulimic symptoms plus at least of one of the following: alcohol abuse, drug abuse, suicide attempts, repeated self-mutilation, sexual disinhibition, and shoplifting. However, differences in pathology between uni-impulsives (i.e., bulimia only) and multi-impulsives have only been found when a more stringent criterion is applied—bulimia plus two impulsive behaviours (e.g., Fichter, Quadfleig, & Reif, 1994). Prevalence rates of multi-impulsivity vary from 6% in a community sample of bulimics (Welch & Fairburn, 1996) to 40% in a catchment area clinical sample (Lacey, 1993). Of those with bulimia plus any other impulsive behaviours, 80% will have bulimia plus two or more behaviours (Lacey, 1993), suggesting a broad pattern of impulsivity within certain individuals.

Bulimic behaviours are similar to other impulsive behaviours (McElroy et al., 1992, McElroy et al., 1995). All appear to be characterised by irresistible urges to commit the act, mounting tension when the individual attempts to resist the behaviour, and relief following the commission of the act (Winchel & Stanley, 1991). In addition, most of these impulsive behaviours arise from affective disturbance rather than from a failure to consider the self-destructive consequence of the relevant action (Fahy & Eisler, 1993). It has been suggested that these behaviours might serve a common ‘escape from awareness’ function, similar to that described by Heatherton and Baumeister (1991) and by Lacey (1986). In support of this, there is evidence that cognitive avoidance and dissociation are often present in impulsive behaviours (Baumeister, Heatherton, & Tice, 1994).

The coexistence of eating disorders and multi-impulsivity is clinically relevant, as these clients tend to do worse in therapy than those with only an eating disorder (Fichter et al., 1994), and multi-impulsive bulimia requires more intensive treatment (Lacey & Read, 1993). For example, Fairburn, Cooper, and Shafran (2003) have included impulsive behaviours as a treatment target in their new formulation of the eating disorders. However, although the clinical importance of these behaviours is recognised, little is known about their origins.

One potential factor that might explain multi-impulsivity is a background of trauma. Trauma has been shown to be associated with a range of impulsive behaviours. For example, in the field of self-injurious behaviour, the clinical literature repeatedly mentions childhood histories of physical or sexual abuse as a potential casual factor (e.g., Bach-y-Rita, 1974, Favazza, 1989, Graff & Mallin, 1967, Pattison & Khan, 1983, Stone, 1987). Similar links have also been highlighted between trauma and bulimic behaviours (e.g., Fallon & Wonderlich, 1997, Steiger & Zanko, 1990, Waller, 1991), and between trauma and alcohol abuse among eating-disordered individuals (Fullerton, Wonderlich, & Gosnell, 1995). However, within the context of an eating disorder, it is not clear whether specific kinds of trauma predispose individuals to particular types and patterns of other impulsive behaviours.

The first aim of this study was therefore to determine the links between childhood trauma and multi-impulsivity in the eating disorders. It was hypothesized that individuals with a multi-impulsive eating disorder would have experienced higher levels of trauma than patients with any other eating disorder. The second aim was to ascertain whether specific types of trauma are predictive of specific impulsive behaviours in eating-disordered patients.