Sexual Assault

and Anorexia Nervosa

Justin0. Schechter, M.D.

Henry P. Schwartz, M.D.
David C. Creenfeld, M.D.

Two cases of sexual assault with subsequent onset or exacerbation of an-

orexia nervosa are described. Features common to anorexia nervosa and
the sexual assault syndrome include feelings of guilt, inadequacy, loss of
control, and distortion of body image.

Sexual assault can cause serious psychologic sequelae, both acute

and prolonged. Burgess and Holmstrom (1974) have delineated a spe-
cific trauma syndrome in which the assault victim characteristically un-
dergoes a two-phase reaction. The initial acute phase is characterized
by physical symptoms and disorganization of lifestyle. The second
phase is one of reorganization in which the woman must develop c o p
ing mechanisms to deal with the trauma.
Sexual assault can challenge a woman's ability to maintain her defen-
ses and can arouse feelings of @t, anxiety, and inadequacy (Notman
& Nadelson, 1976). The result can be a traumatic neurosis that leaves
the patient with a sense of powerlessness and loss of control (Gelinas,
1983). In addition, distortion of body image as a result of the physical
assault has been reported (Sdtuker, 1979). The physical and psychic

justin 0. ktnchtcr, M.D., is fomwrly Chief of the Acute Treatment Unit at the Connecticut
Mental Health Center and instructor in the Departrmnt of Psychiatry, Yale University School
of Medicine. Henry P. Schwartz, M.D., is a Postdoctoral Fellow in the Department of Psy-
chiatry, Yale University School of Medicine. David C. Cmnfdd, MD., is Medical Director
of the Adolescent and Young Adult Treatment Unit at Yale New Haven Hospital and Associ-
ate Clinical Professor in the Department of Psychiatry, Yale University School of Medicine.
Please address reprint requests and correspondence to Justin 0. Schechter, M.D., Stamford
Hospital, P. 0. Box 931 7, Stanford, Connecticut 06904.

lnternational journal of Eating Disorders, Vol. 6, No. 2, 31 3-316 (1987)

0 1987 by John Wiley & Sons, Inc. CCC 0276-3478/87/020313-04504.00
314 Schecter, Schwa-, and Creenteld

injury following such a trauma may also exert a profound effect on an

individual’s body image, which in turn can alter the victim’s self con-
cept, personality, and social behavior (van der Velde, 1985). Tlus dis-
tortion includes primitive fears of loss of bodily control, fear of
mutilation, and feelings of disgust with one’s body. In short, the se-
quelae of sexual assault can be intense and can have signlficant impact
on the victim’s capacity to function.
Distortion of body image and a subjective sense of ineffectiveness
are also characteristic of women suffering from anorexia nervosa
(Bruch, 1982; Schwabe, 1981). In fact, the anorexic’s body typically be-
comes the actual and symbolic focus of a struggle with family members
for control of weight, body contour, and larger general issues of con-
trol.
The onset of anorexia has been noted to occur at times of significant
life change (Bruch, 1978). Stressful physical injury and consequent dis-
tortion of body image may result in posttraumatic anorexia nervosa
(Damlouji & Ferguson, 1985). Although it is presently unknown
whether spedfic environmental factors can precipitate or aggravate an-
orexia nervosa, there are similarities between the psychological se-
quelae of sexual assault and the typical psychologic manifestations of
anorexia nervosa. Common to both are feelings of gwlt, inadequacy,
loss of control, and distortion of body image. Surprisingly, there have
been no reports linking these two conditions. The cases reported here
describe two instances of sexual assault with subsequent development
of the sexual assault syndrome associated with the onset or exacerba-
tion of anorexia nervosa.

CASE 1

Ms. A., a 16-year-old student, was admitted to a hospital medical

service for treatment of hypotension, dehydration, and hypokalemia
after a 23 lb weight loss over a 3-month period. On admission she was
5 ft 4 in. tall and weighed 97 lb, which piaced her in the 25th percentile
for her age. After 3 days of intravenous hydration and caloric supple-
mentation, she was transferred to the psychiatric service. She de-
scribed a 1-12 year period of altered eating patterns that began after
being sexually assaulted. She had been forced into a car when walking
home from school and taken to nearby woods where she was
assaulted. Her assailant inserted his fingers into her vagina while dis-
p a r a p g her. Three weeks later her mother brought her to a psychiat-
ric cliruc for escalating anxiety, nightmares, insomnia, and @ty
nuninations about the assault. She was diagnosed as having acute
posttraumatic stress disorder (PTSD).She was treated with brief psy-
chotherapeutic intervention, and her PTSD symptoms abated. When
Sexual Assault and Anorexia Nervosa 315

admitted for inpatient psychiatric care 1-112 years later, the patient
gave a history of the onset of binge eating and self-induced vomiting
shortly after the sexual assault. This behavior began with weekly ice
aeam binges and later generalized to other foods and occurred with
increasing frequency. After a binge she would feel gurlty, worry about
having an unattractive and bloated appearance, and then purge. She
also increased her physical activity, especially partidpation in school
athletics. After being cut from her school basketball team, she became
determined to lose weight. She restricted her caloric intake to 200 cal-
ories per day, and if she had lost 5 Ib over the course of a week would
reward herself with bingeing and purging on the weekend using food
she had hoarded in her room. She showed significant depressive
symptomatology that included apathy, anergy, dysphoria, irritability,
social withdrawal, and psychomotor retardation. She insisted that she
was obese and unattractive and the only way to improve her mood
was to lose weight.

CASE 2
Ms. B., a 24yearsld single white graduate student, presented for
her first psychiatric admission with a complaint of feeling disgusted
with herself. Her history was sigxuficant for a 12-year period of poor
appetite alternating with binge eating and self-induced vomiting. Ad-
ditional longstanding symptoms included obsession about body weight
and food consumption, poor self-esteem, and distortion of body image.
Four months prior to admission the patient moved away from her
family to attend a graduate education program. During her first month
away from home she suffered from heightened anxiety and occasional
binges and vomiting. Also during this period the patient was raped by
an acquaintance. Following the assault she became preoccupied with
gtulty and anxious ruminations over the role she had played in this
traumatic event. In the months that followed, her anxiety and preoc-
cupations with food and caloric intake became markedly more intense.
She placed herself on a rigid, minimally nutritious diet and would
purge for up to an hour at a time, often to the point of hematemesis.
Her weight dropped from its usual level of 103 Ib to 90 Ib, and after 2
months she discontinued her studies and returned home to live with
her family.

DISCUSSION
In the cases discussed above, the relationship between the sexual
assault syndrome and the subsequent appearance of anorectic symp-
316 Schecter, Schwartz, and Creenfeld

toms is complex. In both case reports, anorectic symptoms occurred

following sigruficant life events that included a sexual assault, and in
both instances the clinical presentation was characterized by sigruficant
@t, loss of control, and distortion of body image. Since sexual assault
involves intimate bodily intrusion, real or implied physical threat, and
often severe humiliation, it is likely that alteration of body image and
pathologic concern with bodily contour and h c t i o n might be a direct
consequence of the assault. This may be particularly true in patients
predisposed to anorexia nervosa, since they are frequently uncomfort-
able with issues of sexual attractiveness and may avoid sexual involve-
ment (Dickstein, 1985). These factors might make it more likely that
sexual assault would lead to traumatic alterations in M y image.
In the report of Ms. A. we see the development of anorectic symp-
toms shortly after an assault. Having manifested symptoms of PTSD,
her subsequent symptoms of anorexia nervosa appeared to be an at-
tempt to improve a worsened body image. In patients who may al-
ready be manifesting symptoms of anorexia nervosa and struggling
with issues of emancipation and independence, as in the case of Ms.
B., sexual assault may serve to heighten concerns about loss of control.
Ms. Bs sharp increase in dieting and vomiting following the assault
correlates with the patient's feelings of gudt and an urgent need to
regain control of her life.
Clearly, further exploration of the association between sexual assault
and anorexia nervosa is warranted. Traumatic neurosis foblowing sex-
ual assault may place a vulnerable individual at increased risk for de-
veloping anorexia nervosa. A 6rst step in gathering additional data on
this association is the acquisition of a careful and detailed sexual his-
tory in those patients who present with eating disorders.

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