Men and women who have experienced interpersonal violence often have poorer health than their nonabused counterparts—and these effects last long after the abuse has ended. Moreover, abuse survivors are significantly more likely to have a number of serious illnesses and to die prematurely compared to nonabused people. They often experience increased rates of cardiovascular disease, diabetes, and metabolic syndrome, the precursor to type 2 diabetes. Using an adult HMO sample, the Adverse Childhood Experiences (ACE) study found that men and women who had experienced four or more types of ACE were significantly more likely to have ischemic heart disease, cancer, stroke, skeletal fractures, chronic obstructive pulmonary disease, chronic bronchitis, and hepatitis. The types of adverse experiences included childhood maltreatment (physical abuse, sexual abuse, and neglect), parental mental illness, parental substance abuse, and parental criminal activity. The researchers counted each type (not incident) of ACE that a person experienced as “one.”
Given these rates of illness, it is not surprising that abuse survivors see doctors more often and have higher patterns of health care use. In an HMO sample, 22% of child sexual abuse survivors had visited a doctor 10 or more times a year, compared with 6% of the nonabused control group. High health care use was also noted in a study of women who had been battered or raped as adults.
In addition to office visits, health care use can include hospitalizations and surgery. Women who have experienced child or domestic abuse were also more likely to have had repeated surgeries. Severity of the abuse experience was the most powerful predictor of number of physician visits and outpatient costs.
One factor that might be driving the higher patterns of health care use among adult survivors is the increased likelihood of one or more chronic pain syndromes. Chronic pain is a major form of disability, accounting for an estimated $125 billion each year in health care costs, and it is common among victims of violence. In one study, pain was the most commonly occurring symptom in a community sample of child sexual abuse survivors.
Of the functional chronic pain syndromes, irritable bowel syndrome has been studied the most with regard to past abuse. In samples of patients in treatment for irritable bowel, abuse survivors comprise 50% to 70%. Abuse survivors can also suffer from chronic pain in other parts of the body. Abuse has been related to chronic or recurring headaches, pelvic pain, back pain, or more generalized pain syndromes. These findings apply to both survivors of childhood abuse and those abused as adults. Patients with these conditions often have marked physiological abnormalities in brain structure and function that are apparent using technology such as positron emission tomography (PET) scans, computed tomography (CT) scans, and magnetic resonance imaging (MRI) of the brain.
Why Maltreatment as Children Makes Adults Sick
While researchers have documented that abuse survivors are more prone to physical illness, they know substantially less about why this occurs. However, researchers have identified five possible pathways by which victimization is likely to influence health in abuse survivors—physiological changes, behavior, cognitive beliefs, social relationships, and emotional health. Adult survivors can be influenced by any or all of these, and the five types influence each other. Indeed, they form a complex matrix of interrelationships, all of which influence health.
Physiological Changes
Traumatic events change the way the body functions. The body becomes “threat sensitized” and more vulnerable to stress reactions and depression when faced with subsequent stressors. There is also evidence that survivors’ pain threshold is lowered, making them more vulnerable to chronic pain syndromes. The more severe the abusive experience, the more dramatic the physiologic changes.
Behavior
Traumatic events increase the risk of participation in harmful activities that include smoking, eating disorders and obesity, substance abuse, and unsafe sexual practices. Sleep disturbances are also common in abuse survivors, and this compromises every aspect of health.
Cognitive Beliefs
What one thinks about oneself and others can have a measurable impact on one’s immune system and cardiovascular health. Shame and low self-esteem and self-efficacy all have deleterious effects on health. Hostile or mistrusting beliefs about others can also have a negative impact on health, and influence the next category: quality of social relationships.
Social Relationships
Abuse survivors have higher rates of unstable relationships, divorce, and revictimization at the hands of intimate partners. Marital strife, for example, increases the risk of heart disease in women. But positive and supportive relationships buffer stress and even increase longevity. In short, one’s social relationships can either enhance health or make it substantially worse. And abuse survivors often have troubled relationships.
Emotional Health
A person’s emotional health also influences his or her physical health. Psychological stress, depression, and posttraumatic stress disorder increase inflammation by increasing levels of proinflammatory cytokines. Elevated inflammation increases the risk of diseases such as cardiovascular disease, metabolic syndrome, and even Alzheimer’s disease.
Recognizing the complexity of the forces that are related to the health of abuse survivors, researchers and health care professionals can strive for an approach that addresses all five of these pathways. Health outcomes are unlikely to improve if such professionals continue in the current mind-set of treating mental health and physical health aftereffects separately. Recognizing, and addressing, all these underlying factors can help health care professionals improve the health of adult survivors of childhood abuse.
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