The potential role of childhood emotional abuse (CEA) in the etiology and maintenance of eating psychopathology is reviewed. While childhood sexual and physical abuse have been hypothesized as risk factors in multifactorial models of eating disorders, a role for CEA has only recently been considered. Initial findings demonstrate a phenomenological link between CEA and eating psychopathology, and suggest that this association might be different to the links for other forms of trauma (i.e., CEA may have a relationship with a broader range of eating symptoms than sexual and physical abuse). However, the psychological processes that might account for such a link are not yet well understood. Potential cognitive and affective mediators are considered, with a particular emphasis upon low self-esteem and anxiety. A model is proposed, to act as a framework for further research into this field. The clinical implications of the research to date and of the proposed model are discussed.
UNDERSTANDING OF THE etiology and maintenance of eating disorders has advanced substantially in the last decade. Anorexia nervosa and bulimia nervosa involve a complex, multifactorial host of biological, familial, and contextual variables (e.g., Fairburn et al. 1999, Lacey 1986 and Slade 1982). Researchers and clinicians continue to disentangle these factors and their interactions, in order to understand the etiology of eating psychopathology. Childhood abuse is one factor whose importance has come to be recognised in recent years (e.g., Fallon & Wonderlich 1997 and Rice 1996). Some aspects of child abuse have been considered extensively—particularly, reported sexual abuse. However, other aspects have received far less attention. It is the purpose of this review to examine critically the literature that bears on one such area—emotional abuse and its relationship with eating problems.
There is a patchy history of attempts to understand the impact of trauma upon eating. The effects of childhood sexual abuse (CSA) upon subsequent eating psychopathology is an area that has generated considerable interest and debate (e.g., Fallon & Wonderlich 1997, Vanderlinden & Vandereycken 1993, Vanderlinden & Vandereycken 1997, Waller 1991 and Wonderlich et al. 1997). While some continue to claim the importance of CSA as a risk factor, particularly in the development of bulimia (e.g., Rorty & Yager 1993 and Wooley 1994), others feel that its role has been overstated Pope & Hudson 1992 and Schmidt 1993. The role of childhood physical abuse (CPA) has attracted substantially less attention in the eating disorders literature. The paucity of studies investigating the link between CPA and eating psychopathology is surprising when one considers that CPA was the first form of abuse to gain the interest of researchers (e.g., Kempe, Silverman, Steele, Droegemueller, & Silver, 1962). Early findings suggest that CPA may act as a nonspecific risk factor for some eating disorders, particularly bulimia Folsom et al. 1993 and Root & Fallon 1988.
With regard to eating psychopathology, by far the least studied form of active trauma is childhood emotional abuse (CEA). (Many terms have been used to describe this form of abuse. Childhood emotional abuse will be used throughout this review, but acknowledgement will be made when a referenced source has employed an alternative term.) There are several reasons for the neglect of CEA, not least the considerable definitional and measurement difficulties. Despite these difficulties, CEA has been recognized as being a core issue in child abuse, and one that merits more attention (Hart & Brassard, 1987). CEA has been defined in many ways, but for the purposes of this review it will be taken to mean “the sustained, repetitive, inappropriate emotional response to the child's experience of emotion and its accompanying expressive behaviour” ( O'Hagan, 1995, p. 456). In the broader literature, CEA is now thought to be more prevalent than other forms of abuse, as well as being more damaging in the long term (O'Hagan, 1993). Its potential importance as a factor in the etiology of eating disorders has been considered (e.g., Root & Fallon, 1988), although empirical research into this link is more recent (e.g., Rorty, Yager, & Rossotto, 1994).
A further difficulty in the trauma literature is that previous research in childhood abuse has compartmentalized forms of trauma (Rosenberg, 1987), meaning that there is little research that integrates findings across all abuse forms. This approach has meant that specific types of abuse (usually CSA) have been studied in isolation, with little or no reference to the broader spectrum of abuse experiences. Thus, research so far has been strikingly acontextual and lacking in integration. Therefore, the first task of this review is to provide a framework for understanding the role of CEA in eating psychopathology.
This review has synthesized findings from the abuse and the eating disorder literatures, examining the evidence that CEA has a role in the etiology of eating problems. Despite the past neglect of CEA, both clinical impressions and initial findings from empirical research suggest that a link does exist between CEA and eating psychopathology. The nature of that link is not yet clear, although low self-esteem (and underpinning negative core beliefs) may be a crucial mediator between the two phenomena.
A testable model has been presented, indicating a possible role for CEA in the development of eating disorders. The model conceptualizes the cognitive and affective processes that might explain how CEA (in combination with other factors) could predispose an individual to develop an eating problem. It is hoped that this model will stimulate further research, and that it will alert clinicians to the potential importance of CEA in the development, maintenance, and treatment of eating psychopathology.
