Issue Date: October 2012 Vol. 7 No. 10
Authors: Debra Rose Wilson, PhD, MSN, RN, IBCLC, AHN-BC, CHT, and and Mariesa R. Severson, MSN, RN, WHNP, ICCE
Psychological consequences of trauma were first seen in veterans of war and described in the literature as shell shock. By 1980, the diagnosis of post-traumatic stress disorder (PTSD) was listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which guides healthcare practitioners with diagnosis, treatment, and reimbursement. For years we have been studying the psychological changes that are the sequelae of childhood trauma. These long-term consequences include a higher incidence of depression, intrusive flashback memories, hypervigilance, maladaptive coping skills, dysfunctional social skills, and an overactive stress response. Research examining the more holistic effect of trauma has exploded due to recent events, such as 9/11, terrorism, and traumatized troops returning from war.
As holistic nurses, we understand that even when the effect seems to be psychological, social or biology is also influenced. The mind and body interact on every level. The ripple effect of early childhood trauma has more than psychological effects. Biology of the brain and immune function are influenced. The child is forever changed. Here we examine the influence of childhood sexual abuse on the long-term health and the nursing care of adult survivors.
Stress
Walter Cannon first described the fight-or-flight response in 1914 as the complex physiological response that prepares the body for fighting or fleeing. The sympathetic nervous system responds to a stressor, suppressing the calming effects of the parasympathetic system. The hypothalamus in the brain secretes hormones that in turn influence the kidneys and the brain. The cascade of chemicals has a ripple effect on many systems, including the respiratory, gastric, cardiovascular, endocrine, renal, and immune. A major part of the brain/hormone/immune interaction, the hypothalamic-pituitary-adrenal axis, becomes involved and further influences physical and psychological functioning.
Adrenocorticotropic hormone is released from the brain and anti-inflammatory steroids such as cortisol suppress the immune system. Ability for healing and even normal cell maintenance is reduced. With altered immune cell levels, the body has increased inflammation, susceptibility to infection, allergic response, and cell mutation. Natural killer cells, for example, whose job it is to correct the cell mutation of cancer, diminish in number. The effect is cumulative: The longer the stress is perceived, the greater the severity of imbalance.
Early trauma changes the brain
When trauma and stress happen early in life, the effects are far more profound and long-lasting. Biological brain development is influenced by genetics, nutrition, social interaction, and experiences. Almost no new brain neurons are formed after birth. There is, instead, a constant rewiring of the existing neurons. New connections are made and old connections are disconnected. This understanding of the plasticity of the brain is what drives rehabilitation after a stroke.
Trauma and early negative experiences affect the development and even structure of the brain. Women who were sexually abused as children show significantly diminished brain volume on brain scans. The structure and function of the hippocampus (responsible for learning and memory), for example, are different when compared to individuals who weren’t traumatized. The medial prefrontal cortex, amygdala, and other neural circuitry of the brain are also changed. The brain shows a sustained and pervasive stress response as the child grows, and this has a long-term effect on immune function. Brain wave patterns change. The brain’s response to inflammation and healing is altered. Neurotransmitter levels adapt to these new abnormal levels. The biological changes in the brain are even more profound if the abuse was early, pervasive, or severe.
Long-term health issues for survivors of childhood sexual abuse
The range of potential adverse health outcomes is extensive and childhood sexual abuse can be seen as a risk factor for many diseases. Those who experienced childhood sexual abuse are one and a half times more likely to report serious health problems.
The figure below shows common long-term sequelae of childhood sexual abuse. Because of the holistic nature, it’s difficult to categorize the conditions into traditional systems or paradigms.
Childhood Sexual Abuse
(Click to download PDF)
Used with permission from Perspectives in Psychiatric Care.
Psychological issues for this population often include anxiety, poor self-esteem, dysfunctional relationships, eating disorders, and PTSD. PTSD results from a threat to self or others accompanied by "intense fear, horror, or helplessness," according to the Veteran’s Administration National Center for PTSD. Maladaptive coping such as denial is overused. Those with a history of childhood sexual abuse have increased reports of fear, anxiety, insomnia, headaches, aggression, anger, hostility, poor self-esteem, and suicide attempts. Higher rates of depression are reported. Depression has also been shown to be associated with impaired immune functioning. Increased cytokines (inflammation) and cortisol (stress) have been identified as mechanisms by which immune system function is impaired and related to depression. Incidences of dysfunctional relationships, intimate partner violence, and self-destructive behavior are higher.
Higher rates of some physical diseases, such as sexually transmitted diseases, hepatitis, or pelvic inflammatory disease, can be attributed to the common behavioral issues for this population that include promiscuity, substance abuse, and/or sexual dysfunction. But for those traumatized early in life, there exists a clear and increased risk of lung disease, ulcers, cardiac disease, diabetes, and cardiac disorders. The high incidence of inflammatory disorders, such as rheumatoid arthritis and allergies, is an example of the imbalanced immune system’s overreaction. Prolonged stress and exposure to cortisol, for instance, cause wounds to heal slowly, indicating an underreacting immune system.
Autoimmune disease
The role of childhood sexual abuse in the development of autoimmune disease is worthy of special attention. Trauma in early childhood predisposes the individual to autoimmune diseases in later life. Some of the strongest evidence linking autoimmune disease to childhood trauma is a retrospective study of over 15,000 adults who were enrolled in the Adverse Childhood Experiences study. Autoimmune disease processes commonly seen in this population are fibromyalgia, Crohn’s disease, irritable bowel syndrome, type 1 diabetes, and rheumatoid arthritis. Patients with a history of childhood sexual abuse may develop fibromyalgia and use outpatient health services and analgesics more frequently. Adult survivors of childhood sexual abuse also report increased pain associated with other medical conditions. Cardiovascular diseases, such as arteriosclerosis and ischemic heart disease, are directly related to maladaptive immune function and inflammation and occur in higher rates in adult survivors of childhood sexual abuse. It’s important to remember that any of these disease processes can occur in people who weren’t sexually abused as children.
Healing is possible
Healing from childhood sexual abuse is possible at any point in life. Nurses should be familiar with local providers for counseling, stress-management training, and holistic care of these survivors. Nurses should take an active role in advocating for the client in the referral process when the history of childhood sexual abuse is identified. The human cost of healing survivors of childhood sexual abuse is still far greater than the cost of preventing childhood sexual abuse from occurring in the first place. Being sexually abused as a child has a lifelong impact on health. Once again we are reminded that an awareness of the holistic perspective is vital for competent nursing care of victims of childhood sexual abuse.
Now that you have read the article, see how you would handle these example scenarios. There is no one right answer.
Scenario #1 Mrs. B. Raider is a 60-year-old menopausal client who presents at her physician’s office following a stressful event of being laid off from her job. When reviewing her record, the nurse notices that this is Mrs. Raider’s 10th visit to the clinic in the last year. She notes a history of back pain, migraine headaches, depression with use of selective serotonin reuptake inhibitors, irritable bowel syndrome, alcoholism, and fibromyalgia. Mrs. Raider has difficulty making eye contact when asked why she is here today, and states that she has been having persistent pelvic pain. She says she is unmarried, not sexually active, and divorced less than a year.
What clues about her history might indicate sexual abuse? What support groups, stress-management training, or nursing interventions may be helpful? Note: To answer the first question, refer to the Childhood Sexual Abuse figure earlier in this article.
Scenario #2 Miss Clarissa Kent is an 18-year-old homeless, obese woman who presents at an urban free clinic with complaints of malodorous vaginal discharge, fever, and pelvic pain for the last 48 hours. She has no contact information, is unaccompanied, and reports a history of I.V. drug abuse. She states she fears she might be HIV-positive. When the nurse inquires about her work-related status, the young woman explains that she recently chose to work for a local escort service to support her drug habit and pay the bills. She reports a long history of poor health and bulimia since she began middle school. She admits to attempting suicide in the past; following the event, she dropped out of school and ran away from home. She says she did this primarily because of the way she was being "treated" by her alcoholic stepfather for most of her life. After sharing this she looks away and states she doesn’t want to talk about it, and asks to see the physician.
What might you say to make her more comfortable continuing her story? What resources exist in your community to help this young woman? What might you say and do if she disclosed a history of sexual abuse?
Scenario #3 Mr. Howell accompanies his wife Rebecca to labor and delivery for the birth of their first baby. The nurse notices that Mr. Howell is very protective of his wife, and that his wife isn’t answering many of the questions that are being asked. Rebecca allows her husband to speak on her behalf and is resistant to changing into the hospital gown or letting the nurse put on the fetal monitors. She seems to become tense and pulls away when light touch is used to help her with relaxation. When the nurse tries to explain the need to do a vaginal exam to check the progress of cervical dilation and effacement, the couple admits that they don’t understand what she is referring to and add that they only established prenatal care about a month ago. They haven’t attended any prenatal classes. When the nurse attempts a vaginal exam, Rebecca is unwilling to adequately open her legs or relax her perineum sufficiently. The nurse explains that the female provider Mrs. Howell has seen for the past month isn’t on call and that a male provider will instead attend their birth. Rebecca begins to suddenly sob uncontrollably, as Mr. Howell becomes angry and defensive towards the nurse. What changes and accommodations could the nurse have made that would have been more sensitive to the needs of Rebecca Howell. What behaviors and symptoms might indicate a possible history of sexual abuse?
Debra Rose Wilson is a professor at Walden University in Minneapolis, Minnesota, and Middle Tennessee State University in Murfreesboro, Tennessee. Mariesa R. Severson is assistant professor at Middle Tennessee State University School of Nursing.
Selected references
Bremner JD. Effects of traumatic stress on brain structure and function: relevance to early responses to trauma. J Trauma Dissociation. 2005;6(2):51-68. doi:10.1300/J229v06n02_06.
Dube SR, Fairweather D, Pearson WS, Felitti VJ, Anda RF, Croft JB. Cumulative childhood stress and autoimmune diseases in adults. Psychosom Med. 2009:71(2):243-250. doi: 10.1097/PSY.0b013e3181907888.
Goodwin RD, Stein MB. Association between childhood trauma and physical disorders among adults in the United States. Psychol Med 2004;34:509–520.
Sachs-Ericsson N, Blazer D, Plant EA, Arnow B. Childhood sexual and physical abuse and the 1-year prevalence of medical problems in the National Comorbidity Survey. Health Psychol. 2005;24(1):32-40.
U.S. Department of Veterans Affairs. (2011). National Center for PTSD. http://www.ptsd.va.gov/professional/pages/forensic-validity-ptsd.asp. Accessed September 20, 2012.
Wilson DR. Health Consequences of childhood sexual abuse. Perspect Psychiatr Care. 2010;46(1):56-64. doi: 10.1177/0123456789123456.
Wilson DR, Warise L. Cytokines and their role in depression. Perspect Psychiatr Care. 2008;44(4):285-289. doi: 10.1111/j.1744-6163.2008.00188.x.
American Nurse Today
http://www.americannursetoday.com/article.aspx?id=9564&fid=9534
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