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Book Forum: Trauma and Dissociation   |    
Trauma, Dissociation, and Impulse Dyscontrol in Eating Disorders
Am J Psychiatry 2000;157:1358-a-1359. doi:10.1176/appi.ajp.157.8.1358-a
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Tampa, Fla.

By Johan Vanderlinden, Ph.D., and Walter Vandereycken, M.D., Ph.D. Philadelphia, Brunner/Mazel, 1997, 256 pp., $29.95.

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In this fascinating book the authors present the evidence for a link between trauma and eating disorders and then provide a detailed outline of the specialized treatment needed by these patients. In the first chapters the authors detail the evidence for a connection between a history of sexual abuse and eating disorders and associated symptoms. They point out that sexual abuse is reported by a higher percentage of patients with eating disorders (20%–50%) than the normal population, but a similar rate of female psychiatric patients report a history of sexual abuse. They report that there is evidence that a history of sexual abuse is higher among patients with bulimia-like symptoms than among patients with restricting anorexia and that patients with a history of sexual abuse are more likely to have comorbid psychiatric disorders.

The authors cite a report finding that patients with a history of trauma had higher scores on the Dissociative Questionnaire, particularly on the subscale for amnesia, than patients without a history of abuse. They describe the variables that may mediate the link between abuse and dissociative symptoms. The presence of comorbid psychiatric disorders is attributed to impulsive dyscontrol. The authors present the results of a study of stealing behavior, which found that 47% of 73 patients had stolen. In a study of self-injurious behavior, almost half of 94 female patients had at least one form of self-injury during the past year.

The fourth chapter describes the multidimensional assessment recommended. Then chapters 5–7 provide very helpful guidelines for the treatment of patients with eating disorders who have a history of trauma. The first goal of treatment is to help the patient regain self-control by using self-monitoring, response prevention techniques, and alternative abreaction techniques (such as moderate exercise to help reduce tension).

In chapter 6, the use of hypnotherapy techniques is described. The authors chose these techniques because they believe that many trauma patients are stuck in a state of negative self-hypnosis, continuously repeating negative suggestions to themselves. Several specific techniques are used to try to reintegrate dissociated portions of the self. The authors present the concept of an "affect bridge" in which the emotion preceding the problematic behavior (e.g., purging) is used as a bridge to the past where a situation occurred that makes the feeling explicable.

In chapter 8, the risks, complications, and pitfalls of psychotherapy with trauma patients are described. The circumstances in which trauma exploration may result in a revictimization experience are described. Those individuals who are not likely to tolerate exploration of the abuse are identified. In a very helpful section, the authors describe risks and complications for the therapists and ways of avoiding detachment or overidentification.

This book provides several novel approaches to patients with eating disorders who have a history of trauma. The indications and contraindications for the use of several hypnotherapy techniques are described. Many of the treatments recommended are not widely used in the United States, but the authors provide cogent arguments for considering their use. This book is strongly recommended for any therapist working with patients with complex eating disorders.




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