1. Medically-Unexplained Symptoms in CSA Survivors Dr Sarah Nelson Dr Julie Taylor Prof Norma Baldwin University of Dundee

2. MUS in Sexual Abuse Survivors A review of the research literature on MUS in people with sexual abuse histories and mental health symptoms National Programme for Improving Mental Health and Wellbeing: Small Projects Initiative 2006

3. MUS in Sexual Abuse Survivors: Wider health issues in CSA Injuries and infections from the assaults themselves Effects of pregnancy, abortions etc at early age Escaping abuse: many risks to health on streets Physical health effects of psychol. effects, e.g. eating disorders, depression, self-injury

4. MUS in Sexual Abuse Survivors: Wider health issues in CSA 2 Effects of misusing drink/drugs to cope with trauma Fear and avoidance of health & dental checks Side-effects of prolonged psychiatric medication Survivors at higher risk for medically-explained conditions like diabetes, heart disease

5. MUS in Sexual Abuse Survivors: Main types of MUS Irritable bowel syndrome & other GI complaints Chronic pelvic pain/severe premenstrual pain Fibromyalgia & other chronic pain Respiratory conditions, wheezing, throat problems Non-epileptic seizures Chronic fatigue Symptoms across several organ systems

6. MUS in Sexual Abuse Survivors: Aims of the study To find out how CSA survivors with MUS and mental health issues have been identified and sampled; the key findings of research literature; theories used to explain inter-connections; any interventions and treatments for the CSA group; gaps in knowledge or understanding which require further research… ………And to make recommendations!

7. MUS in Sexual Abuse Survivors: Methodology of the review Electronic searches of medical, psychiatric and social work databases from 1990: quantitative or qualitative studies Studies had to refer to CSA, MUS and mental health issues Included review and discussion papers for theory section Hand –searches plus SN’s prior knowledge of issue Consultation with experts

8. MUS in Sexual Abuse Survivors: Key review findings 96 studies retrieved + 27 reviews or discussion papers: overwhelmingly a medical literature Main recruitment was from “tertiary care” clinics CSA survivors were main focus in only 9 studies – instead, people with certain symptoms were main focus Only three qualitative studies and three on males: only one intervention identified for this specific group Most researchers were medical specialists not experts in CSA: few collaborations with CSA services or support agencies

9. MUS in Sexual Abuse Survivors: Key review findings 2 Most papers confirm people with CSA are at higher risk for MUS, especially for GI and chronic pain; The more serious the abuse, more serious the impact on MUS, disability, sick days and healthcare use; Childhood physical abuse and adult physical assaults also significant influences on MUS; Recomms. for general good practice include detailed history-taking, respectful listening, referral for psychol therapy.

10. MUS in Sexual Abuse Survivors: Theories of the links Somatisation: emotional stress translates into bodily symptoms Severe trauma causes changes in central nervous system increasing vulnerability to pain and infections (neurobiol. research) Dissociative re-enactments and “body memories” occur

11. MUS in Sexual Abuse Survivors: Theories of the links 2 Depression/anxiety lead people to amplify their physical symptoms Injury and infection through assaults directly influence symptoms, especially chronic pain

12. MUS and Sexual Abuse Survivors: Problems of existing research “An overriding concern with testing which risk factors contribute to which outcomes has produced a repetitive (and competitive) body of case control studies, which have failed to identify helpful interventions for sexually abused people with MUS”

13. MUS and Sexual Abuse Survivors: Problems of existing research 2 Discrete variables used don’t match survivors’ experience, whose forms of abuse & neglect are often interlinked Key concept, somatisation problematic & poorly defined Very little collaboration with specialists in CSA Voices of survivors themselves rarely heard Lack of ethical safeguards or support for abused people filling in intrusive questionnaires

14. MUS and Sexual Abuse Survivors: Problems about “somatisation” Term is variously defined, or left undefined Prone to gender biases - most “somatisers” (“heartsink patients”? ) are women Ignores other possible explanations plus possibility that a medical condition may be inadequately diagnosed No convincing proof that the process even exists!

15. MUS and Sexual Abuse Survivors: Recomms for research CSA survivors must be primary focus of research Needs to be geared to exploring causes and relieving suffering Needs open mind, free of value judgments re. “somatisation” Medical specialists need to collaborate with CSA specialists in design and interpretation of studies

16. MUS and Sexual Abuse Survivors: Recomms for research 2 Need qualitative research with adult survivors with MUS, to explore health history, abuse history, experiences of health system, and interconnections Studies of male survivors with MUS Case histories, exploring medical records and attitudes of clinicians

17. MUS and Sexual Abuse Survivors: Recomms for research 3 Research into direct physical effects of violence and injury, and into “body memories”, including collaboration with torture research experts Collaborative research with vol. sector support agencies Prospective studies with children & young people whose abuse has been documented

18. MUS and Sexual Abuse Survivors: What can new research achieve? Would help in design of good-practice interview schedules for MUS patients Would increase respect and dignity of CSA survivors Would inform design of therapeutic interventions which could be piloted and evaluated Would increase informed knowledge, understanding of causes, and long-term research collaboration

19. MUS and Sexual Abuse Survivors “Er - that’s it!”