The Lived Experience of Violation: How Abused Children Become Unhealthy Adults

by Anna Luise Kirkengen, MD, PhD

Book review by
David D Clarke, MD

Winter 2011 - Volume 15 Number 1

Bringing clarity to the largest blind spot in medicine, Anna Luise Kirkengen, MD, PhD, offers information that can relieve unexplained symptoms and significantly reduce a major source of clinical frustration.

A primary care physician in Oslo, Norway for over 35 years, her subject here is the long-term consequences of child abuse (her PhD topic), particularly physical symptoms. She grabs our attention in the opening paragraph by stating she is "… convinced that the medical profession's understanding of human beings is not only insufficient, but also misleading."1p15 She presents a compelling case for this (over 400 references), but her most vivid teaching technique is detailed histories of individual patients.

These patients frustrate their clinicians with longstanding, undiagnosed symptoms. The first eye-opener is the story of Serena Sager.1p87-103 Beginning in her mid-teens, Ms Sager experiences headaches, eating disorders, left-sided paresthesias, pseudoseizures, abdominal pains, and then attempts suicide by overdose. Later she develops generalized arthralgias, left-sided abdominal and buttock pain, and visual symptoms in the left eye. During the 10 years of her illness, she underwent "… more than 40 consultations with primary care physicians and with specialists in 6 clinical specialties … 4 hospitalizations and … 4 years of psychotherapy."1p94 Despite all that, the correct diagnosis was missed.

She needed someone to link the history of her symptoms with a chronology of her major stresses. Dr Kirkengen reveals how symptoms began when Serena's father left home, leaving the patient with an alcoholic, physically abusive mother. While seeking respite with her aunt and uncle, the uncle rapes her; his hands and body, pressing against her left side where she subsequently develops numerous symptoms. The attack is not reported to authorities. Later, her symptoms flare after a man in a crowded restaurant presses himself against her left side long enough to trigger panic. She is asymptomatic when her uncle is away on long business trips. Her suicide attempt occurs after the mother arranges Serena's birthday party and invites the uncle. Later, symptoms flare after the uncle rapes her again.

Ms Sager's clinicians look for biological explanations of her illnesses and find none. Her psychiatrists diagnose depression and anxiety but fail to elicit the etiologic chronology of her life stresses, even missing the precipitating event for her suicide attempt. She suffers from her symptoms as well as from undiscovered ongoing abuse, from a perceived need to be silent about her traumas, from the discomfort and risk of medical tests, and from self-doubt because of the lack of diagnosis. She was spared unnecessary exploratory surgery, but other patients reviewed by Dr Kirkengen were not.

Numerous similar tragedies are described, putting a human face on the literature that documents outcomes for sexually abused women: "… eating disorders, obesity, danger of suicide, self-injury, use of all kinds of intoxicants, chronic pain, chronic illnesses, various forms of self-destructive acts, isolation, unprotected sex, sexually transmitted diseases, fragmentary schooling, interrupted education, reliance on others' support, poverty, re-victimization …"1p162 Many of these individuals are also mistreated by the medical and judicial systems.

My own experience with thousands of similar patients exactly mirrors Dr Kirkengen's cases. However, she underemphasizes that good outcomes can be achieved in this population. Most patients will accept that stress can cause physical symptoms, if assured that their illness is not imagined. Nondirective opening questions such as "What sort of stress were you under as a child?" can lead, over several encounters, to obtaining a chronology of life stresses that is diagnostic. Once these issues are uncovered, mental health clinicians can develop therapeutic plans that usually provide hope, reduce self-doubt and improve symptoms, sometimes surprisingly quickly.

Most physicians know the importance of inquiring into sensitive areas such as substance abuse, sexual preference, and domestic violence. Dr Kirkengen's book documents the diagnostic and therapeutic benefits of asking adults about their childhood experiences, particularly when their symptoms are unexplained. Her readers will enter the exam room with enough confidence to ask key questions. The answers will continue their education and one of the largest blind spots in medicine will close.

1.    Kirkengen AL. The lived experience of violation: how abused children become unhealthy adults. Bucharest, Romania: Zeta Books; 2010.


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