The Relation of Traumatic Stress to Pain Severity, Mood Disorders

Individuals with a history of abuse display greater levels of pain, anxiety, and depression.
Individuals with a history of abuse display greater levels of pain, anxiety, and depression.

Patients with a history of abuse either in childhood or adulthood have been found to display higher levels of depression, anxiety, pain severity and catastrophizing, as well as reduced physical functioning; in addition, those patients have higher scores on the fibromyalgia survey used to measure “fibromyalgia-ness” than those without a history of abuse, according to a study recently published in the Journal of Pain.1

In the cross-sectional study, the researchers from the University of Kansas School of Medicine, Harvard Medical School and the University of Michigan Medical School found that 15% of their chronic pain population reported a history of abuse. Of those, more than half (56.14%) met the criteria for being “fibromyalgia-positive,” said Dr Nicol, an assistant professor in the Department of Anesthesiology at the University of Kansas School of Medicine in Kansas City, Kansas.

The study is one of the first to examine the influence of centralized pain/central nervous system pain amplification in mediating the relationship between chronic pain and abuse, Dr Nicol said. The findings highlight the importance of screening for childhood and ongoing abuse and affective distress.

“Results from this study suggest a paradigm for chronic pain in patients with a history of abuse wherein both affective distress and increased pain amplification in the central nervous system (`fibromyalgia-ness') can be triggered by trauma and that they play significant roles in the association between abuse and pain,” Dr Nicol noted. 

“Understanding these mechanisms will hopefully help guide clinical practitioners in appropriate treatments for these individuals,” he added

Patients with a history of abuse and chronic pain require an integrative approach to treatment that addresses both their psychological distress and their physical health complaints, Dr Nicol reiterated.

Dr Nancy Elder, MD, MSPH, a professor in the Department of Family and Community Medicine at the University of Cincinnati College of Medicine in Cincinnati, Ohio, who was not an author of the current paper, said the findings were confirmatory of existing literature and clinical practice.

“Unfortunately, because this is a cross-sectional study, the findings [that abuse/trauma and chronic pain and depression/anxiety] are all related does not answer the age-old question of which came first, the anxiety/depression or the pain,” Dr Elder told Clinical Pain Advisor.

“None of this is new, just confirmatory and doesn't really change my thinking as a primary care doctor who takes care of patients with all three conditions and knows clinically and from the literature that all three are related,” she added.

The researchers included 3 081 patients ages 18 years and older, who consulted at the University of Michigan Back and Pain Center for chronic pain from November 2010 to February 2014. Patients self-reported their history of abuse. Of those, 470 patients, or 15.25%, reported a history of abuse.

The study showed that both the fibromyalgia survey score and affective distress independently mediated the relationship between abuse, pain severity and physical functioning. No difference in the distribution of pain was found for those with a history of abuse and those without, except for neuropathic pain, which was higher in those without a history of abuse, and musculoskeletal pain, whichwas more prevalent in those with a history of abuse.

“We believe our unique findings may shed some light on the relationship among these variables, as the data here support a novel biopsychosocial paradigm wherein affective distress and fibromyalgia-ness play significant independent roles in mediating the association between abuse and pain,” the authors stated in the paper.

“Although the observed magnitude of the associations between abuse history and outcome variables are quite small when viewed independently, we have demonstrated the presence of complex mutual interactions and mediations among childhood and adult abuse, affective distress (including depression and anxiety), fibromyalgia-ness, chronic pain severity, and physical functioning.”

Future studies are needed to look at the role of abuse, neglect and chronic stressors, as well as their perceived effect on pain and health outcomes.

Summary and Clinical Applicability

Patients with a history of abuse have greater depression and anxiety, worse physical functioning, greater and worse pain severity, higher catastrophizing and higher scores on the fibromyalgia survey used to measure “fibromyalgia-ness” than those without a history of abuse.

The findings are clinically relevant, as the study suggests that depression and anxiety co-occurring with increased pain in the central nervous system can be triggered by trauma and play significant roles in the association between pain and abuse. Understanding these mechanisms will help clinicians better treat these patients.

The study highlights the importance of screening for childhood abuse as well as ongoing abuse and affective distress. Patients with both abuse and chronic pain need an integrative treatment approach that addresses both their physical health complaints as well as their psychological distress.

Limitations and Disclosures

A major limitation of the study is its cross-sectional nature that precludes inferences and causal relationships and the associations presented may not be valid for every type of chronic pain syndrome. Also the assessment of abuse relied on a single retrospective self-report.

No conflicts of interest were reported.

Reference

Nicol AL, Sieberg CB, Clauw DJ, Hassett AL, Moser SE, Brummett CM. The association between a history of lifetime traumatic events and pain severity, physical function, and affective distress in patients with chronic painJournal of Pain. 2016 doi: 10.1016/j.jpain.2016.09.003.

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