Living with chronic pain can be a highly frustrating, confusing and stressful experience; which can ultimately to lead to psychological distress, a higher risk of mental health factors and lower quality of life overall. Although bio-medical factors set in motion initial pain diagnoses for treatment, it is clear that psychological factors, our mental state and our past experiences around pain can significantly contribute to the development, exacerbation, and process/ pathway pain takes in our mind and body. Thus it also goes without saying that the maintenance and potential treatment paths must also take into account the biochemical, bio-mechanical and bio psycho-social models as well to adequately offer clients with chronic pain the availability for recovery from chronic pain.
Over the course of the last several weeks we have looked at chronic pain and the associated links with mental health. Looking at a broad scope of potential risk factors in an attempt to better understand how we diagnose, the metrics we currently use and where we might bridge gaps in our systems, and offer people in pain more availability to resources and community support.
Successful management of chronic pain depends on a multidimensional assessment, taking into account both the objective and subjective metrics of analyses. To increase the likelihood of successful treatment outcomes, it is important to understand, assess, and treat contributing factors to the development of chronic pain disorders, and potential barriers to recovery of function – all to improve their quality of life.
In today’s post we look at the 4th installment of this Chronic Pain Series which looks to briefly link chronic pain in adults and the linkage to childhood abuse and neglect. While the association between abuse in childhood and adverse adult health outcomes is well established, this link is infrequently acknowledged in the general medical literature.
Child Abuse: It’s in the Stats
- 1 in 3 females and 1 in 6 males in Canada experience some form of sexual abuse before the age of 18.
- 80% of all child abusers are the father, foster father, stepfather or another relative or close family friend of the victim.
- 35% of girls and 16% of boys between grades 7 – 12 had been sexually and/or physically abused
- Among girls surveyed, 17-year-olds experienced the highest rate of sexual abuse at 20%
The impact of child abuse is often discussed in terms of physical, psychological, behavioural and societal consequences. However, in reality it is impossible to separate them completely. The impact of physical consequences can result in trauma or injury to the brain, and psychologically, abuse can result in cognitive delays or emotional difficulties. Our experiences as children shape our belief systems and how we start to understand our place in the world, When violence is a part of this belief system, it alters our growth and development – both from the point of view of the biopyschosocial model, but that of our internal representation in the world.
There are a number of pathways by which early life abuse, neglect and maltreatment could contribute to the development of pain disorders in adulthood. For instance, abusive childhood experiences can often manifest in high risk behaviors and can contribute to the development of negative psychosocial characteristics (depression, anxiety, anger, and social isolation). These in turn can lead to long term physical health problems like; cancer, diabetes, sexually transmitted disease, alcohol or drug abuse, eating disorders, mental illness – the list is endless.
Surviving Child Abuse: My Long Road to Recovery
“I was 6 years old the first time my mother’s second husband hit me. I had left an empty Popsicle wrapper on the table, and forgot to put it in the trash. The memory of how this event shaped is still a bit fuzzy, but what I do remember was my first real and raw understanding of what fear, anxiety and no longer feeling safe feels like – the only word that comes to mind is the word “shattered”. What I do remember is hearing screaming behind me, anger I had never known and as I ran up the stairs blindly grabbing at the carpet, he dragged my 6 year old body back down the stairs – kicking and screaming, my body flailing. I remember being thrown into the spare bedroom. It was dark, there was a chill in the air, I was hot, the salty taste of my tears and my body shaking uncontrollably.
I scrambled on the bed, the screaming was deafening, not sure if it was my screaming, or my mother’s as she knelt in the doorway pleading with him to stop, or it was the rage of my step father that was deafening. All time seemed to slow down and stop. Then I felt something hit the side of my head, a hit hard enough to send me flying off the bed and into the side wall. I remember tucking myself into the fetal position, my face hot, on fire, sweaty, shaking, my head pounding, my heart beat in my ears – it’s too loud. I could taste iron – was that what blood tastes like? The screaming, it wouldn’t stop. Then he left; and told me, lights off and to not come out until I was ready to be “good,” he left. I was alone, I could hear my mom sobbing. I felt shattered. That day forever changed our lives and it was not the last of it’s kind. I felt alone. I became silent. The child in me was no longer present. I was split in half.
Needless, to say, I no longer enjoy orange Popsicle’s.
I stayed in that room for what seemed like hours, laying on the floor, trying to understand what had just happened. Trying to understand why someone who said they loved me and my mother would cause such pain and fear. At the age of 6 – nothing, none of this makes any sense and it re defines, it re shapes how you see the world and your place in it. From that moment on, I slept with a night light on, I had a backpack ready by my bedroom window, a crayoned route to my biological father’s house and I slept with that widow cracked open, even in the winter in case my cat and I had to escape. No child should ever have a mapped out escape route from their own home.
After that day, the abuse, the anger would continue for 9 long years. I would witness him hit my mother, fight with her, knock her down; physically, psychologically and spiritually. Over the years she became less and less the strong, vibrant mother I knew – and more of a woman fighting for her life, running from her demons. He controlled her actions, she lost friends, she rarely went out, she drank, he made her do cocaine with him, watch porn. I was 12, these are not journal entries a 12 year old child should every write. I should be writing about boy crushes, girl guides or sleep overs with friends, but even though all those things happens, I would write about this f***ed up stuff. Because it is – my life’s diary of endless ramblings. He was a sexual predator. For 9 years, I was slapped, spanked, stripped naked, whipped with a belt. My mother screaming as he “disciplined” me. He would come into the bathroom, when I was showering or bathing. He let his friends hit on me and womanize my mother and I. At the age of 14 when we lost our home to debt, I convinced my mom to leave him. Him or me. I became the parent. I got 2 jobs in high-school, she got a restraining order and when the divorce was finalized – the healing began. Humpty Dumpty sat on a wall, Humpty Dumpty had a great fall. All the kings horses and all the kings men, couldn’t put Humpty Dumpty back together again. Where does one find the strength to go on? to move forward? to have faith that yes, life can be better? These were my ramblings from a therapy session as a youth. I was 16.” – Sarah Jamieson
Triumph Over Tragedy:
I tell this story in detail because stories, like mine, need to be told. We cannot sugar coat them. They need to be heard and the silence needs to be broken. Abuse is what started the downward spiral of my mother’s mental illness – a two decade long battle with her demons, her manic depression – later turned- bi polar disorder and addiction. For me – I turned to running as a way to process and understand “what the F*** had happened to me.” In all our trauma, my mother never got angry with me, she was always loving and even at a young age, I knew I was the glue that had to hold it all together. This burden turned out to be my most valued lesson. In my mother’s passing from accidental suicide; I have learned that in my own silence there can be no full healing. I choose to not only speak for myself, but to pay tribute and honor to my mother’s memory by telling her story of courage.
As an adult, I have had decades of therapy to better understand the long term effects of my childhood abuse and chronic pain has been one of them. I have suffered from back pain for nearly a decade. Most of my therapy has been a combination of therapeutic movement found in Yin Yoga, Fascial Stretch Therapy, SomaYoga, Osteopathy, IMS and my appreciation of both running and flow state martial arts and strength training. The real healing comes from the self discipline of re defining and re connecting with loving yourself, trusting yourself and the process and as Brene Brown called it “Gremlin – Ninja-Warrior-Training” to “Dare Greatly.”
The reasons why some children experience long-term consequences of abuse while other’s emerge relatively unscathed are still not fully understood. The ability to cope, and even thrive, following a negative experience is what we call “resilience.” I feel fortunate that I had a number of protective and promotive factors that contributed to my ability to hold my sh*t together. My resilience – I can only say is part of my DNA. My father has always been instrumental in my life and my mother even at her worst, loved me unconditionally. My psychological body (for the most part) seems to be intact, but my physical body has always had pain (understanding that in essence these two are not separate at all). It is a continued journey I walk every day, there are good days and bad days, there are still nightmares, but also memories of love. It is a life long journey of understanding and acceptance and I find solitude in service to others.”
Study by Arizona State University:
Evidence suggests that childhood abuse may be related to the experience of chronic pain in adulthood. In a study performed by Arizona State University, the group used meta-analytic procedures to evaluate the strength of existing evidence to showcase the association between self-reports of childhood abuse and chronic pain in adulthood. Analyses were designed to test the relationship across several relevant criteria with four separate meta-analyses.
Results of the analyses are as follows:
(1) Individuals who reported being abused or neglected in childhood also reported more pain symptoms and related conditions than those not abused or neglected in childhood. When a child has broken bones, fractures, are shaken (as in shaken baby syndrome) it changes the physiological nature of growth and development. Scar tissue can build up, resulting in altered biomechanics later in life etc.
(2) Patients with chronic pain were more likely to report having been abused or neglected in childhood than healthy controls. A variety of somatic symptoms are consistently found to be higher in adults with a history of physical or sexual abuse compared with those without an abuse history.
(3) Patients with chronic pain were more likely to report having been abused or neglected in childhood than non-patients with chronic pain identified from the community.
(4) Individuals from the community reporting pain were more likely to report having been abused or neglected than individuals from the community not reporting pain. Results provide evidence that individuals who report abusive or neglectful childhood experiences are at increased risk of experiencing chronic pain in adulthood relative to individuals not reporting abuse or neglect in childhood. (1)
Adult Onset of Chronic Pain Shows Links to Childhood Abuse:
How specific types of abuse alone or in conjunction with other variables may lead to any of these conditions is unknown, although measurable abnormalities in major physiological regulatory systems (hypothalamic-pituitary-adrenocortical axis and autonomic nervous system) have been found in some adults with a history of abuse.
Fight or flight; are our natural survival mechanics of the human species. Childhood abuse can showcase severe deficiencies in the ability to effectively self-regulate emotion resulting in inappropriate perceptions of threat and exaggerated fight-or-flight responses and this alarm can stay on from childhood to adulthood. Much like the alarm of chronic pain – the nervous system and pain receptors just won’t shut off. Many studies have reported de-regulated neuroendocrine responses in abused children and adults with a history of childhood abuse. When these self-governing pathways are disrupted they can promote pathophysiology in the body; which increases the vulnerability to the development of a chronic pain disorder and potentially interfering with recovery, and/or prolonging the process.
Childhood abuse survivors reported more adult traumas, and demonstrated greater neuroendocrine stress reactivity, suggesting physiological sensitization to stress and higher risk of stress-related illnesses.
In a publication called “The Long-Term Health Outcomes of Childhood Abuse;” at “The National Center for Biotechnology Information” states childhood abuse has been associated with a plethora of psychological and somatic symptoms, as well as psychiatric and medical diagnoses including depression, anxiety disorders, eating disorders, posttraumatic stress disorder (PTSD), chronic pain syndromes, fibromyalgia, chronic fatigue syndrome, and irritable bowel. Compared with non-abused adults, those who experienced childhood abuse are more likely to engage in high-risk health behaviors including smoking, alcohol and drug use,and unsafe sex; to report an overall lower health status; and to use more health services. Viewing these various health conditions and behaviors as the outcome and abuse in childhood as the exposure, many of the criteria for a causal relationship are met.
This publication found that in at least 3 meta-analyses on the effects of childhood sexual abuse find clear and convincing evidence of a link between such abuse and a host of adult psychological symptoms. Retrospective studies also show that childhood abuse has consistent effects on first onset of early adult psychopathology. For example, performing structured interviews in a random community sample of 391 women, Saunders et al. found that 46% of those with a history of childhood sexual abuse, compared with 28% of those with no abuse, had experienced a major depressive episode. Women with such abuse also had significantly greater lifetime prevalence’s of agoraphobia, obsessive-compulsive disorder, social phobia, sexual disorders, PTSD, and suicide attempts than women without such abuse. MacMillan et al., in a community survey of 7016 men and women, examined lifetime psychopathology risk in adults who experienced either sexual or physical abuse as children and found anxiety disorders and depressive disorders to be significantly higher in both men and women with a history of either physical or sexual abuse. (3)
Our Healthcare System: Bridging the Gaps
The need for more visible research that will reach physicians who provide the bulk of front line health care is underscored by failure to give even passing mention to the well-documented link between adult depression and childhood abuse in a recent review on depression in the New England Journal of Medicine. (3)
In Canada, 18% of women over the age of 12 experience chronic pain, as compared with 14% of men.34 Chronic pain is one of many serious long-term health consequences of intimate partner violence (IPV). British Columbia plays a significant role in research and development outlining the current scope of these linkages from chronic pain, trauma and abuse (both childhood abuse and partner/ family violence). A publication in the Journal of Pain, Vol 9, November 2008 in an article called “Chronic Pain in Women Survivors of Intimate Partner Violence “ found that according to the national prevalence survey of women’s experiences of speciﬁc acts of physical and sexual violence by a male partner, 30% of Canadian women are affected in their lifetime. These stats have not changed much in the last 5 years. Domestic violence and abuse still affects 1 in 4 women in North America and according to police statistics more than 60% of daily calls are domestic abuse related.
Chronic pain can affect people of all ages. In Canada, one in five people suffer daily from chronic pain. It is a ‘silent epidemic’. As a member of the board at Pain BC, a local non-profit organization based in Vancouver BC, our role in the community is to help bridge these gaps and to empower both patients and our health care providers and healthcare system to make chronic pain a higher priority on our national agenda. We do this through fostering an inclusive community and educating on the multi tiered scope of chronic pain. We have a shared passion for reducing the burden of pain and for making positive change in the health care system in British Columbia. If you’d like to be part of reducing the burden of pain in BC, get involved.
Learn More: Some of my Top Support Links
More information on how to recognize abuse and to report suspected abuse, and a range of child-welfare and child-protection resources can be found at: www.mcf.gov.bc.ca/child_protection/index.htm
Battered Women’s Support Services: http://www.bwss.org/home/contact-bwss/
(1) Are Reports of Childhood Abuse Related to the Experience of Chronic Pain in Adulthood? A Meta-analytic Review of the Literature by Debra A. Davis MA, Linda J. Luecken Ph D*, and Alex J. Zautra Ph D at Arizona State University – http://resilience.asu.edu/pdf-files/zautra3.pdf
(2) Preventing Childs Abuse is Everyone’s Responsibility: BC Newsroom, April 5, 2013: Sheldon Johnson, Ministry of Children and Family Development http://www.newsroom.gov.bc.ca/2013/04/preventing-child-abuse-is-everyones-responsibility.html
(3) “The Long-Term Health Outcomes of Child Abuse;” by The National Center for Biotechnology Information: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1494926/
(4) “Chronic Pain in Women Survivors of Intimate Partner Violence;” http://www.ucp.pt/site/resources/documents/ICS/GNC/ArtigosGNC/AlexandreCastroCaldas/13_WuMeFoLeVaCa08.pdf The Journal of Pain, Vol 9, No 11 (November), 2008: pp 1049-1057
(5) Canadian Children’s Rights Council – http://www.canadiancrc.com/Child_Abuse/Child_Abuse.aspx
(6) Pain BC – www.painbc.ca