A New Look at Chronic Pain in Abuse Survivors

1
A New Look at Chronic Pain in Abuse Survivors

• Kathleen Kendall-Tackett
• Family Research Lab
• University of New Hampshire

2
The Enigma of Chronic Pain

• Not well understood
• Different mechanism than acute pain
• Chronic pain can occur without tissue damage
• Only 10-15 of pain can be explained by lab or
  radiologic findings
• Strong circumstantial evidence for a link between
  chronic pain and trauma

3
Why Pain?

• Pain is a common symptom
• Community sample of CSA survivors, pain was the
  most common symptom (Teegan, 1999)
• Pain can teach us about mechanisms by which harm
  occurs
• Pain, sleep, depression link

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Why Pain? (contd)

• Pain is a microcosm of all long-term sequelae
• Related to attributional style, social support
  and behavior
• Pain is expensive for patients, and time
  consuming for practitioners
• Common reason for visits to primary, ED, and
  specialists

5
Why Pain? (contd)

• Past abuse is often the missing piece in
  refractory pain
• Without understanding the abuse connection,
  patients are vulnerable to unnecessary procedures
• Surgery rates are twice as high in abuse survivors

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Pain Associated with Past Abuse

• Childhood abuse is associated with five types of
  pain
• Back Pain
• Headaches
• Pelvic Pain
• Irritable Bowel Syndrome
• Fibromyalgia
• Many of these types co-occur

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Abuse and Back Pain (Schofferman et al., 1992)

• In a study of spine surgery, patients were asked
  about five types of childhood trauma sexual,
  physical and emotional abuse, parental substance
  abuse, and abandonment.
• Those reporting three or more types of abuse had
  a surgery failure rate of 85, compared with a 5
  failure rate among those with no history of trauma

8
Headaches and Sexual Assault (Golding, 1999)

• Meta-analysis from five studies with community
  samples (N7,502)
• Past sexual assault was related to headaches.
• The odds of chronic headaches were higher for
  sexual assault that occurred in childhood.

9
Sexual Abuse and Pelvic Pain (Harrop-Griffiths et
al., 1988)

• Patients with pelvic pain were significantly more
  likely to have been victims of either childhood
  (64 vs. 7) or adult sexual abuse (48 vs. 13)
  than the comparison group.
• There was a high incidence of depression in the
  abused group

10
Fibromyalgia and CAN (McBeth et al., 1999)

• Childhood adversity was associated with a
  significantly higher tender point count
• child abuse, parental loss, illness of a family
  member, and parental drug overdose
• Childhood abuse was the best independent
  predictor of high tender-point count (OR6.9)

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Sexual Victimization and IBS (Walker et al., 1993)

• 28 IBS and 19 IBD patients
• Patients with IBS had higher rates of
• severe lifetime sexual trauma (32 vs. 0),
• severe child sexual abuse (11 vs. 0),
• and any lifetime sexual victimization (54 vs.
  5).

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Functional vs. Organic GI Illness

• Study compared health of women with functional
  vs. organic GI illnesses
• 60 of the total sample reported physical or
  sexual abuse
• 67 for functional diagnoses
• 56 for organic conditions (cirrhosis, hepatitis
  B C)
• (Drossman et al., 1996 Leserman et al., 1996)

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VAW and Chronic Pain(Kendall-Tackett, Marshall
Ness, in press)

• Sample from primary care (N110)
• Women who had been abused as children or adults
  were more likely to report two or more symptoms
  of chronic pain
• Abdominal pain
• Pain or stiffness in joints or muscles
• Pain during urination
• Arthritis
• Back pain
• Severe headaches

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Psychiatric Symptoms (Scarinci et al., 1994)

• Scarinci and colleagues drew a sample of 50
  patients with one of three pain syndromes (GERD,
  IBS, NCCP)
• Abused patients (PA or CSA) had significantly
  lower pain threshold levels and significantly
  lower cognitive standards for judging stimuli as
  noxious
• Even after controlling for psychiatric
  disturbance

15
Pain Psychiatric Co-Morbidity (Kendall-Tackett,
in press)

• 11 studies of pain and childhood abuse
• 91 reported co-occurring major depression
• 36 reported co-occurring generalized anxiety
  disorder
• 36 reported co-occurring substance abuse
• Other problems included PTSD, phobia and panic
  disorder

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Trauma may Lower Pain Thresholds

• Intense, repeated, or prolonged stimuli may lower
  pain threshold
• Nerve damage changes receptors, and transmitters,
  and can trigger a cascade of changes in the CNS
• Lower intensity sensations perceived as painful
  due to central sensitization
• Touch, bodily sensations

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Secondary Hyperalgesia

• Hypersensitivity to sensation spreading to
  non-injured tissue
• Results from a synergism between the neuropeptide
  Substance P and N-methyl D-aspartate (NMDA)
  receptors
• Pain hypersensitivity, and functional changes
  within the central nervous system are expressions
  of neuronal plasticity

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Pathophysiology of FMS

• Lower levels of serotonin and serotonin
  metabolite 5-HIAA in cerebral spinal fluid of FM
  patients
• Higher levels of Substance P (three times) in CSF
• By CT scan, impaired blood flow to the left and
  right hemithalami, and the right and left heads
  of the caudate nucleus

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Pathophysiology of FMS (contd)

• HPA disturbances including lower levels of
  cortisol and diurnal disturbances in cortisol
  levels
• Sleep disturbances
• Alpha wave disturbances during delta sleep
• Phasic pattern of alpha disturbance more common
  in FMS

20
Pathophysiology of IBS

• Hyperalgesia more common in IBS patients after
  exposure to painful stimuli
• Abnormal pattern of activation of anterior
  cingulate cortex in IBS patients (all cortex, no
  ACC)
• ACC responsibility for release of endorphins
• Without this release, more pain

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Pathophysiology of IBS (contd)

• Enteric Nervous System
• Small intestine has the same number of nerve
  cells as spinal cord (100 million)
• More nerve cells in the rest of the gut
  (esophagus, stomach, and large intestine) than in
  the spinal cord
• Serotonin manufactured in the gut, and serotonin
  receptors in enteric nerves

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What We Know about Abuse and Pain

• Abuse survivors have higher rates of functional
  and organic pain
• Pain syndromes co-occur
• Pain syndromes have commonalities
• Lower pain thresholds, possible smooth muscle
  disorder
• We still cant prove abuse causes pain