New research shows link between mental health problems and chronic pain

Thanks for posting that, Ellen. I forwarded it on to the mailing list for TMS practitioners and I'm sure that they will love it.

This study reminds me of the Adverse Childhood Experiences (ACE) study. Dr. David Clarke, author of They Can't Find Anything Wrong, is a big fan of the ACE study as a tool for understanding TMS and has written a series of great blog posts about it. We serve together on the board of the Psychophysiologic Disorders Association and he has given me permission to repost his blog articles here, so I'll post the ones about the ACE studies below.

Adults who had Stress in Childhood (1)
Childhood stress can cast a long shadow. Thanksgiving week is an appropriate time to look at the issue since this holiday is often a challenge for my patients who are still in touch with their families of origin.

The childhood stress may have been obvious and personal (abuse, neglect), or indirect (parental substance abuse or violence between parents) or more subtle (“nothing I did was ever good enough” one of my patients told me). The common denominator often is a significant reduction in the child’s self-esteem with associated emotional pain that may be deeply buried.

This can lead to a number of problems including:

• Choosing bad partners (who may perpetuate the childhood stress survivor’s poor treatment)
• Addictions (provide relief of emotional pain)
• Short temper
• Eating disorders
• Self-mutilation
• Depression & Anxiety
• Caring for others but neglecting oneself

In the next post I will review some research findings in this area.

Adults who had Stress in Childhood (2)
Researchers have been shocked at the profound impact childhood stress can have on health in adults. The ACE (Adverse Childhood Experience) Study *, led by my friend Vincent Felitti, MD in San Diego, is one of the best examples. They studied 18,000 people who were having routine check-ups. You can read a summary here .

A questionnaire asked if people had experienced:

• Physical abuse
• Emotional abuse
• Sexual contact abuse

The questionnaire also asked about growing up in a household where:

• Someone was in prison
• The mother was treated violently
• An alcoholic or drug abuser was present
• Someone was mentally ill
• At least one biological parent was lost to the patient during childhood (regardless of cause)

An ACE score was calculated by assigning one point for each of these eight categories that a person had experienced. 53% of their subjects had a score of at least one. 25% had a score of 2. 7% had a score of 4 or more. 22% reported sexual abuse.

Then they looked at health outcomes in relation to ACE score. They found that with higher ACE scores, people were many times more likely to:

• Have multiple physical symptoms
• Smoke or have emphysema or heart disease
• Have a sexually transmitted disease or hepatitis
• Use intravenous drugs or abuse alcohol
• Suffer from Depression or have attempted Suicide
• Be Obese or have Diabetes
• Be divorced or a victim of violence from an intimate partner
• Have multiple sexual partners or an unintended pregnancy

This is discouraging information for some people. However, for me this research reveals an opportunity to intervene in people’s lives to address the root cause of many health problems. More research in the next post.

* Felitti VJ et al (1998). The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine. 14:245-258.

Adults who had Stress in Childhood (3)
Adult patients seen by primary care medical clinicians often are affected by stress in childhood. Recent evidence of this is a study of 380 women at a medical clinic at Oregon Health & Science University in Portland *. Their survey asked about physical or sexual childhood abuse and assessed the impact of these on physical symptoms.

A remarkable 36% of their subjects reported having been abused as children. The study did not ask about other forms of family dysfunction such as emotional abuse or neglect, parental alcoholism or inter-parental violence or the proportion would have been even higher. The child abuse group had a 37% higher score than the not-abused group on the part of the survey that measured physical symptoms. This implies a huge impact of child abuse on health care utilization. This was happening even though the average age of these patients was 51, meaning that the abuse was decades in the past for most of them.

The bad news here is that medical clinicians usually focus on the patient’s physical symptoms and not on the underlying issues described in this study. The good news is that research like this will increase awareness that uncovering these problems can help find the root cause of many symptoms. More about this study in the next post.

* Nicolaidis, C et al. Differences in Physical and Mental Health Symptoms and Mental Health Utilization Associated with Intimate-Partner Violence versus Childhood Abuse. Psychosomatics 50:4, Jul-Aug 2009.

Adults who had Stress in Childhood (4)
The long-term effects of childhood stress impact relationships and mood in adults. The study* described in the last post surveyed 380 women who came to a general medical clinic. In addition to questions about abuse in childhood, patients were surveyed about whether they had ever experienced intimate-partner violence (IPV) and also about depression. (The vast majority of those who had experienced IPV were no longer in an abusive relationship.)

46% of the group physically or sexually abused as children had also experienced IPV as an adult compared to 20% of the group not abused as children. This supports the idea that adults abused as children have a tendency to choose partners who treat them in a way that is consistent with their early difficult experience.

The child abuse group also had a 50% higher score on the part of the survey that measured depression. 55% of the child abuse group had at least mild symptoms of depression, compared to 28% of the not-abused group. The child abuse group was also over three times as likely to be under care of a mental health professional as the not-abused group, indicating another important effect on health care use.

My practice experience is consistent with these research findings and leads me to conclude that significantly better health outcomes would result if:

• Medical clinicians were trained to inquire routinely about past abuse
• Patients accepted that real physical and mental symptoms can result from past abuse
• Mental health professionals were given the opportunity to use their skills to assist people in overcoming the long-term consequences of past abuse.

* Nicolaidis, C et al. Differences in Physical and Mental Health Symptoms and Mental Health Utilization Associated with Intimate-Partner Violence versus Childhood Abuse. Psychosomatics 50:4, Jul-Aug 2009.

Adults who had Stress in Childhood (5)
For the million American children identified by social agencies as being maltreated every year, and for the many more whose abuse is not brought to the attention of authorities, a new study* shows that the long shadow of their misfortune falls on their economic potential as adults.

A sample of 5000 American adults reported their childhood history of any maltreatment, physical abuse, sexual abuse and severe neglect. Those who had this history were compared with those who had not with respect to their employment status, income level and Medicaid usage. Statistical techniques were used to filter out the effect of each individual’s race, age, gender and childhood economic status.

The research showed that adults who experienced any form of maltreatment as children were twice as likely to be unemployed as those who experienced no maltreatment. The group that experienced physical abuse was 2.4 times more likely to be unemployed than those with no maltreatment. For those who experienced more than one form of maltreatment the ratio was 2.9.

In parallel with this, the proportion living in poverty was 60% higher in those physically abused, 2 times higher if severely neglected and 2.8 times higher if subjected to multiple forms of maltreatment.

Surprisingly, sexual abuse survivors did not have a higher rate of unemployment but they did have a higher rate of using Medicaid service.

These results indicate a large cost to society of maltreated children when they become adults. The expense comes not only from unemployment insurance, Medicaid costs and poverty-related social support but also from loss of individual productivity and tax revenue. In addition, the author points out that low socioeconomic status and a past history of being mistreated are both risk factors for an individual to abuse their own children, thus perpetuating a cycle. It is possible that programs designed to alleviate poverty would have more long-term success if they included assessment and counseling for adults mistreated as children.

*Zielinski DS. Child maltreatment and adult socioeconomic well-being. Child Abuse Negl. 2009 Oct;33(10):661-5.