Biopsychosocial Paradigm Proposed for FM, Abuse, Pain Interaction

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. These patients also have higher fibromyalgia (FM) survey scores 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 “FM-positive”, Andrea Nicol, MD, assistant professor with the Department of Anesthesiology at the University of Kansas School of Medicine, and colleagues wrote.

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. 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,” the researchers noted.

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.

Nancy Elder, MD, University of Cincinnati College of Medicine, Ohio, who was not involved in the stated study, 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 said.

“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 3081 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 FM 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, which was 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.

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 FM survey used to measure FM 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

1. 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 pain. Journal of Pain. 2016 doi: 10.1016/j.jpain.2016.09.003. 

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This article originally appeared on Clinical Pain Advisor