Does childhood sexual abuse cause fibromyalgia?

Sexual-Assault History and Long-Term Physical Health Problems

Having a history of sexual assault is associated with both poor general health and limitations in physical functioning, as well as with specific health problems such as chronic pelvic pain, premenstrual disturbance, other gynecologic symptoms, fibromyalgia, headache, other pain syndromes, and gastrointestinal disorders. In studies evaluating the possible role of depression in these associations, depression among sexually assaulted persons did not account for their poorer health. Although there are unanswered questions in the literature on the associations between sexual assault and health, existing findings are consistent with standard criteria for inferring causal relationships from observational data. For example, many assault-health associations are supported by multiple, independent studies, and many demonstrate dose-response relationships (i.e., more incidents of sexual assault, or more severe assaults, are associated with more adverse health outcomes).

Pain/Depression dyad: a key to a better understanding and treatment of functional somatic syndromes

Functional somatic syndromes include some of the most common and frustrating illnesses seen by primary care physicians and medical specialists. An extensive literature search of the 2 best characterized functional somatic syndromes, fibromyalgia and irritable bowel syndrome, reveals the overlap of these 2 disorders and their close relationship to depression. New pathophysiologic studies have shown that there are similar central nervous system changes in fibromyalgia, irritable bowel syndrome, and depression. These clinical and biologic similarities are consistent with the observations that the effective management of fibromyalgia and irritable bowel syndrome is comparable to that of depression.

Child abuse and chronic pain in a community survey of women

This study examined the relationship between a self-reported history of child physical and sexual abuse and chronic pain among women (N = 3,381) in a provincewide community sample. Chronic pain was significantly associated with physical abuse, education, and age of the respondents and was unrelated to child sexual abuse alone or in combination with physical abuse, mental disorder (anxiety, depression, or substance abuse), or low income. Number of health problems and mental health disorders did not mediate the relationship between physical abuse and chronic pain. Despite considerable evidence from the clinical literature linking exposure to child maltreatment and chronic pain in adulthood, this may well be the first population-based study to investigate this relationship for child physical and sexual abuse independently. The significant association between childhood history of physical abuse and pain in adulthood calls for a greater awareness of the potential for chronic pain problems associated with this type of maltreatment. Further research is needed to understand the mechanism for this complex relationship.

Stressful experiences in childhood and chronic back pain in the general population

OBJECTIVES

To determine if stressful experiences in childhood are associated with an increased risk of chronic back problems later in life.

METHODS

We conducted a prospective cohort study in the Canadian household population. Study participants were respondents to the first 3 cycles of the National Population Health Survey in Canada who were 18 years of age or older at baseline (n = 9552). Cases of chronic back pain during a 4-year follow-up period were ascertained with an interviewer-administered questionnaire. Stressful experiences in childhood were measured by an index consisting of 7 questions.

RESULTS

In multivariate analyses, the risk of back pain was 1.17 (95% confidence interval 0.97-1.41) for 1 stressful event and 1.49 (95% confidence interval 1.21-1.84) for 2 or more events. The effect was consistent across subgroups defined by gender, socioeconomic status, and health status. Specific events associated with an increased risk included fearful experiences, prolonged hospitalization, and parental unemployment.

DISCUSSION

Our study shows that persons reporting multiple stressful experiences in childhood are at increased risk of developing chronic back problems.

Traumatic experiences in childhood and the risk of arthritis: a prospective cohort study

BACKGROUND

Recent data suggest that psychosocial factors, including childhood and adulthood stressors, may play a significant role in the development of chronic musculoskeletal pain and other symptoms. The purpose of this study was to determine if traumatic experiences in childhood are associated with an increased risk of self-reported arthritis later in life.

METHODS

We used longitudinal data (N=9,159) from the first 3 cycles of the National Population Health Survey (NPHS) in Canada. New cases of arthritis were identified using an interviewer-administered questionnaire. Psychological trauma in childhood or adolescence was measured by a 7-item questionnaire asking about physical abuse, fearful experiences, hospitalization, being sent away from home, and 3 types of parental disturbance. The effects of trauma were examined in a multivariable discrete-time proportional hazards model.

RESULTS

The incidence of self-reported arthritis was 27.1 per 1,000 person-years. We found a relative risk of 1.17 (95% CI=0.92, 1.48) for one traumatic event and 1.27 (95% CI=0.99, 1.62) for two or more traumatic events. Independent effects were observed for prolonged hospitalization (HR=1.33, 95% CI=1.05, 1.68) and being very scared (HR=1.29, 95% CI=1.02, 1.62). In subgroup analyses, no significant interactions were found between trauma and sex, socio-economic status, or baseline health.

CONCLUSIONS

In this large prospective study, we found a moderate increase in the risk of arthritis among persons reporting multiple traumatic experiences in childhood.

Predicting the onset of widespread body pain among children

OBJECTIVE

To determine factors associated with, and the predictors of, widespread body pain in children.

METHODS

A population-based prospective study was conducted among school children in Northwest England. At baseline, subjects completed a self-report questionnaire on widespread body pain. Information was collected on behavioral and emotional factors, other somatic symptoms, and measures of physical activity/inactivity. Children who were free of widespread pain were contacted again 12 months later to determine any new onset of widespread pain. Regression analyses were used to identify the factors that were associated with the reporting of widespread pain at baseline, and to determine the factors that predicted the new onset of symptoms at followup among those children free of widespread pain at baseline. Results were expressed as relative risks (RR) with 95% confidence intervals (95% CI).

RESULTS

A total of 1,440 children (96%) agreed to participate in the survey at baseline, and of those eligible, 1,081 (88%) participated at followup. The reporting of widespread pain (prevalence 14.6%) and its new onset at the 12-month followup (prevalence 7.7%) was common. At baseline, symptoms were associated with adverse behavioral and emotional factors (RR 2.5, 95% CI 1.8-3.6), with the report of other common childhood somatic symptoms (e.g., frequent headache; RR 3.5, 95% CI 2.2-5.5), and with high levels of sports activity (RR 1.9, 95% CI 1.3-2.9). Furthermore, all of these factors (in the absence of widespread pain at baseline) increased the likelihood of symptom onset at followup.

CONCLUSION

Children who report behavioral problems or other somatic symptoms are at increased risk, at least in the short term, of developing chronic widespread pain. It remains to be determined whether these are long-term risk factors for the onset of such symptoms, and whether they could be predictors of the development of other functional syndromes.

Risk factors for anabolic-androgenic steroid use among weightlifters: a case-control study

Anabolic-androgenic steroid (AAS) use represents a major public health problem in the United States, but the risk factors for this form of drug use are little studied. We evaluated 48 men who had used AAS for at least 2 months and 45 men who had never used AAS, using a verbal interview and a battery of questionnaires covering hypothesized demographic, familial, and psychosocial risk factors for AAS use. All subjects in both groups were experienced weightlifters; thus, differences between groups were likely to be associated specifically with AAS use, rather than with weightlifting in general. The AAS users and non-users generally described similar childhood and family experiences, but users reported significantly poorer relationships with their fathers and greater childhood conduct disorder than non-users. At the time that they first started lifting weights, AAS users and non-users were similar in their perceived physical, social, and sexual status, but users were significantly less confident about their body appearance. AAS users displayed much higher rates of other illicit substance use, abuse, or dependence than non-users, with use of other illicit substances almost always preceding first use of AAS. These findings suggest that AAS use may be most likely to occur in men with high levels of antisocial traits and low levels of body esteem.

Sleep disturbances linked to fibromyalgia

Fibromyalgia (FM) is a chronic muscle disorder characterized by muscle aches and pain of varying intensities. Sleep disturbances have been recognized as one of the probable causes of this disorder. Pharmacological and nonpharmacological approaches are often used to manage the symptoms of sleep disturbances. This article provides a brief background on FM, discusses the physiology of sleep, reviews the current literature on sleep disturbances associated with FM, provides insight to interventions that might be beneficial given the data available, and recommends ongoing research.

Idiopathic Environmental Intolerance

Toxicogenic and psychogenic theories have been proposed to explain idiopathic environmental intolerance (IEI). Part 2 of this article is an evidence-based causality analysis of the psychogenic theory using an extended version of Bradford Hill's criteria. The psychogenic theory meets all of the criteria directly or indirectly and is characterised by a progressive research programme including double-blind, placebo-controlled provocation challenge studies. We conclude that IEI is a belief characterised by an overvalued idea of toxic attribution of symptoms and disability, fulfilling criteria for a somatoform disorder and a functional somatic syndrome. A neurobiological diathesis similar to anxiety, specifically panic disorder, is a neurobiologically plausible mechanism to explain triggered reactions to ambient doses of environmental agents, real or perceived. In addition, there is a cognitively mediated fear response mechanism characterised by vigilance for perceived exposures and bodily sensations that are subsequently amplified in the process of learned sensitivity. Implications for the assessment and treatment of patients are presented.

A prospective study of the effects of sexual or physical abuse on back pain

A prospective investigation of the effects of abuse on future pain and disability was conducted in order to understand better the possible causal role of abuse. Participants were 422 females from a previous population study (Pain 73 (1997) 47-53) who either reported no spinal pain (n=194) or some spinal pain (n=228) at the baseline. A standardized questionnaire was used to assess self-reported physical and sexual abuse during childhood and as an adult. One year later, a follow-up questionnaire was used to evaluate pain and physical function outcomes. Results for the No Pain Group showed that only self-reported physical abuse at baseline was associated with an increased occurrence of new episodes of back pain (odds RATIO=2.65). Both sexual and physical abuse were linked to as much as four-fold increase in the occurrence of a new episode of functional problems at follow-up. However, for the Pain Group, no significant differences were found between those reporting and not reporting abuse at baseline and either pain or disability at follow-up. This unique prospective study with individuals from the general population underscores the probable importance of abuse in the etiology of a pain or disability problem. Nevertheless, since no clear relationship between abuse and pain was shown for those already reporting pain at baseline, the role of abuse in the development of persistent pain is still not comprehensible. There is a need for investigations with prospective designs employing patients as well as nonpatients as subject.

The role of psychiatric disorders in fibromyalgia

The cardinal features of fibromyalgia are chronic widespread pain in the presence of widespread tenderness as measured by multiple tender points. Despite extensive investigations, the etiology of this syndrome remains unclear. Increased rates of psychiatric disorders, particularly depressive, anxiety, and somatoform disorders, are apparent in clinic populations. Epidemiologic evidence suggests that this is also true for community subjects. Depression, generalized psychological distress, and other psychological factors have been shown to be associated with the onset and persistence of fibromyalgia symptoms. However, the bodily processes through which such factors may lead to the onset of fibromyalgia are unclear. Recent investigations have demonstrated altered stress system responsiveness, most notably the hypothalamic-pituitary-adrenal stress axis, in patients with fibromyalgia. These findings, and one promising avenue for investigating the interaction between psychological and biological factors in the onset of chronic pain syndromes including fibromyalgia, are discussed.

Psychological determinants of fibromyalgia and related syndromes

Fibromyalgia and other chronic pain and fatigue syndromes constitute an increasingly greater societal burden that currently is not being approached effectively by traditional Western medicine. Although the hallmarks of fibromyalgia--chronic widespread pain, fatigue, and multiple other somatic symptoms--have neurophysiologic and endocrinologic underpinnings, these biological aspects derive primarily from psychological variables. Female gender, adverse experiences during childhood, psychological vulnerability to stress, and a stressful, often frightening environment and culture are important antecedents of fibromyalgia. To understand fibromyalgia and related syndromes and to provide optimum care requires a biopsychosocial, not a biomedical, viewpoint.

Victimization in chronic fatigue syndrome and fibromyalgia in tertiary care: a controlled study on prevalence and characteristics

The authors studied the prevalence and characteristics of different forms of victimization in 95 patients suffering from chronic fatigue syndrome (CFS) or fibromyalgia (FM) compared with a chronic disease group, including rheumatoid arthritis (RA) and multiple sclerosis (MS) patients, and a matched healthy control group. The authors assessed prevalence rates, nature of victimization (emotional, physical, sexual), life period of occurrence, emotional impact, and relationship with the perpetrator by a self-report questionnaire on burdening experiences. CFS and FM patients showed significantly higher prevalences of emotional neglect and abuse and of physical abuse, with a considerable subgroup experiencing lifelong victimization. The family of origin and the partner were the most frequent perpetrators. With the exception of sexual abuse, victimization was more severely experienced by the CFS/FM group. No differences were found between healthy control subjects or RA/MS patients, and between CFS and FM patients. These findings support etiological hypotheses suggesting a pivotal role for chronic stress in CFS and FM and may have important therapeutic implications.

Effects of hyaluronic acid on cartilage degradation

Based on the published literature available so far, it appears that naturally derived hyaluronic acid (HA) and newer formulations available on the market belong to the pharmacologic class of slow-acting drugs for the treatment of osteoarthritis. These compounds seem to have the potential to modulate the painful symptoms of osteoarthritis as well as to improve the function of the osteoarthritis joint. Positive clinical consequences are based on direct and indirect effects of viscosupplementation associated with a normalization of the rheologic properties of the osteoarthritic synovial fluid, decreased inflammation, and end-coating of the pain receptors in the osteoarthritis joint. Few in vivo data exist in humans to support the concept that HA formulations could have a structure-modifying effect on human osteoarthritis cartilage. Animal-based studies have demonstrated positive effects of exogenous HA on pain in the joint, heat shock proteins, and in models of osteoarthritis. Although many promising effects of exogenous HA have been reported, there remains uncertainty as to the effectiveness of reversing cartilage injury and other manifestations of joint diseases with exogenous HA because of difficulties in interpreting and unifying results of these studies. This is due largely to differences of cartilage source in models of joint/cartilage injury, multiple end points, the controls employed, analytical techniques, and the molecular weight of exogenous HA used. There exists a need for uniform agreement as to the choice of injury model, time points of the study, evaluation tools, and source and molecular weight of the HA used if we are to determine whether exogenous application of HA has a truly beneficial role in the reversal of cartilage injury.

A Case Series of Women With Postpartum-Onset Obsessive-Compulsive Disorder

BACKGROUND: There is emerging evidence that postpartum women are at risk for the development or worsening of obsessive-compulsive disorder. The purpose of this study was to provide data regarding the demographics, phenomenology, associated psychiatric comorbidity, family history, and response to open treatment with fluvoxamine in subjects with postpartum-onset obsessive-compulsive disorder. METHOD: Seven consecutive subjects were recruited from an outpatient obstetrical practice and by advertisement. Subjects completed the Structured Clinical Interview for DSM-IV, the Yale-Brown Obsessive Compulsive Scale, and a semistructured interview for family history, demographic data, and clinical features. Three of the 7 subjects participated in a 12-week, open-label trial of fluvoxamine treatment of postpartum-onset DSM-IV obsessive-compulsive disorder. RESULTS: The women described a mean age at onset of 28 years, and 4 subjects had a chronic course. Six subjects reported onset after the birth of their first child, and the mean time to onset was 3.7 weeks postpartum. All subjects experienced both obsessions and compulsions and reported aggressive obsessions that involved their children. None of the subjects acted on their obsessions to harm the children, but 5 reported dysfunctional mother-child behavior. All 7 subjects met criteria for at least 1 comorbid psychiatric disorder, with a mood disorder the most common. Family histories were notable for high rates of mood disorders and psychoactive substance use disorders in first-degree relatives. Two of the 3 subjects who entered the open-label trial of fluvoxamine experienced a positive response, defined as a 30% or greater decrease in the total score of the Yale-Brown Obsessive Compulsive Scale. CONCLUSION: Obsessive-compulsive disorder may present in the postpartum period and become chronic. Symptoms of the disorder may adversely affect the mother-child relationship, and it is important to assess for obsessions and compulsions in postpartum women who present with anxiety and/or depression. Fluvoxamine may be effective in reducing the symptoms of postpartum-onset obsessive-compulsive disorder. Controlled studies are needed to confirm these findings.

Pain in fibromyalgia

Just as our caveman forebears were frail in the face of predatory animals, we are frail in today's society of childhood neglect or abuse, bumper-to-bumper traffic, frustration at work, and multiple daily hassles. The same neuroendocrine systems and pain regulatory mechanisms that protected early man during acute stress are still encoded in our genome, but may be maladaptive in psychologically and physiologically vulnerable people faced with chronic stress. Many patients with fibromyalgia become vulnerable because of the long-lasting psychological and neurophysiological effects of negative experiences in childhood. Ill-equipped with positive cognitive, emotional, and behavioral skills as adults, they display maladaptive coping strategies, low self-efficacy, and negative mood when confronted with the inevitable stressors of life. Psychological distress ensues, which reduces thresholds for pain perception and tolerance (already relatively low in women) even further. Converging lines of psychological and neurobiological evidence strongly suggest that chronic stress-related blunting of the HPA, sympathetic, and other axes of the stress response together with associated alterations in pain regulatory mechanisms may finally explain the pain and fatigue of fibromyalgia. Vulnerable people who can be classified by the ACR criteria as having fibromyalgia do not have a discrete disease. They are simply the most ill in a continuum of distress, chronic pain, and painful tender points in the general population.

Sexual and physical abuse in women with fibromyalgia: association with outpatient health care utilization and pain medication usage

OBJECTIVE

To evaluate the relationship between sexual and/or physical abuse and health care usage in patients with fibromyalgia (FM) and identify variables that may influence this relationship.

METHODS

We assessed history of sexual/physical abuse, health care utilization, and medication usage, as well as related variables in 75 women with FM using standardized questionnaires, structured interviews, and laboratory pain perception tasks.

RESULTS

Fifty-seven percent of FM patients reported a history of sexual/physical abuse. Compared to non-abused patients, abused patients reported significantly greater utilization of outpatient health care services for problems other than FM and greater use of medications for pain (P < or = 0.025). Consistent with our expectations, abused patients also were characterized by significantly greater pain, fatigue, functional disability, and stress, as well as by a tendency to label dolorimeter stimuli as painful regardless of their intensities (P < or = 0.05). Additional analyses suggested that the high frequency of sexual/physical abuse in our patients was associated primarily with seeking health care for chronic pain rather than the FM syndrome itself or genetic factors.

CONCLUSION

There is an association in FM patients between sexual/physical abuse and increased use of outpatient health care services and medications for pain. This association may be influenced by clinical symptoms, functional disability, psychiatric disorders, stress, and abnormal pain perception. The relationships among these variables should be further tested in prospective, population-based studies.

Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: II. Sexual, physical, and emotional abuse and neglect

OBJECTIVE

Two recent reports have found associations between fibromyalgia and sexual victimization, but had methodologic characteristics that limited their interpretation.

METHOD

We compared 36 patients with fibromyalgia and 33 patients with rheumatoid arthritis by using structured interviews for sexual, physical, and emotional victimization histories, as well as dimensional self-report measures of victimization severity.

RESULTS

Compared with the patients with rheumatoid arthritis, those with fibromyalgia had significantly higher lifetime prevalence rates of all forms of victimization, both adult and childhood, as well as combinations of adult and childhood trauma. Although childhood maltreatment was found to be a general risk factor for fibromyalgia, particular forms of maltreatment (eg, sexual abuse per se) did not have specific effects. Experiences of physical assault in adulthood, however, showed a strong and specific relationship with unexplained pain. Trauma severity was correlated significantly with measures of physical disability, psychiatric distress, illness adjustment, personality, and quality of sleep in patients with fibromyalgia but not in those with rheumatoid arthritis.

CONCLUSIONS

Fibromyalgia seems to be associated with increased risk of victimization, particularly adult physical abuse. Sexual, physical, and emotional trauma may be important factors in the development and maintenance of this disorder and its associated disability in many patients.

The fibromyalgia syndrome

The term fibromyalgia describes a complex syndrome characterized by pain amplification, musculoskeletal discomfort, and systemic symptoms. Although its existence has been controversial, nearly all rheumatologists now accept fibromyalgia as a distinct diagnostic entity. In fact, in the United States it is the third or fourth most common reason for rheumatology referral. Exciting new insights into the aetiology, pathogenesis, diagnosis and treatment of fibromyalgia will be reviewed.

Sexual abuse and chronic musculoskeletal pain: prevalence and psychological factors

OBJECTIVE

We investigated the prevalence of a history of sexual abuse among patients with long-term musculoskeletal pain. Psychological factors associated with abuse and pain were also studied.

DESIGN

First, the prevalence of abuse was determined based on self-report on a valid and reliable abuse questionnaire. Subsequently, a cross-sectional method, in which patients were categorized as abused or nonabused, was employed and responses to a battery of questionnaires compared.

PATIENTS

Seventy-five consecutive patients undergoing assessment for chronic musculoskeletal pain participated.

OUTCOME MEASURES

These included Beck's Depression Inventory, the Coping Strategies Questionnaire, the Multidimensional Pain Inventory, the Uppsala Type A Behavior Questionnaire, the Pain and Impairment Rating Scale, as well as ratings of pain intensity.

RESULTS

Thirty-eight percent of the women and 10% of the men reported some form of sexual abuse, usually during adulthood. A majority (77%) had disclosed the abuse to someone, but >85% did not believe that the abuse negatively affected their pain or sex lives. Abused women, relative to nonabused ones, had poorer scores on 27 of the 29 assessment variables. Abused female patients had significantly higher levels of depression, stress from daily hassles, affective distress, and more frequent negative responses from spouses, in addition to having lower levels of social activities, life control and effective coping for pain than did the nonabused female patients.

CONCLUSION

These data extend the relationship between sexual abuse and pain to a Swedish population suffering from musculoskeletal complaints. Our findings suggest that intervention in the pain treatment setting may need to address further the problems of effective coping strategies and depression.