Types of Trauma and Self-Reported Pain That Limits Functioning in Different-Aged Cohorts

Abstract

There is a growing body of literature that childhood or adult trauma exposure can have lifelong mental and physical health impacts. In this large cross-sectional analysis, authors investigated combinations of trauma types and pain resulting in functional limitations among women recruited into a statewide health registry. Combinations of traumas such as child physical abuse (CPA), child sexual abuse (CSA), and adult violence were hypothesized to be associated with greater likelihood of limiting pain and earlier symptom onset, relative to women with no or singular trauma exposures. Pain prevalence rates (PRs) and adjusted prevalence rate ratios (aPRRs) were highest among women experiencing multiple forms of violence (43.3% among women disclosing CPA, CSA, and adult violence; aPRR = 2.06, p < .001), intermediate for women experiencing CPA or CSA yet no adult violence (37.0%; aPRR = 1.76, p < .001), and lower among women experiencing adult violence only (27.1%; aPRR = 1.29, p < .001), relative to women never experiencing violence (20.7%). As hypothesized, the effect of combinations of trauma on chronic pain was consistently greatest for those reporting limiting pain at younger ages. Implications include the need to identify combinations of traumatic events across the life span, and to intervene early to reduce the impact of trauma on health and functioning.

Keywords

violence exposure trauma pain that limits functioning

Exposure to violence is a traumatic event that affects 50% to 70% of the U.S. population, with lifetime exposure rates increasing over time (B. L. Green et al., 2000; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). Child physical abuse (CPA) and sexual abuse rates occur at 226 per 1,000 and 127 per 1,000, respectively (Stoltenborgh, Bakermans-Kranenburg, & van Ijzendoorn, 2013). In population studies of people above age 65, 70% to 90% report exposure to a potentially traumatic event during their lifetime (Creamer & Parslow, 2008; Ozer, Best, Lipsey, & Weiss, 2003). These high incident rates have established trauma exposure as one of the most salient public health issues in contemporary society.

The link between childhood adversity and long-term health and behavioral health is well established (Felitti et al., 1998; J. G. Green et al., 2010; Higgins & McCabe, 2001). Early studies focused on a dose–response relationship between exposure to childhood adversity (broadly defined) and subsequent health risk behaviors and outcomes (including pain; Bellis, Lowey, Leckenby, Hughes, & Harrison, 2014; Dube, Cook, & Edwards, 2010). However, the trauma literature clearly points to the differential impact of certain types of events, rendering straight dose–response explanations of these associations insufficient (Wilson, Smith, & Johnson, 2013). The U.S. National Comorbidity Study documents that some forms of childhood abuse are more strongly associated with adult outcomes than others, and that some comorbidities are nonadditive (Kessler, Davis, & Kendler, 1997). This finding has been replicated and expanded upon in recent studies that document child sexual abuse (CSA) as a signature risk of the development of postexposure pathology (Chu, Williams, Harris, Bryant, & Gatt, 2013; Ehring & Quack, 2010; Pérez-Fuentes et al., 2013). Child maltreatment in the form of physical or sexual abuse often occurs within the context of a familial unit, where there is an assumption of trust and protection (Courtois, 2004). Intrafamilial violations of trust through physical or sexual abuse can lead to profound, long-term biopsychosocial distress and poor health outcomes (Dorahy et al., 2009; Ford, Stockton, Kaltman, & Green, 2006; Herman, 1992).

Although the literature is replete with data supporting the co-occurrence of child and adult trauma exposure over the life span (Cloitre et al., 2009; Dube, Williamson, Thompson, Felitti, & Anda, 2004; Walsh, MacMillan, & Jamieson, 2002), few studies have documented the associated health outcomes of these exposures in graded aged cohorts. Examinations of trauma experiences that ignore the impacts of different types of violence exposure across stages of life may implicitly convey the assumption that the meaning and sequelae of each event is equal and held constant, regardless of timing or the presence of other exposures. Failure to investigate health outcomes considering the relative contribution of different types of traumatic events, singularly, and in combination, at different stages of life, may lead to misattribution of event-specific risk.

The empirical literature documents higher prevalence rates of adverse outcomes of trauma exposure in females compared with their male counterparts (Tolin & Foa, 2006). Several researchers have hypothesized that these differences are due, in part, to increased rates of exposure to sexual assault and CSA in females (Fergusson, Swain-Campbell, & Horwood, 2002), issues related to reporting symptoms of distress (Norris, Foster, & Weisshaar, 2002; Perkonigg, Kessler, Storz, & Wittchen, 2000), and/or peritraumatic cognitive, emotional, and behavioral responses that influence perceptions of fear and distress (Clark & Ehlers, 2004; Mineka & Zinbarg, 2006). Differences in cumulative trauma exposure over time may be an important consideration for females, with repeated experiences of traumatic events subsequent to the index event predicting greater biopsychosocial distress (Brewin, Andrews, & Valentine, 2000). Similarly, the pain literature has produced equivocal findings regarding how gender influences the expression of pain, but many researchers acknowledge that gonadal hormones, endogenous pain modulatory systems, gender roles, and cognitive/affective factors may affect how females interpret stimuli (Edwards, 2005; Fillingim, King, Ribeiro-Dasilva, Rahim-Williams, & Riley, 2009), increasing the need to further explore the phenomenon of posttrauma pain expression in women.

There is an expanding interest in the association between pain and traumatic stress, with the prevalence of co-occurrence of each ranging from 30% to 81% in adult samples following combat experience, motor vehicle accidents, and other discrete events (Lew et al., 2009; Otis, Keane, & Kerns, 2003; Sayer et al., 2009). It is also evident from this literature that pain and traumatic stress may negatively interact to produce undesirable outcomes that include greater disability (Sherman, Turk, & Okifugi, 2000) and an overall compromised path to recovery (Otis et al., 2003). There are several reasons this may occur. Physical injuries incurred during victimization experiences may lead to chronic health sequelae (e.g., sexually transmitted diseases, muscle and/or joint damage, fractures) that can lead to chronic conditions that create pain over the life span (Asmundson, Coons, Taylor, & Katz, 2002; Resnick, Acierno, & Kilpatrick, 1997). Several authors have postulated that an association between childhood maltreatment and chronic pain as an adult may have its origins in the dysregulation of the hypothalamus–pituitary adrenal (HPA) axis prompted by a perceived threat to self (Bugental, Martorell, & Barraza, 2003; Chiang, Taylor, & Bower, 2015; Hart & Rubia, 2012). This neurobiological stress response activates the release of stress hormones aimed at producing survival behavior. Trauma has been documented to produce changes in neural development, HPA axis functioning, autonomic nervous system dysregulation, and increased inflammation (Chiang et al., 2015). This regulatory process may also be altered by the presence of severe or chronic trauma exposure, especially if trauma occurs early in life (Bugental et al., 2003). Other physiologic pathways explaining an association between trauma exposure, stress, and pain may include sleep alterations, which exacerbate other physical symptoms or reduce the pain threshold (Hart & Rubia, 2012; Sachs-Ericsson, Cromer, Hernandez, & Kendall-Tackett, 2009). Behavioral explanations of the trauma exposure and pain association focus on the acquisition of high risk behaviors (e.g., substance use, smoking, promiscuity) that may lead to other injuries or disease states (Sachs-Ericsson et al., 2009).

Although evidence that an association between chronic pain conditions and childhood physical and sexual abuse exists (Kendall-Tackett, 2007; Sachs-Ericsson et al., 2009), many studies produce equivocal findings about the nature of this relationship. Although childhood abuse was associated with back pain, at 1 year post exposure, one study found no relationship between the two variables for those who had pain at baseline, suggesting the trauma experience did not precede the pain condition (Linton, 2002). Similarly, another prospective study found no association between childhood abuse and pain syndromes, though methodological problems may have led to a misclassification of abuse survivors, thereby diluting group differences (Raphael, Widom, & Lange, 2001). Retrospective reports of child abuse and current pain ratings were found to be mediated by depression, though only partial mediation was found, and no relationships were noted between CPA and pain (Brown, Berenson, & Cohen, 2005). In contrast, multiple studies document high rates of reported pain in survivors of CSA (Coles, Lee, Taft, Mazza, & Loxton, 2015; Newman et al., 2000; Romans, Belaise, Martin, Morris, & Raffi, 2002; Sonneveld et al., 2013) and CPA (Afifi, Mota, MacMillan, & Sareen, 2013; Herrenkohl, Hong, Klika, Herrenkohl, & Russo, 2013). It is noteworthy that the majority of studies that investigate the relationship between pain and childhood abuse are conducted with help-seeking populations, which may artificially inflate or otherwise distort associations between this experience and subsequent pain (Raphael, Chandler, & Ciccone, 2004).

This current study adds to the existing literature by using a large, community-based sample with a wide range of trauma exposures, and provides information on how the experience of trauma, singularly or in combination, affects rates of pain resulting in health limitations within different age cohorts. This is especially important as younger age has consistently been reported as a potential risk factor for the development of adverse health and behavioral health outcomes post victimization (Brewin et al., 2000; Hobfoll, 2002). To this end, this article examined the association between different combinations of trauma exposure including CPA or CSA and intimate partner stalking, physical or sexual violence, or physically forced sex by someone other an intimate partner, and pain that limits functioning in three age cohorts in a population-based sample, controlling for education. Specifically, this investigation examined the following hypotheses:

Hypothesis 1: The rates of pain resulting in physical limitations (and adjusted prevalence rate ratios [aPRRs]) will be associated with having experienced more than one form of either childhood abuse (CSA and/or CPA) or adult violence including stalking, sexual or physical partner violence, or forced sex by someone other than a partner compared with women never experiencing such trauma.

Hypothesis 2: Pain rates and aPRRs for multiple trauma combinations and pain will be highest among women who report pain symptoms at an earlier age.

Method

The Kentucky Women’s Health Registry (KWHR) is a longitudinal database that includes health surveys from 16,645 women, participating from 2006 to 2014. The KWHR provides opportunities to connect researchers to women in Kentucky who are interested in participating in research advancing women’s health. The KWHR is an all-comer, convenience sample database, where participants may self-select or be invited to the KWHR by providers, colleagues, friends, and/or family; eligibility for KWHR are (a) identifying as a woman, (b) being older than 18 years of age, and (c) residing or knowing a resident of Kentucky. KWHR participation consists of completing an annual survey (electronic and paper from 2006 to 2012 and electronic only from 2013 to present). In addition, participants may also elect to receive recruitment information for other research studies conducted outside of the KWHR for which they may be eligible. No compensation was provided to respondents for their participation. For the purposes of this article, longitudinal data are aggregated across survey years to identify any potential exposure to violence such that only one record per participant is used. Therefore, the study design is a secondary data analysis using a cross section of the longitudinal KWHR.

Measurement

Trauma exposure

Adult violence exposure was measured by four items that solicited a yes or no response: adult physical violence (Has an intimate partner, hit, kicked, punched, or otherwise hurt you?), adult sexual violence (Has an intimate partner, used force [like hitting, holding down, or using a weapon] to make you have sex [any sex act, not just intercourse]?), adult stalking (Has an intimate partner, ever repeatedly followed you, spied on you, made unsolicited phone calls to your place of work or at home, damaged your property, or stalked you in any way?), and adult forced sex not intimate partner violence (IPV; Has anyone other than an intimate partner or anyone else used force—such as hitting, holding down, or using a weapon to make you have sex, any sex act, not just intercourse?).

Child violence exposure was measured by two items that solicited a yes or no response: CPA (Did a parent, stepparent, or guardian ever hit, kick, punch or otherwise hurt you?) and CSA (Did any parent, stepparent, or guardian or any other person make you have sex [any sex act, not just intercourse] by using force or by threatening to harm you or someone close to you?).

Simplified (noncumulative) trauma measures were also created to indicate the potential impact of one form of trauma on pain. These simplified trauma measures included (a) any child abuse (created by combining affirmative responses to either of child physical or sexual abuse items), (b) adult violence (created by combining affirmative responses to all four adult violence items), and (c) any experiences of childhood abuse or adult violence were combined to provide an overall measure of trauma exposure. Given the significant degree of overlapping in trauma experienced in childhood and as an adult, the created (nonoverlapping) cumulative trauma measure of trauma was hypothesized to be a more predictive indicator of lifetime pain prevalence than these simplified dichotomous indicators of trauma.

To operationalize Hypothesis 1, the impact for the collective, lifetime experiences of trauma during childhood or as an adult, combinations of childhood abuse were cross-tabulated with experiences of adult violence to create nonoverlapping trauma exposure categories (e.g., child physical violence only, child sexual violence only, child physical and sexual violence only, adult violence only, child physical and adult violence, child sexual and adult violence, child physical and sexual violence with adult violence, and no violence experienced reported; see Table 1—cumulative childhood and adult violence experiences). The strategy was to measure cumulative impact of trauma (proxy for trauma dose) on prevalence rates of health limitations due to pain. The items from the KWHR were used to create this trauma exposure measure (see Table 1 for items). Response options for these items were “yes”; “yes, in my lifetime”; or “yes, in the past 12 months.” Affirmative responses were collapsed across all survey years and across all questions to provide a self-reported measure of ever experiencing the violence/trauma within each individual item, for each respondent.

Table 1.

Frequency of Abuse or Violence Experienced as a Child (Physical or Sexual) or as an Adult.

Form of Abuse by Timing		Combinations^a of Abuse by Timing and Types
	n (%)(N = 16,093)		n (%)(N = 16,093)
		No abuse^a	7,893 (49.0%)
Any childhood^(1,2)	4,028 (25.0%)
		CPA only^a	916 (5.7%)
		CSA only^a	284 (1.8%)
		CPA + CSA^a	170 (1.1%)
Any adult^(3,4,5,6)	6,830 (42.4%)
		Adult only^a	4,172 (25.9%)
		CPA + adult^a	1,394 (8.7%)
		CSA + adult^a	508 (3.2%)
		CPA + CSA + adult^a	756 (4.7%)
Any child or adult abuse^{(1,2,3,4,5,or 6)}	8,200 (51.0%)	Forms of adult IPV or forced sex among women experiencing child abuse or adult violence (n,% of 8,200)● 4,612 (56.2%) physical IPV 3;● 2,213 (27.0%) sexual IPV 4;● 4,272 (52.1%) stalking IPV 5;● 2,147 (26.2%) forced sex not IPV 6

Note. Row percentages; denoted proportion of adult violence, n = 8,200 experiencing either child or adult violence; forms of adult violence may co-occur. CPA = child physical abuse; CSA = child sexual abuse; IPV = intimate partner violence; KWHR = Kentucky Women’s Health Registry.

Denotes mutually exclusive categories of lifetime childhood or adult abuse/violence experienced by women included in KWHR.

Dependent Variables

To capture pain experiences that are significant and likely to be chronic, the primary dependent variable was self-reported experience with pain that limits functioning (any physical pain, not necessarily related to violent injury). Participants in the KWHR (across all surveys) were asked to report whether they experienced limitations because of pain in muscles or joints.

Demographic Characteristics

The literature has documented a number of demographic variables, which may function as protective factors for the development of biopsychosocial distress (e.g., age, gender, education, race, ethnicity; Bonanno, 2005). Current demographics were used to separately determine potential confounders associated with the pain and trauma exposures. These characteristics included race, current marital status, college education (yes or no), employment status (employed, unemployed, not in workforce, or other), insurance (private, Medicaid, Medicare, VA, or uninsured/unknown), sexual attraction (exclusively heterosexual or otherwise), region of residence (Appalachian designated or other counties), and rural or urban residence (Beale codes 4 or greater). Age was also included as a demographic characteristic and potential effect modifier (for Hypothesis 2).

Data

A total of 16,645 unique female respondents participated in the KWHR. A total of 552 (3%) participants were excluded from the analysis because of missing violence exposures or pain experiences, resulting in an analytic sample size of 16,093. For this analytic sample, the distribution of respondents increased from 2006 to 2014 (2006: 677, 4%; 2007: 780, 5%; 2008: 1,443, 9%; 2009: 972, 6%; 2010: 1,385, 9%; 2011: 2,100, 13%; 2012: 2,400, 15%; 2013: 3,087, 19%; and 2014: 3,244, 21%).

Statistical analysis

Descriptive summaries of the frequency of trauma by specific survey items, combinations, and nonoverlapping trauma combinations were included in Table 1. The measure of association was the PRR for trauma and pain adjusted for both age and education as confounders (test of Hypothesis 1). To assess potential confounding, the demographic characteristics (column 1) of the sample (N = 16,093 women; column 2 number in the strata) were provided in Table 2; then with demographic strata (row %), the prevalence of pain resulting in health limitations was presented (column 3) for simple comparisons using chi-square tests and associated p values, and finally, the prevalence of childhood abuse or adult violence was presented as the exposure (again as row prevalence percentages, in column 4). Decisions regarding confounding factors were based on associations with both pain and trauma. Although potential confounders were identified through bivariate associations with pain and trauma, significant overlap existed between potential confounding variables, so only age and education were retained as confounders in multiple variable models. Associations between pain prevalence and simplified trauma exposure categories (child abuse, adult violence, or either), and the cumulative nonoverlapping trauma measure were provided in Table 3.

Table 2.

Demographic Characteristics of Pain Resulting in Health Limitations and Lifetime Trauma (Exposure).

Demographic Characteristics(Column 1)	Number in Strata(Column 2)	Ever Reporting Health Limitations Due to Pain in Muscles or Joints(Column 3)		Lifetime Childhood Abuse or Adult Violence(Column 4)
N = 16,093		n (%)^a	p	n (%)^a	p
Age group			<.0001		<.0001
Age 18-39	4,671	762 (16.3%)		2,369 (50.7%)
Age 40-54	5,014	1,588 (31.7%)		2,875 (57.3%)
Age 55+	6,408	2,166 (33.8%)		2,956 (46.1%)
Race			.05		<.0001
White	15,003	4,177 (27.8%)		7,537 (50.2%)
Non-White	974	300 (30.8%)		592 (60.8%)
Marital status			<.0001		<.0001
Married	10,242	2,721 (26.6%)		4,749 (46.4%)
Separated	238	69 (29.0%)		185 (77.7%)
Divorced	2,415	813 (33.7%)		1,749 (72.4%)
Widowed	934	407 43.6		406 (43.5%)
Never married	2,150	474 (22.0%)		1,049 (48.8%)
College education or higher			<.0001		<.0001
No	6,922	2,429 (35.1%)		3,875 (56.0%)
Yes	9,171	2,087 (22.8%)		4,325 (47.2%)
Employment			<.0001		<.0001
Employed	10,563	2,377 (22.5%)		5,497 (52.0%)
Unemployed	324	114 (35.2%)		229 (70.7%)
Not in labor force	4,914	1,933 (39.3%)		2,301 (46.8%)
Other	221	63 (28.5%)		132 (59.7%)
Insurance group			<.0001		<.0001
Private	13,506	3,425 (25.4%)		6,614 (49.0%)
Medicare	1,126	581 (51.6%)		547 (48.6%)
Medicaid	240	117 (48.8%)		188 (78.3%)
Veteran’s Administration	194	63 (32.5%)		111 (57.2%)
Uninsured or unknown	940	297 (31.6%)		701 (74.6%)
Sexual orientation^a			<.0001		<.0001
Exclusively heterosexual	15,054	4,107 (27.3%)		7,577 (50.3%)
Not exclusively heterosexual	615	218 (35.4%)		436 (70.9%)
Appalachian			<.0001		.92
No	11,888	3,197 (26.9%)		6,043 (50.8%)
Yes	3,479	1,150 (33.1%)		1,765 (50.7%)
Rural/urban			<.0001		.79
Rural	5,544	1,817 (32.8%)		2,825 (51.0%)
Urban	9,823	2,530 (25.8%)		4,983 (50.7%)

Row percent (% ever experiencing pain; % lifetime childhood abuse or adult violence within strata of demographic characteristics). Demographic variables are based on the most recent survey with the exception of age and sexual orientation. Sexual orientation is based on all surveys and age is from the first report of pain if pain was reported.

Table 3.

Frequency of Pain Resulting in Health Limitations by Trauma Exposure and Demographic Characteristics of Women in KWHR.

	Number in Strata	Ever Reported Health Limitations Due to Pain in Muscles or Jointsn (%)	Age-Adjusted PRR(95% CI)^a
Simplified trauma exposures	16,093	4,516 (28.1%)
Child abuse
No	12,065	2,924 (24.2%)	Ref.
Yes	4,028	1,592 (39.5%)	1.53 [1.45, 1.60]
Adult violence
No	9,263	2,176 (23.5%)	Ref.
Yes	6,830	2,340 (34.3%)	1.41 [1.35, 1.48]
Child or adult violence
No	7,893	1,729 (21.9%)	Ref.
Yes	8,200	2,787 (34.0%)	1.49 [1.42, 1.57]
Trauma exposures (nonoverlapping categories)
No childhood or adult violence	7,893	1,729 (20.7%)	Ref.
CPA only	916	292 (29.0%)	1.38 [1.25, 1.53]
CSA only	284	86 (27.6%)	1.32 [1.11, 1.57]
CPA and CSA only	170	69 (37.0%)	1.76 [1.48, 2.11]
Adult violence only	4,172	1,195 (27.1%)	1.29 [1.21, 1.37]
CPA and adult violence	1,394	566 (36.3%)	1.73 [1.61, 1.86]
CSA and adult violence	508	195 (34.8%)	1.65 [1.48, 1.85]
CPA and CSA and adult violence	756	384 (43.3%)	2.06 [1.91, 2.23]
			χ² = 445.01, p < .0001

Note. KWHR = Kentucky Women’s Health Registry; PRR = prevalence rate ratio; CI = confidence interval; CPA = child physical abuse; CSA = child sexual abuse.

Adjusted for age and education.

To account for potential confounding and effect modification, multiple variable log-binomial regression was used to estimate the relationship between trauma exposures and pain while adjusting for age and college education (Hypothesis 1). To examine the potential moderating impact of age, interactions with age (three groups) and trauma exposure were also examined (Hypothesis 2); stratified results were presented for significant interaction effects. Trauma exposure was defined as any childhood violence/trauma, any adult violence, and by cumulative levels of violence/trauma experiences; individual models are used for each violence exposure type. Results were presented with aPRRs and 95% confidence intervals (CIs; Table 4). Prevalence ratio estimates were obtained using PROC GENMOD (link = log, dist = bin). Given the large sample size and multiple comparisons, p < .001 was used to establish statistical significance.

Table 4.

Trauma Exposure Combinations (CPA or CSA and Adult IPV or Forced Sex) and Pain Resulting in Health Limitations by Age Cohorts.

	By Trauma Exposures (Column 1) Number and Adjusted^a Pain Prevalence Rates (95% CI) and aPRRs Within Age Cohorts (Columns 2-4)
Combinations of Trauma Exposure(Column 1)	Age 18-39(n = 4,671)(Column 2)	Age 40-54(n = 5,014)(Column 3)	Age 55+(n = 6,408)(Column 4)
No childhood or adult violence
n with pain by trauma	204	478	1,047
Pain prevalence rate (95% CI)	9.4 [8.2, 10.7]	22.8 [21.1, 24.6]	30.6 [29.1, 32.2]
aPRR (95% CI) for pain and trauma	Ref.	Ref.	Ref.
CPA only
n with pain by trauma	33	90	169
Pain prevalence rate (95% CI)	16.9 [12.4, 23.1]	36.4 [30.9, 42.8]	37.2 [33.0, 41.8]
aPRR (95% CI) for pain and trauma	1.80 [1.28, 2.52]	1.60 [1.33, 1.92]	1.21 [1.07, 1.38]
CSA only
n with pain by trauma	10	36	40
Pain prevalence rate (95% CI)	15.2 [8.6, 26.9]	36.3 [28.0, 47.0]	34.2 [26.7, 43.8]
aPRR (95% CI) for pain and trauma	1.62 [0.90, 2.91]	1.59 [1.21, 2.09]	1.12 [0.87, 1.44]
CPA and CSA only
n with pain by trauma	12	26	31
Pain prevalence rate (95% CI)	26.9 [16.7, 43.5]	45.5 [34.3, 60.3]	45.4 [35.3, 58.5]
aPRR (95% CI) for pain and trauma	2.87 [1.74, 4.71]	2.00 [1.49, 2.68]	1.48 [1.15, 1.92]
Adult violence only
n with pain by trauma	272	449	474
Pain prevalence rate (95% CI)	20.3 [18.3, 22.6]	31.3 [29.0, 33.7]	33.9 [31.5, 36.4]
aPRR (95% CI) for pain and trauma	2.16 [1.83, 2.56]	1.37 [1.23, 1.53]	1.11 [1.01, 1.21]
CPA + adult
n with pain by trauma	106	231	229
Pain prevalence rate (95% CI)	28.4 [24.2, 33.3]	46.5 [42.4, 51.0]	42.1 [38.2, 46.3]
aPRR (95% CI) for pain and trauma	3.02 [2.46, 3.72]	2.04 [1.81, 2.30]	1.37 [1.23, 1.53]
CSA + adult
n with pain by trauma	41	86	68
Pain prevalence rate (95% CI)	29.6 [22.9, 38.1]	42.0 [35.9, 49.1]	39.9 [33.3, 47.9]
aPRR (95% CI) for pain and trauma	3.15 [2.37, 4.19]	1.84 [1.55, 2.20]	1.30 [1.08, 1.58]
Both CPA and CSA + adult
n with pain by trauma	84	192	108
Pain prevalence rate (95% CI)	40.5 [34.6, 47.5]	52.5 [47.9, 57.6]	48.0 [42.1, 54.7]
aPRR (95% CI) for pain and trauma	4.32 [3.51, 5.31]	2.31 [2.04, 2.61]	1.57 [1.36, 1.80]

Note. If pain was reported, then age is from the first report, otherwise, from the most recent survey. Pain and violence are based on all surveys. Demographics are based on the most recent survey. CPA = child physical abuse; CSA = child sexual abuse; IPV = intimate partner violence; CI = confidence interval; aPRR = adjusted prevalence rate ratio.

Adjusted for college education yes/no.

Results

Overall Sample and Trauma Exposure: Simplified and Cumulative Combinations (Table 1)

A total analytical sample of 16,093 women was used for this analysis. One quarter of the sample (25.0%) disclosed either childhood physical or sexual abuse, 42.4% disclosed adult violence, and 51.0% experienced either childhood abuse or adult violence. CPA with no other trauma grouping was reported by 5.7% of women, whereas CSA alone (1.8% of sample) and CPA and CSA alone (no adult violence; 1.1%) were less commonly reported. Adult violence with no CSA or CPA was the most commonly reported form of trauma (25.9%). Childhood abuse and adult violence were frequently co-occurring. Among the 8,200 experiencing either adult violence or childhood abuse, 56.2% disclosed lifetime physical IPV, 27.0% sexual IPV, 52.1% stalking by an intimate partner, and 26.2% disclosed forced sex by someone other than an intimate partner.

Demographic Correlates of Pain and Trauma (Table 2)

Demographic factors remaining associated with pain included increased age, being widowed, having less a college education, not being in the labor force (retired or disabled), being on Medicaid or Medicare, not being exclusively heterosexual, and living in Appalachian or rural counties. Similarly, demographic correlates of adult or childhood trauma included age (40-54), non-White race, being separated or divorced (yet not widowed), having less than a college education, being unemployed, on Medicaid, and not being exclusively heterosexual; neither living in Appalachian nor rural counties was associated with trauma.

Simplified and Cumulative Trauma Combinations and Pain With Health Limitations (Table 3)

Childhood abuse (CPA or CSA), without considering adult violence, was associated with a 56% increased prevalence rate of pain (age-adjusted PRR = 1.56; 39.5% of women disclosing childhood abuse reported pain relative to 24.2% never experiencing childhood abuse). Similarly, adult violence, without considering childhood abuse, was associated with a 47% increased prevalence rate of pain (age-adjusted PRR = 1.47; 34.3% of women disclosing adult violence reported pain relative to 23.5% never experiencing these forms of adult violence). Both simplified measures of trauma indicated a strong association between pain and childhood abuse and adult violence, respectively. Note than adult violence was more commonly disclosed (42.4% vs. 25.0%; see Table 1).

When looking at pain prevalence rates for the nonoverlapping measure of cumulative trauma combinations, pain rates were highest among women experiencing more than one form of trauma (37.0% CPA and CSA, 34.8% CSA and adult violence, 36.3% CPA and adult violence) and were highest for those experiencing all three forms (43.3% of CPA and CSA and adult violence). Pain prevalence was lowest among women never experiencing either form of trauma (20.7%). After adjusting for age and education, relative prevalence rates of pain were highest for women experiencing all three forms of trauma (aPRR = 2.06; 95% CI = [1.91, 2.23]), intermediate for women experiencing two of the three forms (aPRR=1.76, 1.73, and 1.65 for childhood physical and sexual, childhood physical and adult, and childhood sexual and adult, respectively), and lowest for those experiencing only one form (aPRR=1.38, 1.32, and 1.29 for childhood physical only, childhood sexual only, and adult violence only, respectively). Note that experiencing “only” one form of trauma (CPA, CSA, or adult only) remained a strong correlate of pain resulting in health limitations (Table 3).

Age Modifies the Effect of Trauma Combinations on Pain With Health Limitations (Table 4)

Age modified the rate ratios for trauma and chronic pain (χ² for interaction = 49.63, p < .0001) such that the aPRR for experiencing all three forms of trauma (CPA, CSA, and adult violence) for women <40 years was 4.32, 2.31 among those aged 40 to 54 years, and was lowest for women 55 years and older (1.57). A similar pattern of higher aPRR for pain within combinations of trauma categories was observed across the three age cohorts such that the highest aPRR was consistently among the youngest women (<40 years) and the lowest aPRR was observed for the older women (55+ years). Further evidence of age effect modification was that 95% CIs for the age-specific pain and trauma aPRR do not overlap. Experiencing more than one form of trauma was associated with a three- to fourfold increased prevalence of pain resulting in health limitations among those reporting symptoms before age 40.

Discussion

In this cross-sectional analysis, both simplified childhood abuse and adult violence exposure measures were associated with an increased prevalence rate of physical pain that limits functioning. However, as hypothesized, cumulative trauma combinations, which incorporated multiple co-occurring forms were more strongly associated with this adult pain experience. These findings suggest that clinical assessments of CSA, CPA, and adult partner violence or sexual assault may be helpful in identifying those at increased risk of chronic pain (and potential associated medication mismanagement). This observation suggests dose–response patterning between trauma and pain resulting in limitations in adulthood, with repeated exposure across developmental stages acting as a signature risk of the development of significant pain in adults.

Our findings also suggest an increased risk of limiting pain in adulthood for those who experienced CPA and CSA, over and above singular forms of exposure in childhood, and adjusted for education. This combination of childhood abuse exposures represents early life assaults that may be experienced as physically and psychologically painful. In studies of trauma memories, peritraumatic pain was identified as a salient feature in trauma event recall (Norman, Stein, Dimsdale, & Hoyt, 2008; Schilling, Aseltine, & Gore, 2008). The findings of this study in the context of this literature suggests that pain associated with this experience of combined childhood physical and sexual abuse may be associated with strong memory encoding that is easily retrievable and available over the life span (Seltzer & Yarczower, 1991), and when combined with adult violence exposure increases the likelihood of debilitating pain that is unexpected in younger women. The salience of this type of victimization experience in younger women may be related to an immediacy affect; however, a similar trend was not found in the adult-only exposure group, suggesting pain associated with childhood physical and sexual abuse is a particularly enduring and refractory phenomenon. Further research is needed to determine whether the peritraumatic pain associated with physical abuse, sexual abuse, and/or adult violence exposure, alone, or in combination with other potential moderating factors creates a neurophysiological pathway for pain over the life course.

The finding that, as hypothesized, age modified the effect of cumulative trauma combinations on pain such that women experiencing at least two forms of child or adult trauma were 3 to 4 times more likely to begin to have pain symptoms earlier than age 40, suggests that trauma may be etiologically linked with earlier pain presentations. This finding in the youngest adult cohort of respondents suggests the perception of pain that limits functioning is not solely related to the normal process of aging.

Several studies have documented that decrements in health indicators may persist up to 20 years beyond violence exposure (Dube et al., 2010; Dube et al., 2004; Felitti et al., 1998). Several researchers have posited that psychological factors may have direct influence on the persistence of physical symptom reports and perceptions of wellness (Kimberling, Clum, & Wolfe, 2000). The complex trauma framework specifically describes the link between psychological distress associated with intrafamilial violence and physiological dysregulation, resulting in a tendency to over- or underrespond to pain stimuli (Cook et al., 2005). Research examining the role of posttraumatic stress disorder (PTSD) as a moderator of this relationship is an important next step.

Given the association between pain and cumulative violence exposure over time, as well as the high prevalence of trauma experiences in the population, universal screening by using a comprehensive trauma history profile during an initial health exam is warranted. For those clients who have been exposed to childhood physical and sexual abuse and adult violence exposure, a referral for a comprehensive trauma assessment can be used to track individuals into evidence-based trauma treatment to prevent or attenuate associated negative health effects.

The development of pain may follow a similar biological course as the onset of a traumatic stress disorder (Otis et al., 2003), whereas as a perceived lack of control may foreshadow both conditions. In this case, chronic pain may be related to the belief that noxious physical sensations are manifesting in an unpredictable and uncontrollable manner, mimicking the life experience of trauma exposure and the subsequent psychological and physical pain that may have followed. Like PTSD, pain has been found to be moderated by increased positive coping behavior and increased capacity for self-regulation (Kerns, Otis, & Wise, 2002; Kerns, Rosenberg, & Otis, 2002). This suggests that increasing an individual’s self-efficacy toward managing symptoms of pain or distress, and increased perceptions of control may be useful targets for intervention that may produce a twofold effect.

Limitations

When relying on retrospective data, there is potential measurement bias as accuracy of pain symptoms may change over time. However, in these data, differential childhood abuse reporting patterns by age cohort do not appear to indicate differential misclassification linked to trauma exposure, which could affect relevant measures of associations. Similarly, the impact of childhood exposure could be biased downward if those respondents who underreported exposure also minimized pain symptoms. Because this is secondary data analysis, there were limitations on the range and extent of data available. For example, the list of childhood exposures used in this study is not exhaustive, and is focused on different types of interpersonal violence. Although these forms of trauma exposure have been found to be the most deleterious to development (Anda et al., 2006; Lupien, McEwen, Gunnar, & Heim, 2009), the contribution of other trauma experiences (e.g., disasters, crime, motor vehicle accidents) to the experience of pain may have precluded the discovery of some subtleties in the trauma exposure and pain association that would be noteworthy. In this study, number of different types of violence exposure was used as a proxy for dose, however, the duration and intensity of these experiences is unknown, and should be further investigated. There may be differences in willingness to reflect on past distressing experiences, which could vary by age cohort or subgroup and lead to differential reporting patterns. Analyzing clusters of respondents by age groups and violence types used in this study resulted in some small cell sizes, indicating that replication of these findings with larger samples is needed. Finally, this study focuses exclusively on women, to further document the prevalence and risk ratios of pain syndrome in differentially exposed age cohorts. Future studies that compare these findings in males and females are warranted.

Conclusion

This study investigates the experience of violence at different stages of life, and perceptions of pain with health limitations in a non-help-seeking sample of women with a wide range of well-being states and experiences, thereby providing a snapshot of how different types of trauma exposure affect the quality of life in a community of women. However, there is much to learn about how gender influences the experience of pain. Women are not a homogeneous group, and future research should investigate other subgroup differences (e.g., culture, sexual orientation), which may affect the expression of pain over the life span. Although research seeks to produce findings that will generalize to broad population groups, focused investigation on the experience of women respects the unique and individual experiences of this group, and serves as a catalyst for expanding our understanding of the role that gender plays in the development of pain following specific experiences with violence.

Footnotes

Authors’ Note

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Health. The study protocols were approved by the appropriate institutional review board.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The project described was supported by the NIH National Center for Advancing Translational Sciences through grant number UL1TR001998.

Author Biographies

Ginny Sprang, PhD, is a professor in the College of Medicine, Department of Psychiatry at the University of Kentucky, and the executive director of the U.K. Center on Trauma and Children. She is the principal investigator of multiple federal and state grants that examine child traumatic stress, treatment effectiveness, and best practices protocols. She serves on the steering committee for the National Child Traumatic Stress Network and as a consultant to the Department of Justice. She has published extensively in the area of child traumatic stress and secondary traumatic stress.

Heather M. Bush, PhD, is the Kate Spade & Company Foundation Endowed Professor in the Center for Research on Violence Against Women, and a faculty associate at the Center on Trauma and Children. She is an associate professor in the Department of Biostatistics, College of Public Health. Prior to her academic appointment in 2006, she worked as a senior biostatistician in industry and was responsible for the design and analysis of Phase IV studies, observational studies, health registries, and large simple safety studies.

Ann L. Coker, PhD, MPH, serves as professor in the Department of Obstetrics and Gynecology, College of Medicine, and jointly in the Department of Epidemiology, College of Public Health. She holds a PhD in epidemiology from the University of North Carolina. She is a nationally recognized expert in the effect of partner violence on women’s health. She holds an Endowed Chair in the Center for Research on Violence Against Women and is a faculty associate of the Center on Trauma and Children.

Candace J. Brancato, MS, is a senior statistician in the Department of Biostatistics. Her primary roles include support for statistical design, data analysis, data management, and statistical programming. Prior to coming to the United Kingdom, she served as a senior statistician in the pharmaceutical industry, performing analysis, and SAS programming for disease and product registries ranging in size from 200 to 20,000 patients.

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