Karen G. Raphael

Childhood victimization and pain in adulthood: a prospective investigation.

&NA; Evidence of the relationship between childhood abuse and pain problems in adulthood has been based on cross‐sectional studies using retrospective self‐reports of childhood victimization. The objective of the current study was to determine whether childhood victimization increases risk for adult pain complaints, using prospective information from documented cases of child abuse and neglect. Using a prospective cohort design, cases of early childhood abuse or neglect documented between 1967 and 1971 (n=676) and demographically matched controls (n=520) were followed into young adulthood. The number of medically explained and unexplained pain complaints reported at follow‐up (1989–1995) was examined. Assessed prospectively, physically and sexually abused and neglected individuals were not at risk for increased pain symptoms. The odds of reporting one or more unexplained pain symptoms was not associated with any childhood victimization or specific types (i.e. sexual abuse, physical abuse, or neglect). In contrast, the odds of one or more unexplained pain symptoms was significantly associated with retrospective self‐reports of all specific types of childhood victimization. These findings indicate that the relationship between childhood victimization and pain symptoms in adulthood is more complex than previously thought. The common assumption that medically unexplained pain is of psychological origin should be questioned. Additional research conducting comprehensive physical examinations with victims of childhood abuse and neglect is recommended.

Psychiatric comorbidities in a community sample of women with fibromyalgia

Abstract Prior studies of careseeking fibromyalgia (FM) patients often report that they have an elevated risk of psychiatric disorders, but biased sampling may distort true risk. The current investigation utilizes state‐of‐the‐art diagnostic procedures for both FM and psychiatric disorders to estimate prevalence rates of FM and the comorbidity of FM and specific psychiatric disorders in a diverse community sample of women. Participants were screened by telephone for FM and MDD, by randomly selecting telephone numbers from a list of households with women in the NY/NJ metropolitan area. Eligible women were invited to complete physical examinations for FM and clinician‐administered psychiatric interviews. Data were weighted to adjust for sampling procedures and population demographics. The estimated overall prevalence of FM among women in the NY/NJ metropolitan area was 3.7% (95% CI = 3.2, 4.4), with higher rates among racial minorities. Although risk of current MDD was nearly 3‐fold higher in community women with than without FM, the groups had similar risk of lifetime MDD. Risk of lifetime anxiety disorders, particularly obsessive compulsive disorder and post‐traumatic stress disorder, was approximately 5‐fold higher among women with FM. Overall, this study found a community prevalence for FM among women that replicates prior North American studies, and revealed that FM may be even more prevalent among racial minority women. These community‐based data also indicate that the relationship between MDD and FM may be more complicated than previously thought, and call for an increased focus on anxiety disorders in FM.

Problems of recall and misclassification with checklist methods of measuring stressful life events.

The prevalent use of life event category checklists to facilitate event recall may be one reason that previous studies find that life events play only a small and ambiguous role in the development of health problems. In this study, 136 persons with temporomandibular pain disorder syndrome (TMPDS) and 131 healthy controls reported the occurrence of life events in 10 monthly interviews, using an event category checklist. At the end of the study, they reported retrospectively and in detail about life events over the previous monthly periods. Only one quarter of the event categories appeared in both the monthly interviews and retrospective report for the same period. Detailed analyses revealed problems of inaccuracy inherent in checklists that exacerbate problems of recall. The findings indicate that checklist category approaches should not be used when the goal is to understand the role of stress in adverse health outcomes. Suggestions are made about more adequate methods.

Sexual and physical abuse in women with fibromyalgia syndrome: a test of the trauma hypothesis

Objectives:According to the trauma hypothesis, women with fibromyalgia syndrome (FMS) are more likely to report a history of sexual and/or physical abuse than women without FMS. In this study, we rely on a community sample to test this hypothesis and the related prediction that women with FMS are more likely to have posttraumatic stress disorder than women without FMS. Methods:Eligibility for the present study was limited to an existing community sample in which FMS and major depressive disorder were prevalent. The unique composition of the original sample allowed us to recruit women with and without FMS from the community. A total of 52 female participants were enrolled in the present FMS group and 53 in the control (no FMS) group. Sexual and physical abuse were assessed retrospectively using a standardized telephone interview. Results:Except for rape, sexual and physical abuse were reported equally often by women in the FMS and control groups. Women who reported rape were 3.1 times more likely to have FMS than women who did not report rape (P < 0.05). There was no evidence of increased childhood abuse in the FMS group. Women with FMS were more likely to have posttraumatic stress disorder symptoms (intrusive thoughts and arousal) as well as posttraumatic stress disorder diagnosis (P < 0.01). Discussion:With the exception of rape, no self-reported sexual or physical abuse event was associated with FMS in this community sample. In accord with the trauma hypothesis, however, posttraumatic stress disorder was more prevalent in the FMS group. Chronic stress in the form of posttraumatic stress disorder but not major depressive disorder may mediate the relationship between rape and FMS.

Post-traumatic stress disorder moderates the relation between documented childhood victimization and pain 30 years later.

&NA; Cross‐sectional designs and self‐reports of maltreatment characterize nearly all the literature on childhood abuse or neglect and pain in adulthood, limiting potential for causal inference. The current study describes a prospective follow up of a large cohort of individuals with court‐documented early childhood abuse or neglect (n = 458) and a demographically matched control sample (n = 349) into middle adulthood (mean age 41), nearly 30 years later, comparing the groups for risk of adult pain complaints. We examine whether Post‐Traumatic Stress Disorder (PTSD) mediates or moderates risk of pain. Assessed prospectively across multiple pain measures, physically and sexually abused and neglected individuals generally showed a significant (p < .05) but notably small (&eegr;2 = .01) increased risk of pain symptoms in middle adulthood. Although PTSD was associated with both childhood victimization (p < .01) and risk of middle adulthood pain (p < .001), it did not appear to mediate the relationship between victimization and pain. However, across all pain outcomes other than medically unexplained pain, PTSD robustly interacted with documented childhood victimization to predict adult pain risk: Individuals with both childhood abuse/neglect and PTSD were at significantly increased risk (p < .001, &eegr;2 generally = .05−.06) of pain. After accounting for the combined effect of the two factors, neither childhood victimization nor PTSD alone predicted pain risk. Findings support a view that clinical pain assessments should focus on PTSD rather than make broad inquiries into past history of childhood abuse or neglect.

Prevalence of myofascial temporomandibular disorder in US community women

This study estimates the prevalence of the myofascial subtype of temporomandibular disorders (M-TMD) defined by Research Diagnostic Criteria (RDC), and relates that prevalence to the surveyed report of facial pain. From among 20 000 women selected at random in the NY metropolitan area who completed a telephone survey of facial pain, 2000 were invited for an RDC/TMD examination; 782 examinations were completed. Prevalence was estimated in analyses that were weighted to correct sampling biases. Differences among demographic strata were evaluated with logistic regression. The prevalence of M-TMD was estimated to be 10.5% (95% CL = 8.5-13.0%). Prevalence was significantly higher among younger women, among women of lower socio-economic status, among Black women, and among non-Hispanic women. The report of facial pain in the telephone survey (10.1%) had high specificity for M-TMD diagnosis (94.7%), but low sensitivity (42.7%). M-TMD is a fairly common disorder among American women. Among those reporting facial pain during the last month, half met RDC palpation criteria for M-TMD; thus, a formal physical examination is imperative to establish this diagnosis. Prevalence varies with age, socio-economic status, race and Hispanic ethnicity. A substantial number of RDC-diagnosed cases of M-TMD did not report facial pain in the survey; the reason for this requires further study.

A community-based survey of fibromyalgia-like pain complaints following the World Trade Center terrorist attacks.

&NA; A purported pathogenic mechanism for the development of fibromyalgia, a medically unexplained syndrome involving widespread pain, is stress and associated psychiatric disorder. The major stressor of recent World Trade Center terrorist attacks provides a natural experiment for evaluating this mechanism. This study sought to determine whether symptoms consistent with fibromyalgia increased post‐September 11 and whether exposure to specific terrorism‐related events or prior depression predicted symptom increase. In a large community sample of women in the New York/New Jersey metropolitan area (n=1312), a cohort initially surveyed for pain and psychiatric symptoms before September 11th were recontacted approximately 6 months after the attacks to assess current symptoms and specific terrorism‐related exposures. ‘Fibromyalgia‐like’ (FM‐L) four‐quadrant pain reports consistent with a diagnosis of fibromyalgia were compared at baseline and follow‐up. Result showed that FM‐L rates did not increase significantly between baseline and post‐attack follow‐up. Event exposure did not relate to FM‐L onset at follow‐up, nor did depressive symptoms at baseline interact with event exposure. Depressive symptoms did not predict new onsets better than the extent of their comorbidity with FM‐L at baseline. The failure to detect a significant increase in symptoms consistent with a diagnosis of fibromyalgia and the failure of new onsets of such symptoms to be accounted for by exposure to major stressors or prior depressive symptoms suggests that these hypothesized risk factors are unlikely to be of major importance in the pathogenesis of fibromyalgia.

Is major depression comorbid with temporomandibular pain and dysfunction syndrome? A pilot study.

AbstractThere is a lack of information about the precise strength of the relationship between chronic pain and depression. In a prior study, women with temporomandibular pain and dysfunction syndrome (TMPDS) had much higher scores than did controls on a measure of nonspecific psychological distress. The question arose as to whether rates of clinical depression are also unusually high in TMPDS patients. Their former treating clinician rated cases for likely lifetime presence or absence of depression. A subset of those rated as likely depressed then had their diagnoses verified independently through a structured clinical interview by a psychiatrist and clinical psychologist. Results revealed a minimum lifetime prevalence rate for major depression of 41%. A rate of this magnitude in TMPDS cases is clearly much higher than would be found for women of similar background in the general population.

The examination of myofascial face pain and its relationship to psychological distress among women.

In this study, 110 female myofascial face pain patients were assessed monthly for 10 months on measures of pain, distress, and stressful life events. D. A. Kenny and A. J. Zautras (1995) structural equation model for examining the separate trait, state, and error components of the variables was used to analyze the data. Both pain and distress had sizable trait variance, and the trait components were correlated. The 2 variables also showed sizable state variance, and the states of pain covaried with states of distress. A significant time-lagged relationship between the 2 variables was found: Increases in distress led to elevations in pain 1 month later. Stressful life events arising from major social roles were also associated with greater distress, but not pain. Illness events unrelated to the pain syndrome were associated with both pain and distress.

Fibromyalgia Syndrome: Presentation, Diagnosis, Differential Diagnosis, and Vulnerability

Fibromyalgia syndrome (FMS) presents with widespread soft tissue pain. Common comorbidities include severe insomnia, body stiffness, affective symptoms, irritable bowels, and urethral syndrome. A 1990 research classification depends on a history of widespread pain and prominent tenderness to palpation at 11 or more of 18 specific tender points. It is a criteria-based diagnosis rather than one by exclusion and can accompany other medical conditions. FMS occurs worldwide, and can present any age, but is most common in adult females. Although numerous studies and reviews contend that FMS may be caused by psychological stress such as sexual abuse, critical epidemiological review fails to support that concept. Existing data suggest that some individuals with FMS may have a dysregulated physiological stress response system that predates the onset of symptoms.