Timothy C. Toomey

Sexual and physical abuse history in gastroenterology practice: how types of abuse impact health status.

Objective There is an increasing amount of literature pointing to a relationship between sexual and/or physical abuse history and poor health status, although few studies provide evidence concerning which aspects of abuse may impact on health. In female patients with gastrointestinal (GI) disorders, the present study examined the effects on health status of: 1) history of sexual abuse and physical abuse, 2) invasiveness or seriousness of sexual abuse and physical abuse, and 3) age at first sexual and physical abuse. Method: The sample included 239 female patients from a referral gastroenterology clinic who were interviewed to assess sexual and physical abuse history. Results: We found the following: 1) 66.5% of patients experienced some type of sexual and/or physical abuse; 2) women with sexual abuse history had more pain, non-GI somatic symptoms, bed disability days, lifetime surgeries, psychological distress, and functional disability compared to those without sexual abuse; 3) women with physical abuse also had worse health outcome on most health status indicators; 4) rape (intercourse) and life-threatening physical abuse seem to have worse health effects than less serious physical violence, and sexual abuse involving attempts and touch; and 5) those with first abuse in childhood did not appear to differ on health from those whose first abuse was as adults. Conclusions: The authors conclude that asking about abuse should be integrated into history taking within referral-based gastroenterology practices.

Impact of Sexual and Physical Abuse Dimensions on Health Status: Development of an Abuse Severity Measure

Objective Despite the abundant literature showing a relationship of sexual and/or physical abuse history with poor health status, few studies provide evidence about with dimensions of abuse may have a worse impact on health. In female patients with gastrointestinal (GI) disorders, the present study aims to identify which dimensions of abuse history (eg, number of perpetrators, injury) might predict poor current health status, in order to develop an empirically based severity of abuse measure. Methods Of a sample of 239 female patients from a referral gastroenterology clinic, this paper primarily focuses on 121 women with a past history of contact sexual abuse (N = 99), and/or life threatening physical abuse (N = 68). Results Among those with a sexual abuse history, 24% of current health status was explained by serious injury during abuse (p =.0006), victimization by multiple perpetrators (p =.03), and being raped (p =.09). Among the physically abused, rape (in addition to life threat) (p =.0001), and multiple life-threatening incidents (p =.002) explained 39% of the variance in overall health. Among the women with a sexual and/or physical abuse history, the experience of rape, serious injury during sexual abuse, and multiple life-threatening incidents explained one fourth of the variance in current health status. Based on these three dimensions of abuse, we created an abuse severity measure which explained about one fourth of the variance in health status among the subgroup with abuse history, and among the entire clinic sample. Conclusions Given the high prevalence of abuse in referral practice, and the potential health impact of previous abuse, it is important that history taking include details concerning the abuse experience. The severity of abuse measure developed in this paper should prove useful for both research and clinical practice.

Effects of coping on health outcome among women with gastrointestinal disorders.

Background Studies have shown that the nature and quality of coping may positively or negatively affect health outcome; however, this relationship has not been well studied among patients with gastrointestinal (GI) disorders. Objectives The primary objective was to study the effect of different coping strategies on the health outcome of women with GI disorders and how these coping strategies may modify the effects of education, GI disease type, neuroticism, and abuse severity on health outcome. Methods We followed 174 patients in a referral GI clinic for 12 months to assess their health status as a derived variable of daily pain, bed disability days, psychological distress, daily dysfunction, number of visits to physicians, and number of surgeries and procedures. We obtained at baseline their GI diagnosis (functional vs. organic), neuroticism score (NEO Personality Inventory), sexual and/or physical abuse history, and scores on two coping questionnaires. Regressions analyses were used to determine the relative effect of the coping measures on health outcome and their modifying effects on education, GI disease type, neuroticism, and abuse severity. Results A higher score on the Catastrophizing scale and a lower score on the Self-Perceived Ability to Decrease Symptoms scale (Coping Strategies Questionnaire ) predicted poor health outcome. Less education, a functional GI diagnosis, a higher neuroticism score, and greater abuse severity also contributed to poor health status. However, the effect of GI disease type and neuroticism on health outcome was significantly reduced by the coping measures. Conclusions Maladaptive coping (eg, catastrophizing) and decreased self-perceived ability to decrease symptoms may adversely affect health outcome and may modify the effect of GI disease type and neuroticism on health outcome.

Relationship of sexual and physical abuse to pain and psychological assessment variables in chronic pelvic pain patients

&NA; This study examines the incidence of sexual and physical abuse and its relationship to selected pain description and psychological variables in a sample of 36 chronic pelvic pain patients. Abuse was measured on a 6‐item reliable scale, and abused and non‐abused respondents were compared on 4 categories of variables expected to be related to the effects of abuse (pain description, functional impact of pain, others response to pain, and psychosocial impact of pain). Results indicated that 19 of 36 patients reported prior abuse. Physical abuse was reported less commonly than sexual abuse. No differences between the abused and non‐abused groups were noted on demographic, pain description, or the functional interference variables. On the psychological variables, however, the abused group reported less perceived life control, greater punishing responses to pain, and higher levels of somatization and global distress than the non‐abused group. These results indicate a high incidence of sexual abuse in patients with chronic pelvic pain and suggest that abused and non‐abused patients differ on psychological but not pain description or self‐reported functional interference variables.

Acupuncture and chronic pain mechanisms.

&NA; Forty patients with chronic pain below the waist level not amenable to conventional medical and/or surgical treatment were randomly assigned to one of two different methods of acupuncture, after studying the underlying pain mechanisms using a Multidisciplinary Pain Clinic approach and the differential spinal block (DSB). One group received acupuncture needling in the classical acupuncture points referred to as meridian loci needling (MLN) and the other group received tender area needling (TAN) with needles inserted in the dermatomal distribution of the painful areas. The responses between the two groups showed no significant difference. Results were then related to the predetermined somatopsychological basis of the individuals pain problems as classified by the DSB. A group of patients in whom pain relief occurred upon subarachnoid injection of 0.25% procaine followed by sympathetic blockade or 0.5% procaine injection followed by hypalgesia without motor loss, also reported maximum subjective improvement in their pain level following acupuncture therapy performed at a later time. The other group of patients in whom pain persisted despite sensory and motor blockade (1% procaine) responded very poorly to acupuncture therapy. DSB was found to be complimentary to acupuncture therapy in that it facilitated patient selection for the therapy.

Relationship of sexual and physical abuse to pain description, coping, psychological distress, and health-care utilization in a chronic pain sample

OBJECTIVE We investigated the association of physical/sexual abuse to pain description, coping, psychological distress, and health-care utilization in a heterogeneous sample of chronic pain patients. DESIGN A cross-sectional, retrospective design was used. Patients were categorized as abused (n = 22) or nonabused (n = 58) based on responses to a valid and reliable sexual/physical abuse questionnaire. MAIN OUTCOME MEASURES Pain description (Visual Analog Scale measures of pain intensity and frequency, and the McGill Pain Questionnaire); coping ability and attributional style (Functional Interference Estimate, Self-Control Schedule, Pain Locus of Control Scale); psychological distress (SCL-90-R Global Severity Index); and a Health-care utilization measure. RESULTS AND CONCLUSIONS No differences between abused and nonabused groups were found for the pain description or functional interference variables. Compared to the nonabused group, the abused group had significantly lower Self-Control Schedule scores, higher Pain Locus of Control Scale Chance Factor scores, and higher SCL-90-R Global Severity Index scores and was more likely to use the emergency room for pain symptoms. These results replicate the findings of previous studies of the effects of abuse in more specific pain samples and underscore the importance of assessment of abuse in patients with chronic pain. The data suggest that interventions which involve coping-skills training or self-control management of pain may be affected by an abuse history via reduced perceptions of efficacy, resourcefulness, and beliefs that external variables are responsible for pain.

Relationship between perceived self-control of pain, pain description and functioning.

&NA; Recent research has shown an association between preferred coping style and pain report. The present study explores in a sample of 51 patients with chronic pain of myofascial origin the relationship between a dispositional measure of coping, the internality dimension of the Pain Locus of Control Scale (PLOC), and ratings of pain intensity, frequency, and pain‐related behavioral functioning. Patients above the median on the internality dimension of the PLOC reported their pain as less intense and frequent than those below the median. No differences were noted on the behavioral functioning measures. Results are consistent with previous studies and indicate an association between ability to control pain and variations in magnitude and periodicity of pain. The clinical implication of the data is that strategies which provide reduction in pain intensity and frequency might be expected to result in increased perception of personal control of pain.

Spatial distribution of pain: a descriptive characteristic of chronic pain

Abstract Self‐report of spatial distribution of pain has been employed to assess anatomic accuracy of pain description. To date, there is little information on behavioral or psychological characteristics of chronic pain patients as a function of spatial distribution of pain sites. In the present study, 92 patients presenting to a multidisciplinary pain clinic with chronic facial, back, or extremity pain enumerated total sites of pain throughout the body. Responses were categorized into low (1–2), moderate (3–5) and high (6–18) discrete sites of pain. Patients completed self‐report scales assessing various activity abilities and health behaviors, a measure of pain description (McGill Pain Language Questionnaire, MPQ), and health related measures of personality (Illness Behavior Questionnaire, IBQ) and cognitive style (Multifactorial Health Locus of Control, MHLC). One‐way ANOVAs revealed significant differences as a function of spatial distribution on a number of behavioral (down‐time, walking, recreational, vocational and social abilities; total drug use, number of health professionals consulted), pain description (Total Words Chosen‐MPQ, Sum of Ranks‐MPQ, and Sensory‐MPQ) and psychological variables (Disease Conviction‐IBQ and Affective Disturbance‐IBQ). Results suggest spatial distribution of pain site to be a useful clinical diagnostic indicator of psychological disturbance in chronic pain patients.

Site of pain: Relationship to measures of pain description, behavior and personality☆

&NA; Recent research has focused on identification of clinically meaningful subgroupings within the chronic pain population in contrast to prior emphasis on the homogeneity of these patients. The present study investigates site of pain as a potentially useful classification variable for identification of differences among chronic pain patients. In the study 92 patients presenting to a multidisciplinary pain clinic with chronic, benign pain were categorized as to site of pain (head/neck, low back, neither, both). Patients completed self‐report scales assessing various activity abilities and health behaviors, a measure of pain description (McGill Pain Questionnaire (MPQ)), health related measures of personality (Illness Behavior Questionnaire (IBQ)), and health beliefs (Multidimensional Health Locus of Control (MHLC)). One‐way ANOVAs revealed significant differences as a function of pain site on a number of behavioral variables (downtime, walking, recreational and social abilities), pain description (MPQ — number of words chosen, total sum of ranks, sensory and affective) and psychological variables (IBQ — disease conviction, psychologic vs. somatic perception of illness and MHLC — internality). These results suggest site of pain to be of significance in the elaboration of behavioral and psychological response to chronic pain and implications for treatment are discussed.

Relationship of pain drawing scores to ratings of pain description and function

We examined the relationship between pain distribution and measures of self-reported behavioral functioning, pain intensity, frequency, and quality in 51 patients with chronic pain. Results indicate that patients with more distributed pain report their pain as more disruptive to important areas of functioning and also report their pain as more intense and frequent. These results corroborate previous findings and suggest that pain distribution may be used as a useful clinical marker of disability status in chronic pain patients.