Childhood victimization and pain in adulthood: a prospective investigation

Pain 92 (2001) 283±293

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Childhood victimization and pain in adulthood: a prospective investigation Karen G. Raphael*, Cathy Spatz Widom, Gudrun Lange Department of Psychiatry, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, 30 Bergen Street, ADMC 14, Newark, NJ 07107, USA Received 2 October 2000; received in revised form 22 December 2000; accepted 10 January 2001

Abstract 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 ˆ 676) and demographically matched controls (n ˆ 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 speci®c types (i.e. sexual abuse, physical abuse, or neglect). In contrast, the odds of one or more unexplained pain symptoms was signi®cantly associated with retrospective self-reports of all speci®c types of childhood victimization. These ®ndings 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. q 2001 International Association for the Study of Pain. Published by Elsevier Science B.V. All rights reserved. Keywords: Childhood trauma; Unexplained pain symptoms; Adulthood±childhood correlation

1. Introduction Dating back to psychoanalytic conceptualizations in the 1950s and early 1960s (Engel, 1959; Lesse, 1963) early childhood trauma and suffering have been assumed to predispose an individual to pain-proneness in adulthood. More recent empirical research suggests that a history of early childhood victimization, especially sexual abuse, is related to the development of several functional somatic syndromes. Prominent among these syndromes are those involving pain of indeterminate and possibly psychological origin. Among researchers, a strong belief exists in the association between early abuse and adult functional pain complaints (e.g. Longstreth et al., 1998). A number of studies have reported child abuse among patients with ®bromyalgia, a controversial functional syndrome characterized by chronic widespread pain. For example, Walker et al. (1997) found that, compared with * Corresponding author. Tel.: 11-973-972-5462; fax: 11-973-972-8305. E-mail address: [email protected] (K.G. Raphael).

women with rheumatoid arthritis, women seeking treatment for ®bromyalgia were more likely to report a history of childhood emotional and physical abuse, as well as neglect. Boisset-Pioro et al. (1995) compared women with ®bromyalgia with women with other rheumatic diseases who attended a university rheumatology clinic and found them to report signi®cantly higher lifetime prevalence rates of sexual and physical abuse. Comparing women seeking treatment for ®bromyalgia to controls who had no connective tissue disease or major medical condition, Taylor et al. (1995) found only marginally higher rates of lifetime sexual abuse among those with ®bromyalgia. Similar studies have examined rates of childhood abuse among adult women with chronic pelvic pain syndrome. Elevated rates of childhood sexual abuse and physical abuse have been found in women with chronic pelvic pain, compared with non-pain controls (Harrop-Grif®ths et al., 1988; Rapkin et al., 1990; Walling et al., 1994) or controls with other pain disorders (Bodden-Heidrich et al., 1999; Rapkin et al., 1990; Walling et al., 1994). Elevated rates of childhood trauma have also been reported for

0304-3959/01/$20.00 q 2001 International Association for the Study of Pain. Published by Elsevier Science B.V. All rights reserved. PII: S 0304-395 9(01)00270-6

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chronic refractory low back pain patients (Schofferman et al., 1992, 1993) and chronic headache patients (Domino and Haber, 1987). Some suggest that childhood trauma history is associated speci®cally with `psychogenic pain' syndromes rather than pain of clear organic origin (Adler et al., 1989), although others argue that the literature does not support this distinction (Fry et al., 1997). Research has also examined pain symptoms among individuals who self-report histories of abuse in childhood (Bendixen et al., 1994; Dickinson et al., 1999; Finestone et al., 2000; Lechner et al., 1993; Leserman et al., 1998; Linton, 1997; McBeth et al., 1999; Moeller et al., 1993). Although less able to rule out clear organic causes for pain complaints, these studies are more likely to draw samples from individuals not seeking treatment for pain. This sampling strategy is an advantage, since some literature has suggested that trauma history may be associated with health care seeking (Aaron et al., 1997; Alexander et al., 1998; Talley et al., 1997) but not necessarily symptom status. One community study (McBeth et al., 1999) examined the association between various types of childhood adversity and tender points, i.e. areas of the body that elicit pain upon palpation. Those with a self-reported history of childhood abuse or other early adversities (such as parental loss, family member illness, etc.) were more likely to have high tender point counts than subjects who did not report such histories. In a reanalysis of data from a general population survey (Linton, 1997), women but not men who reported pronounced spinal pain during the past year were more likely to self-report childhood sexual abuse. In a random sample survey of Norwegian college students, Bendixen et al. (1994) found that men but not women reporting childhood sexual abuse were more likely than those without such reports to have sought past-year medical consultation for headache, abdominal or muscular pain; child abuse was not signi®cantly related to frequency of these pain complaints for either men or women. Other studies use general medical samples or other specialized samples of patients who are not speci®cally seeking treatment for pain. Using family practice clients, Dickinson et al. (1999) reported that women with a history of severe sexual abuse had elevated rates of bodily pain complaints. Another study (Lechner et al., 1993) in a primary health care center found that women reporting childhood sexual abuse had more overall medical symptom complaints, but did not signi®cantly differ from those without abuse histories on musculoskeletal complaints. In contrast, Leserman et al. (1998) found that women seeking treatment in a gastroenterology clinic who had self-reported lifetime abuse histories had more musculoskeletal symptoms than other women. Moeller et al. (1993) found that women attending a private gynecology clinic who said that they experienced childhood abuse were more likely than those reporting no abuse to describe frequent headaches and stomachaches. Recently, Finestone et al. (2000)

reported that women attending group therapy for victims of childhood sexual abuse more often had diffuse pain symptoms, as well as a diagnosis of ®bromyalgia, than nonabused control subjects. Thus, compared with studies of childhood victimization among those with speci®c functional pain disorders, the results from research using samples that have not been selected speci®cally for pain treatment-seeking tend to be less consistent, although most studies suggest an association between early victimization and pain symptoms in adulthood. The most frequently reported relationship is between childhood sexual abuse and pain symptoms in adult women. One methodological problem shared by these studies is that their assessment of child abuse was based on retrospective self-reports. The accuracy of retrospective recall for childhood events has been debated vigorously (Berliner and Williams, 1994; Briere and Conte, 1993; Loftus, 1993; Widom, 1989b; Williams, 1994). There seems to be general acceptance that memory is at least party reconstructive (Fivush, 1993; Neisser, 1967; Radke-Yarrow et al., 1970) and that recall may be in¯uenced by current psychological status (Raphael and Cloitre, 1994). Despite the potential problems inherent in reliance on retrospective assessments of childhood victimization, to date, only one prospective study has been conducted (Rimsza et al., 1988). In this 2-year follow-up of children and adolescents who were victims of documented cases of sexual abuse, chart review and caregiver interviews revealed elevated rates of muscle tension and gastrointestinal symptoms, including abdominal pain, among the abuse victims compared with a matched control group. Whether these problems persist into adulthood is unknown. Assuming that early childhood victimization is associated with pain symptoms in adulthood, one potential mechanism for the linkage is that childhood trauma places an individual at increased risk for the development of psychiatric problems, especially depression (Bodden-Heidrich et al., 1999; Briere and Runtz, 1988; Dickinson et al., 1999; Harrop-Grif®ths et al., 1988; Mullen et al., 1988; Walker et al., 1988, 1992), and that functional pain disorders are somatic manifestations of depression (Blumer and Heilbronn, 1982; Bohr, 1996). It is also possible that depression and pain have a shared biopsychosocial pathogenesis (Al®ci et al., 1989; Hudson and Pope, 1994, 1996), perhaps involving HPA axis dysregulation. Whether elevations in pain complaints are restricted to adult victims of childhood abuse who manifest psychiatric disorder, especially depression, has not previously been examined. In sum, a number of existing studies suggest an elevation in rates of pain complaints and functional pain syndromes among victims of child abuse. However, because of heavy reliance on retrospective self-reports of childhood victimization and the relatively short time frame of the one prospective study (Rimsza et al., 1988), existing knowledge of the long-term health consequences of childhood victimization is limited. This paper seeks to extend knowledge by using data from a

K.G. Raphael et al. / Pain 92 (2001) 283±293

prospective cohort study examining pain symptoms among individuals with documented cases of early childhood victimization, including childhood sexual abuse, physical abuse, and neglect. 1.1. Aims This paper has ®ve major goals: (1) To replicate the results of earlier studies showing an elevation in adult pain symptoms associated with sexual abuse using a prospective cohort design with documented cases of childhood abuse and to determine whether the relationship extends to childhood physical abuse and neglect; (2) To determine whether these early childhood victimization experiences lead to a reduced threshold for treatment-seeking or disability associated with pain symptoms rather than symptom expression per se; (3) To determine whether early childhood victimization is associated speci®cally with medically unexplained pain, i.e. pain that may be `psychogenic', rather than pain associated with a major medical condition or injury; (4) To determine whether the relationship between childhood victimization and pain complaints varies as a function of other characteristics. For example, is the elevation in pain complaints among child abuse victims restricted to those with major depressive disorder? Does the relationship between childhood victimization and subsequent pain symptoms in young adulthood vary as a function of a person's gender, age, or welfare status as a child?; (5) To replicate these analyses using information obtained from retrospective self-reports from individuals in the same sample. Should the results of the prospective investigation differ substantially from the existing body of literature based on retrospective research, a reanalysis of these relationships using retrospective self-reported data will serve to rule out the possibility that the ®ndings are unique to the speci®c characteristics of the present sample. 2. Methods 2.1. Design The data employed in these analyses are part of a research project based on a cohort design study (Leventhal, 1982; Schulsinger et al., 1981) in which abused and neglected children were matched with non-abused and non-neglected children and followed prospectively into young adulthood. Because of the matching procedure, the subjects are assumed to differ only in the risk factor: that is, having experienced childhood sexual or physical abuse or neglect. Since it is not possible to randomly assign subjects to groups, the assumption of equivalency for the groups is an approximation. The control group may also differ from the abused and neglected individuals on other variables associated with abuse or neglect. (For complete details of the study design and subject selection criteria, see Widom, 1989a.)

285

In the ®rst phase of this research, a large group of children who were abused and/or neglected approximately 20 years ago were followed up through an examination of of®cial juvenile and adult criminal records and compared with a matched control group of children. The rationale for identifying the abused and neglected group was that their cases were serious enough to come to the attention of the authorities. Only court substantiated cases of child abuse and neglect were included here. Cases were drawn from the records of county juvenile and adult criminal courts in a metropolitan area in the Midwest during the years 1967 through 1971. To avoid potential problems with ambiguity in the direction of causality, and to ensure that the temporal sequence was clear (i.e. child abuse or neglect led to subsequent outcomes), abuse and neglect cases were restricted to those in which children were less than 11 years of age at the time of the abuse or neglect incident. Thus, these are cases of early childhood abuse and/or neglect. Physical abuse cases included injuries such as bruises, welts, burns, abrasions, lacerations, wounds, cuts, bone and skull fractures, and other evidence of physical injury. Sexual abuse charges varied from relatively non-speci®c charges of `assault and battery with intent to gratify sexual desires' to more speci®c charges of `fondling or touching in an obscene manner', sodomy, rape, incest, and so forth. Neglect cases re¯ected a judgment that the parents' de®ciencies in child care were beyond those found acceptable by community and professional standards at the time. These cases represented extreme failure to provide adequate food, clothing, shelter, and medical attention to children. Cases of `involuntary' neglect due to factors such as temporary institutionalization of the legal guardian or failure to pay child support were excluded from the neglect sample. Those children who were adopted as an infant were also excluded from the documented abuse group, because name changes and moves from the county or state made it impossible to trace them. A control group was established with children who were matched on age, sex, race, and approximate family social class during the time period of the study (1967±1971). Children who were under school age at the time of the abuse and/or neglect were matched with children of the same sex, race, date of birth (^1 week), and hospital of birth through the use of county birth record information. For children of school age, records of more than 100 elementary schools for the same time period were used to ®nd matches with children of the same sex, race, date of birth (^6 months), class in elementary school during the years 1967±1971, and home address, preferably within a ®ve-block radius of the abused or neglected child. An effort was made to locate two matches to allow for loss of control group members. Those reported in of®cial records to have been abused or neglected were eliminated and replaced, where possible, with a second matched subject. Any child with an of®cial record of abuse or neglect was removed from the control group, regardless of whether the case was before or after the

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period of the study. Overall, there were matches for 74% of the abused and neglected children. The second phase of the research involved tracing, locating, and interviewing the abused and/or neglected individuals and controls (approximately 20 years later). The follow-up was designed to document long-term consequences of childhood victimization across a number of outcomes (cognitive and intellectual, emotional, psychiatric, social and interpersonal, occupational, and general health). Two-hour follow-up interviews were conducted between 1989 and 1995 and included a series of structured and semi-structured questionnaires and rating scales. The National Institute of Mental Health Diagnostic Interview Schedule revised DIS-III-R (Robins et al., 1989), which corresponds to DSM-III-R Axis I diagnoses (American Psychiatric Association, 1987), was used to gather information on psychiatric diagnoses, including major depressive disorder and somatization disorder. The DIS-III-R is a fully structured interview schedule designed for use by lay interviewers. Although the DIS-III-R is a structured interview schedule, interviewers received a week of training in the administration of the interview. Computer programs for scoring the DIS-III-R were used to compute DSM-III-R diagnoses. The interviewers were blind to the purpose of the study, to the inclusion of an abused and/or neglected group, and to the participants' group membership. Similarly, the subjects were blind to the purpose of the study. Subjects were told that they had been selected to participate as part of a large group of individuals who grew up in that area in the late 1960s and early 1970s. Subjects who participated signed a consent form acknowledging that they were participating voluntarily. Of the original sample of 1575 (908 abused and neglected individuals and 667 controls), 1307 subjects (83%) have been located and 1196 interviewed (76%). Of the people not interviewed, 43 were deceased (prior to interview), eight were incapable of being interviewed, 268 were not found, and 60 refused to participate (a refusal rate of 3.8%). Comparison of the current follow-up sample with the original sample indicates no signi®cant differences in terms of percent male, white, abused and/or neglected, poverty in childhood census tract, or mean current age. Approximately half the sample is female (48.7%) and about two-thirds is white (62.9%). The mean age of the sample at the time of the interview was 28.7 (SD ˆ 3:84). There were no differences between the abused and neglected group and controls in terms of gender, race/ethnicity, or age. The average highest grade of school completed for the sample was 11.47 (SD ˆ 2:19), although abused and neglected individuals had completed signi®cantly (P , 0:001) less school (mean ˆ 10:99, SD ˆ 1:99) than controls (mean ˆ 12:09, SD ˆ 2:29). At follow-up, two thirds of the control group had completed high school, whereas less than half (48%) of the abused and neglected children had done so. Occupational status of the sample was

coded according to the Hollingshead Occupational Coding Index, (Hollingshead, 1975) ranging from 1 (laborer) to 9 (professional). Median occupational level of the sample was semi-skilled workers, and less than 7% of the overall sample was in levels 7±9 (managers through professionals). More of the controls were in higher occupational levels than abused and neglected subjects (P , 0:001). 2.2. Measures and variables 2.2.1. Documented child abuse and neglect This is a dichotomous variable based on of®cial reports of child abuse and/or neglect. Those subjects with documented child abuse and/or neglect (n ˆ 676) were coded 1, and controls with no of®cial reports of abuse or neglect (n ˆ 520) were coded 0. This overall categorization of child abuse and neglect includes three speci®c types which are also coded separately and are de®ned here. For documented childhood sexual abuse, those subjects with an of®cial report of sexual abuse (n ˆ 96), as described earlier in the section on the selection of subjects, were coded 1; controls with no of®cial reports of abuse or neglect were coded 0. For documented childhood physical abuse, those subjects with an of®cial report of sexual abuse as described earlier (n ˆ 100) were coded 1; controls with no of®cial reports of abuse or neglect (n ˆ 520) were coded 0. Similarly, for documented neglect, those subjects with an of®cial report of neglect as described earlier (n ˆ 480) were coded 1; controls with no of®cial reports of abuse or neglect (n ˆ 520) were coded 0. 2.2.2. Self-report of childhood victimization This re¯ects the person's retrospective self-report of their childhood victimization experiences obtained during interviews in young adulthood. All subjects (abused and neglected and controls) completed the self-report of childhood victimization measures. The selection of speci®c measures for use in the construction of the self-report of childhood victimization indicator was based on a series of psychometric analyses of the accuracy of adult recollections of early childhood victimization. (For further details, see Widom and Morris, 1997; Widom and Shepard, 1996.) Measures that had the overall best psychometric qualities were selected for use here and combined to form an overall measure of self-reported childhood victimization. Selfreported childhood victimization (a dichotomous variable re¯ecting self reported childhood victimization vs. no selfreported childhood victimization) is de®ned as reporting any of three types of childhood victimization experiences and includes childhood physical abuse, sexual abuse and neglect. The criteria for the three speci®c types of childhood victimization which make up the components of the overall self-reported childhood victimization measure are described below. Respondents were considered to have self-reported childhood sexual abuse if they met one of three criteria (see

K.G. Raphael et al. / Pain 92 (2001) 283±293

Widom and Morris, 1997). Respondents were ®rst presented with a list of explicitly sexual behaviors (ranging from `an invitation or request to do something sexual' to `another person fondling you in a sexual way' to `intercourse') and asked: `Up to the time you ®nished elementary school (before 6th grade), did you ever have any of the following experiences...?' This was followed by the question: `Do you consider any of these experiences to have been sexual abuse?' This response constituted the ®rst criterion for self-reported childhood sexual abuse, representing the person's cognitive appraisal (or de®nition) of the event or experience as being childhood sexual abuse. Thus, the ®rst criterion was based on two parts of the respondent's answer: ®rst, a report of having any of these sexual experiences before age 12 and then a positive response to the followup question about abuse. Respondents were also asked a separate set of questions about whether they had `ever had a sexual experience with anyone 10 years older' (Finkelhor, 1979) and how old they were when this happened for the ®rst time. A cutoff of age 12 was used to de®ne childhood sexual abuse. Responses to these questions formed the basis for the second criteria for self-reported childhood sexual abuse. If the person reported having had a sexual experience with a person 10 years older, prior to the age of 12, they were considered to have selfreported childhood sexual abuse. The third criterion was a positive answer to the question: `Has anyone ever bothered you sexually or tried to have sex with you against your will?' This question was followed-up by a question about the age at which this occurred. This measure of childhood sexual abuse was again restricted to events that occurred before age 12. A person was considered to have self-reported childhood sexual abuse if they met any of the three criteria described above. These three criteria had the best psychometric qualities in a comparison of adult recollections of early childhood sexual abuse using documented cases of childhood sexual abuse to assess `accuracy'(Widom and Morris, 1997). (For more detail regarding the discriminant validity of the three criteria as well as relative improvement over chance, see Widom and Morris, 1997.) 2.2.3. Self-reported physical abuse This was assessed through the use of two different measures. The ®rst measure is the `Very Severe Violence' subscale of the Con¯ict Tactics Scale (CTS) (Straus, 1979), the most stringent of the CTS indices. In the present study, CTS items were framed in the context of an introduction which asked respondents about `...things that your parents or the people in your family might have done when they had a disagreement with you when you were growing up, that is, up to the time you ®nished elementary school'. This age limit was imposed to de®ne a measure of early childhood victimization consistent with of®cial information about the documented abuse experience (for those subjects with a documented history of abuse or neglect). The Very Severe

287

Violence subscale of the CTS includes the following items: (1) kick, bite, or hit you with a ®st; (2) beat you up; (3) burn or scald you; (4) threaten you with a knife or gun; or (5) use a knife or gun. Response categories included never, once, twice, sometimes, frequently, or most of the time, and were collapsed to create a dichotomous variable of `ever' or `never' (comparable to the of®cial designation of abuse/ neglect). A second measure was designed to provide an alternative means to retrospectively assess childhood physical abuse (self-report of child abuse ± physical; SRCAP). Respondents were asked, `Up to the time you ®nished elementary school, did anyone either inside or outside of your family ever' (1) beat or really hurt you by hitting you with a bare hand or ®st; (2) beat or hit you with something hard like a stick or baseball bat; (3) injure you with a knife, shoot you with a gun, or use another weapon against you; (4) hurt you badly enough so that you needed a doctor or other medical treatment; (5) physically injure you so that you were admitted to a hospital. Respondents were also asked, `Did either of your parents ever beat you when you didn't deserve it?' Self-reported physical abuse was indicated by a positive response to any item on either the CTS Very Severe Violence subscale or the SRCAP measure. In psychometric analyses (Widom and Shepard, 1996) comparing adult recollections of earlier childhood victimization with known victimization experiences (documented cases of physical or sexual abuse or neglect), there was good discriminant validity for these two self-report measures of childhood physical abuse. 2.2.4. Self-reported childhood neglect This is de®ned by a positive response to any one of three items: (1) `Were there ever times when you were a young child that a neighbor fed you or cared for you because your parents didn't get around to shopping for food or cooking, or when neighbors or relatives kept you overnight because no one was taking care of you at home?' (2) `When you were a young child, did anyone ever say that you weren't being given enough to eat, or kept clean enough, or that you weren't getting enough medical care when it was needed?' (3) `When you were a very young child, did your parents ever leave you home alone while they were out shopping or doing something else?' Our global measure of Self Report of Childhood Victimization includes any self-reports of childhood physical abuse (n ˆ 610), sexual abuse (n ˆ 291), and neglect (n ˆ 384). Overall, 62.5% (n ˆ 743) of the sample reported some history of childhood victimization. The analyses described below relating to speci®c types of victimization (physical abuse, sexual abuse, and neglect) are based on the classi®cation of subjects into those who experienced any of that type of childhood victimization. We do not restrict the classi®cation to subjects who report only that type of childhood victimization and no other type of victimization experiences ± referred to here as `pure' types or single forms of victimization.

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2.3. Pain symptoms To assess the frequency of current pain complaints, items from the Somatization module of the Diagnostic Interview Schedule III-R (DIS-III-R) (Robins et al., 1989) were used. Basic counts of pain symptom complaints were derived by summing the number of positive responses to questions about: Have you ever had abdominal or belly pain, back pain, pain in the joints, pain in arms or legs, chest pains, headaches, pain when you urinated, burning pain around private parts, and pain anywhere else. The following items were preceded by the phrase: `Have you ever had a lot of trouble with...': abdominal or belly pain, back pain, headaches. This measure is referred to as pain symptom counts. The second measure of pain symptoms was derived by subsetting the ®rst symptom count, using further information derived from structured probes that are a standard part of the DIS-III-R. To determine the number of nontrivial pain symptoms, a measure was derived which counted the number of pain symptoms to which there was a positive response and in which the respondent told the interviewer that they either told a doctor or other professional about the problem or reported that the symptom interfered with his or her life or activities a lot. This is referred to as pain problem counts. The third measure of pain symptoms was derived by dividing the pain problem count by the pain symptom count, yielding an index of how likely it was that any experienced symptom caused either treatment-seeking or life interference. This measure is referred to as problem percent. The fourth measure of pain symptoms was derived by counting the number of pain symptoms that the respondent said were always the result of a physical illness or injury. This measure is hereafter referred to as pain illness counts. The last measure of pain symptoms was derived by counting the number of pain symptoms that were experienced, but were not attributed entirely to either medication, drugs, alcohol, physical illness or injury. These unexplained pain counts form a subset of the items that are typically used to render a DSM-III-R diagnosis of Somatization disorder. 2.4. Depression Lifetime history of major depression was obtained from the DIS-III-R (Robins et al., 1989) Depression module. Diagnoses of Major Depression are based on DSM-III-R criteria which included: (A) at least ®ve symptoms had been present during the same two-week period and represent a change from previous functioning and at least one of the symptoms is either depressed mood or loss of interest or pleasure; (B) it cannot be established that an organic factor initiated and maintained the disturbance and/or the disturbance is not a normal reaction to the death of a loved one; (C) hallucinations or delusions did not exist for as long as two weeks during the disturbance; and (D) the symptoms were not superimposed on Schizophrenia, Schizophreni-

form Disorder, Delusional Disorder, or Psychotic Disorder. In our sample, 23.2% of the respondents met the DSM-III-R criteria for lifetime history of MDD, and 13.1% met criteria for current MDD. 2.5. Control variables White, non-Hispanic is a self-reported variable. Respondents who reported their race/ethnicity as white, non-Hispanic were coded as 1 (62% of the respondents were white, non-Hispanic). All others were coded as 0, with the largest remaining group compromised of black, non-Hispanic (33%). Since the subjects were interviewed at different ages (between the years 1989 and 1995), it is important to control for disproportionate risk of developing physical symptoms. Analyses include controls for age at the time of the interview. Respondents' ages ranged from 18 to 40 years (mean ˆ 28:7 ^ 3:9). Approximately 90% of the subjects were over 23 years of age at the time of the interview and almost half were over 30. Welfare as a child, a dichotomous variable, is included as an indicator of childhood poverty to control for economic disadvantage. This variable was assessed by the person's response to an interview question: `At any time during your childhood, did either of your parents ever receive welfare payments or food stamps?' Responses of `yes' were coded as 1 and others were coded as 0 (53% of the respondents reported welfare in childhood). This measure, rather than an indicator of current economic status, was used as a control, as current economic status might be a consequence of childhood victimization and therefore inappropriate as a control variable. 3. Results 3.1. Childhood victimization and pain in young adulthood Table 1 shows mean values of pain counts by child abuse and neglect group vs. controls, adjusting for the effects of age, sex, race (white vs. other) and welfare status as a child. Since the pain count measures were not normally distributed, analyses were also conducted with log-transformations of these dependent variables. Since conclusions about the relationship between childhood victimization and pain counts were entirely consistent across log-transformed and original dependent variables, analyses were demonstrated to be robust to deviations from normality. For ease of interpretability, results using non-transformed dependent measures are shown. Collapsing across all types of childhood victimization (sexual abuse, physical abuse and neglect), those experiencing one or more of the three types of childhood abuse and neglect did not differ from those with no trauma on any pain count index. Childhood sexual abuse, most often studied in relation to pain symptoms and syndromes, did not show a

K.G. Raphael et al. / Pain 92 (2001) 283±293

289

Table 1 Documented childhood victimization and pain symptoms in young adulthood (controlling for age, sex, race, and welfare status as a child) a Pain measure

Any documented abuse or neglect (n ˆ 676)

Control (n ˆ 520)

Documented sexual abuse (n ˆ 96)

Control (n ˆ 520)

Documented physical abuse (n ˆ 100)

Control (n ˆ 520)

Documented neglect (n ˆ 480)

Control (n ˆ 520)

Pain symptom counts Pain problem counts Pain illness counts Unexplained pain counts Problem percent

2.51 (0.08) 1.98 (0.07) 1.45 (0.06) 0.50 (0.04) 79.8 (0.01)

2.36 (0.09) 1.83 (0.08) 1.32 (0.06) 0.48 (0.04) 76.0 (0.02)

2.66 (0.21) 2.07 (0.18) 1.53 (0.15) 0.52 (0.09) 82.7 (0.04)

2.35 (0.09) 1.82 (0.08) 1.32 (0.06) 0.48 (0.04) 75.9 (0.02) §

2.68 (0.20) 2.23 (0.18) 1.58 (0.15) 0.60 (0.10) 84.7 (0.04)

2.28 (0.08) § 1.77 (0.07) ³ 1.28 (0.06) § 0.46 (0.04) 75.9 (0.02) ³

2.41 (0.09) 1.88 (0.08) 1.38 (0.07) 0.48 (0.04) 78.1 (0.02)

2.32 (0.09) 1.79 (0.08) 1.30 (0.06) 0.47 (0.04) 75.9 (0.02)

a

Values are mean (SE). ³P # 0:05, §P # 0:10.

signi®cant relationship to any type of pain symptom count, even prior to Bonferroni correction for multiple comparisons. There was a tendency for a documented history of early physical abuse to be associated with a signi®cant increase in the number of pain complaints, but it was restricted to those pain complaints causing either life interference or treatment seeking, i.e. pain problem counts. This association and the association between documented physical abuse and problem percent was no longer signi®cant after Bonferroni correction for multiple comparisons. Early physical abuse was not associated signi®cantly with unexplained pain counts. A documented history of childhood neglect bore no relationship to the number of pain complaints, regardless of the form of the measure. Only 34% of the sample experienced one or more `unexplained' pain symptom. Logistic regression was used to predict the odds of having one or more unexplained pain symptoms from demographic factors (age, sex, race, and welfare status as a child) and childhood victimization group. The odds of reporting one or more unexplained pain symptoms was not signi®cantly associated with any experience of childhood victimization (odds ratio …OR† ˆ 1:20, 95% con®dence interval (CI): 0.92, 1.57, P . 0:10), sexual abuse (OR ˆ 1:39, 95% CI: 0.85, 2.26, P . 0:10), physical abuse (OR ˆ 1:23, 95% CI: 0.74, 2.05, P . 0:10) or neglect (OR ˆ 1:20, 95% CI: 0.89, 1.61, P . 0:10). Thus, across all types of early childhood victimization, and across the different measures of pain complaints, our results revealed no signi®cant relationship between early child abuse and neglect and pain complaints in young adulthood.

cance, with the exception of the relationship between a history of childhood physical abuse and unexplained pain symptoms (P ˆ 0:006) (see Fig. 1). Although a history of MDD generally bore a relationship to the number of unexplained pain symptoms (F…1; 1083† ˆ 50:05, P , 0:0001), this relationship was found exclusively among those without a history of physical abuse. Among those with a history of childhood physical abuse, there was no relationship between major depression and unexplained pain symptoms (F…1; 79† ˆ 0:31, P . 0:10). In contrast, among those with no early childhood abuse or neglect, the expected relationship between major depression and unexplained pain symptoms was found (F…2; 494† ˆ 25:85, P , 0:001). Among those experiencing other forms of child abuse (i.e. sexual abuse and/or neglect, but not physical abuse), the expected relationship between major depression and unexplained pain symptoms was found (F…1; 498† ˆ 37:27, P , 0:001). In contrast to ®ndings for unexplained pain symptoms, the count of pain complaints attributed to illness or injury did not differ by MDD status (P . 0:10). As illustrated in Fig. 2, there is an overall relationship between a diagnosis of lifetime major depression and the number of pain complaints due to illness or injury (F…1; 577† ˆ 9:74,

3.2. Childhood victimization, depression, and pain symptoms in young adulthood Since major depressive disorder (MDD) may provide a mechanism through which childhood trauma leads to pain in adulthood so that the association is restricted to those individuals who experienced major depressive disorder (MDD), we next tested for interactions of each form of childhood victimization with lifetime history of major depression diagnosis in predicting each of the ®ve pain symptom measures. None of the MDD interaction effects approached signi®-

Fig. 1. (Adjusted) mean unexplained pain counts broken down by a documented history of childhood physical abuse and lifetime history of major depressive disorder. Lines are drawn to aid point differentiation but do not imply a continuation function.

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These ®ndings persist after Bonferroni correction for multiple comparisons. After controlling for demographic factors (age, sex, race, and welfare status as a child), logistic regression analyses also revealed that self-reported childhood victimization was signi®cantly associated with the report of one or more `unexplained' pain symptoms. The odds of one or more unexplained pain symptom was signi®cantly associated with any self-reported childhood victimization (OR ˆ 1:98, 95% CI: 1.50, 2.62, P , 0:0001), sexual abuse (OR ˆ 2:20, 95% CI: 1.54, 3.15, P , 0:0001), physical abuse (OR ˆ 2:07, 95% CI: 1.55, 2.77, P , 0:0001) and neglect (OR ˆ 2:38, 95% CI: 1.70, 3.32, P , 0:0001). Fig. 2. (Adjusted) mean pain illness counts broken down by a documented history of childhood physical abuse and lifetime history of major depressive disorder. Lines are drawn to aid point differentiation but do not imply a continuation function.

P ˆ 0:002) but early childhood physical abuse did not moderate this relationship (F…1; 577† ˆ 1:73, P . 0:10). 3.3. Demographic characteristics, childhood victimization and pain symptoms in young adulthood Next, to determine whether the relationship between childhood victimization and adult pain symptoms differs across individuals with different demographic characteristics, we tested for an interaction between each of the three types of victimization (sexual abuse, physical abuse, and neglect) as well as the experience of any type of early childhood victimization and each of the following demographic variables: age, gender, and welfare status as a child (yes/no). This exploratory analysis resulted in 12 tests for each of the 5 pain measures, leading to a total of 60 tests. To balance the risk of Type I and Type II error, the P value for these tests was set at P , 0:01. After accounting for the demographic factors and the main effect of childhood victimization, no interaction term was signi®cant at P , 0:01. 3.4. Retrospective self-reports of childhood victimization and pain in young adulthood Given that these results contradict the results of earlier studies in which childhood victimization experiences were assumed to be important factors, we tested whether the same relationships (or lack of relationships) between childhood victimization and pain symptoms would be found using retrospective self-reports of childhood victimization. Table 2 presents our ®ndings based on the respondents' selfreports of childhood victimization. Based on retrospective self-reports of childhood victimization, we found a signi®cant relationship between childhood victimization and adult pain complaints, with the exception of one pain measure assessing the problem percent (percentage of pain complaints causing treatment-seeking or life interference).

4. Discussion Prior research has suggested a positive relationship between childhood victimization and the experience of pain in adulthood. Our prospective results using court documented cases of childhood sexual and physical abuse and neglect do not provide support for such a relationship between early childhood victimization and pain symptoms assessed in young adults. There was a tendency for a documented history of childhood physical abuse to be associated with the number and proportion of pain symptoms causing life interference or treatment-seeking, but this association did not persist after control for multiple comparisons. A documented history of sexual abuse, a childhood trauma long-presumed to be associated with medically unexplained pain symptoms, was not signi®cantly associated with any measure of pain symptoms, even prior to statistical adjustment. On the other hand, our retrospective results, based on self-reported history of abuse or neglect, replicate and con®rm earlier research ®ndings. Given that there was no signi®cant interaction between childhood victimization and either sex, race, age, or welfare status as a child, it is unlikely that these ®ndings are speci®c to the sample studied here. It should be noted, however, that this sample differs from the treatment-seeking samples used in many prior studies. Our clear replication of the results of most earlier studies based on retrospective self-reports also argues against this possibility. There was no evidence that the relation between childhood victimization and pain complaints in adulthood was restricted to those with a history of major depressive disorder. In fact, for physical abuse and unexplained pain complaints, the opposite pattern was found. Physical abuse was associated with unexplained pain only among those without a history of major depressive disorder. One way of interpreting this interaction is to note that, among those without a history of abuse, the generally expected relationship between major depression and unexplained pain complaints is found. Among those with a documented history of physical abuse, the common link between major depression and unexplained pain complaints was not

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291

Table 2 Retrospective self-reports of childhood victimization and pain symptoms in young adulthood (controlling for age, sex, race, and welfare status as a child) a Pain measure

Any self-reported Control childhood (n ˆ 520) victimization (n ˆ 743)

Self-reported sexual abuse (n ˆ 291)

Control (n ˆ 520)

Self-reported physical abuse (n ˆ 610)

Control (n ˆ 520)

Self-reported Control neglect (n ˆ 520) (n ˆ 384)

Pain symptom counts Pain problem counts Pain illness counts Unexplained pain counts Problem percent

2.68 (0.07) 2.12 (0.06) 1.52 (0.05) 0.57 (0.03) 78.9 (0.01)

3.03 (0.12) 2.43 (0.10) 1.76 (0.09) 0.64 (0.06) 81.3 (0.02)

2.12 (0.09)* 1.62 (0.08)* 1.20 (0.07)* 0.39 (0.04)* 76.2 (0.02) §

2.74 (0.08) 2.19 (0.07) 1.57 (0.06) 0.58 (0.04) 79.7 (0.01)

2.05 (0.09)* 1.57 (0.08)* 1.18 (0.07)* 0.38 (0.04)* 76.6 (0.02)

2.73 (0.10) 2.11 (0.09) 1.48 (0.08) 0.62 (0.05) 77.2 (0.02)

a

2.07 (0.09)* 1.58 (0.08)* 1.19 (0.07)* 0.38 (0.04)* 76.6 (0.02)

2.04 (0.09)* 1.57 (0.08)* 1.18 (0.07) ² 0.37 (0.04)* 76.7 (0.02)

Values are mean (SE). *P # 0:001, ²P # 0:01, §P # 0:10.

evident. This may suggest that childhood experience of physical abuse leads to hypoalgesia or a generalized decreased tendency to express distress in somatic terms. Given that the interaction was speci®c to unexplained pain rather than any pain symptoms, the latter explanation seems more plausible. These ®ndings may relate to some speculations in the child maltreatment literature about possible mechanisms linking childhood victimization (particularly childhood physical abuse) to subsequent violence (Widom, 2000). Relatively little is known about the processes linking child abuse and neglect to later outcomes, although it is likely that there will be multiple mechanisms or pathways. For example, one possibility is that the experience of abuse or neglect may lead to changes in the child. As a result of being beaten continually, a child might become emotionally `desensitized'in a very speci®c way: the link between pain and distress is broken. This might also work to protect the individual in later life by the development of certain `steeling' effects to overcome stress and adverse life events. Whether desensitization serves a positive or negative function remains an empirical question, however. Earlier publications based on the same sample used here examined the overlap between documented and selfreported childhood victimization (Widom et al., 1999; Widom and Shepard, 1996; Widom and Morris, 1997). Seventy-three percent of those with documented victimization self-reported victimization, and 49% of those without documented victimization also self-reported victimization. This pattern suggests that undocumented victimization is likely to have been present in our control sample. It also shows substantial underreporting of documented childhood victimization experiences in adulthood. The discrepancy between the prospective and retrospective results leads to a question about the role of forgetting. Could it be that denial of childhood victimization represents a form of healthy coping? Is it only victimization experiences that acquire a sustained attribution of `abuse' in adulthood that lead to increased somatic complaints? Our results suggest that not self-reporting childhood victimization is associated with the lack of somatic repercussions. However,

given the complexity of the issue, further research is clearly needed. There are several limitations to the current study that are not eliminated as a function of its prospective design. First, as discussed above, it is clear that the control group contains cases of undocumented abuse. This might be a particular problem in a low socioeconomic status sample (cf. Drake and Zuravin, 1998). If so, misclassi®cation error might attenuate differences between the groups in terms of later pain outcomes. On the other hand, further analyses (available on request) argue against the possibility of a Type II error. Speci®cally, the association between childhood victimization status and pain outcomes was virtually identical between those whose family was on welfare as children vs. those whose family was not. This symmetry of ®ndings across welfare status groups increases our con®dence that a Type II error has not been made, since misclassi®cation among those classi®ed as non-victimized should have been more common among those with welfare histories. Furthermore, the abused and neglected group includes the kind of serious cases of child abuse and neglect which come to the attention of public authorities. If childhood victimization is associated with pain complaints in adulthood, the effect would be expected to be most prominent for those experiencing the most severe forms of child abuse or neglect. The small effects reported here are inconsistent with the large effects typically found in retrospective studies, and even those with small sample sizes. Another limitation is that outcome measures were based solely on self-report symptoms. To rule out the possibility of medical causes for pain or to classify subjects according to pain syndromal status (for ®bromyalgia or chronic pelvic pain, for example), comprehensive physical and diagnostic examinations would be needed, but were not conducted. Nevertheless, these functional syndromes require, ®rst and foremost, a self-report of pain. We can infer that it would be unlikely, given our pattern of results, for there to be elevations in rates of functional pain syndromes among adults with a childhood history of abuse or neglect. The omission of comprehensive physical examinations

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left us solely dependent upon the subjects' inference that their pain symptoms were due to a medical illness or injury or were, alternately, `unexplained'. However, the interaction between depression, pain symptoms, and documented physical abuse was speci®c to unexplained rather than medically explained pain symptoms. This lends some credence to our classi®cation of unexplained and medically explained pain symptoms, based upon subjects' self-reports. These ®ndings need to be viewed in the context of a clinical literature based on individuals typically seeking treatment for functional pain problems who recall a history of early childhood abuse and neglect. One of the potential dangers of this phenomenon is that patients who recall such abuse often perceive themselves to be trapped by a history they cannot undo. This can cause feelings of helplessness leading to passivity. In turn, this passivity could interfere with both pain relief and restoration of function, the goals of many current treatment approaches (Stanton-Hicks et al., 1998). Early childhood victimization and medically unexplained pain are not intrinsically linked. The widespread belief in this link has contributed to the view of unexplained pain as `psychogenic'. However, our ®ndings reinforce the notion that a medically unexplained pain complaint is not necessarily a psychogenic one. This revised view may help to reduce the stigmatization of patients (Marbach et al., 1990) who are led to believe that their pain problems are caused by psychological rather than physical factors. In conclusion, our ®ndings do not support the hypothesis of an association between childhood victimization and pain symptoms in adulthood. Further research is needed to understand the role of retrospective self-reports of childhood victimization in elevated pain symptoms and syndromes. Acknowledgements Supported by grants from NIMH (MH-49467) and the National Institute of Justice (86-IJ-CX-0033 and 89-IJCX-0007). We thank Amie Shuck and Juanita Hobson for assistance in the preparation of this article. References Aaron LA, Bradley LA, Alarcon GS, Triana-Alexander M, Alexander RW, Martin MY, Alberto KR. Perceived physical and emotional trauma as precipitating events in ®bromyalgia. Associations with health care seeking and disability status but not pain severity. Arthritis Rheum 1997;40:453±460. Adler RH, Zlot S, Hurny C, Minder C. Engel's `Psychogenic Pain and the Pain-Prone Patient': a retrospective, controlled clinical study. Psychosom Med 1989;51:87±101. Alexander RW, Bradley LA, Alarcon GS, Triana-Alexander M, Aaron LA, Alberts KR, et al. Sexual and physical abuse in women with ®bromyalgia: association with outpatient health care utilization and pain medication usage. Arthritis Care Res 1998;11:102±115. Al®ci S, Sigal M, Landau M. Primary ®bromyalgia syndrome ± a variant of depressive disorder? Psychother Psychosom 1989;51:156±161.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Washington, DC: American Psychiatric Association, 1987. Bendixen M, Muus KM, Schei B. The impact of child sexual abuse ± a study of a random sample of Norwegian students. Child Abuse Negl 1994;18:837±847. Berliner L, Williams LM. Memories of child sexual abuse: Response to Lindsay and Read. Appl Cognitive Psychol 1994;8:379±387. Blumer D, Heilbronn M. Chronic pain as a variant of depressive disease: the pain-prone disorder. J Nerv Ment Dis 1982;170:381±406. Bodden-Heidrich R, Kuppers V, Beckmann MW, Rechenberger I, Bender HG. Chronic pelvic pain syndrome (CPPS) and chronic vulvar pain syndrome (CVPS): evaluation of psychosomatic aspects. J Psychosom Obstet Gynecol 1999;20:145±151. Bohr T. Problems with myofascial pain syndrome and ®bromyalgia syndrome. Neurology 1996;46:593±597. Boisset-Pioro MH, Esdaile JM, Fitzcharles MA. Sexual and physical abuse in women with ®bromyalgia syndrome. Arthritis Rheum 1995;38:235± 241. Briere J, Conte J. Self-reported amnesia for abuse in adults molested as children. J Trauma Stress 1993;6:21±31. Briere J, Runtz M. Symptomatology associated with childhood sexual victimization in a nonclinical adult sample. Child Abuse Negl 1988;12:51± 59. Dickinson LM, deGruy III FV, Dickinson WP, Candib LM. Health-related quality of life and symptom pro®les of female survivors of sexual abuse. Arch Fam Med 1999;8:35±43. Domino JV, Haber JD. Prior physical and sexual abuse in women with chronic headache: clinical correlates. Headache 1987;27:310±314. Drake B, Zuravin S. Bias in child maltreatment reporting: revisiting the myth of classlessness. Am J Orthopsychiatry 1998;68:295±304. Engel GL. `Psychogenic' pain and the pain-prone patient. Am J Med 1959;26:899±918. Finestone HM, Stenn P, Davies F, Stalker C, Fry R, Koumanis J. Chronic pain and health care utilization in women with a history of childhood sexual abuse. Child Abuse Negl 2000;24:547±556. Finkelhor D. Sexually victimized children. Free Press: New York, 1979. Fivush R. Developmental perspectives on autobiographical recall. In: Goodman GS, Bottoms BL, editors. Child victims, child witnesses: understanding and improving testimony, New York: Guilford, 1993, pp. 1±24. Fry RP, Crisp AH, Beard RW. Sociopsychological factors in chronic pelvic pain: a review. J Psychosom Res 1997;42:1±15. Harrop-Grif®ths J, Katon W, Walker E, Holm L, Russo J, Hickok L. The association between chronic pelvic pain, psychiatric diagnoses, and childhood sexual abuse. Obstet Gynecol 1988;71:589±594. Hollingshead AB. Four factor index of social status, 1975. Hudson JI, Pope HG. The concept of affective spectrum disorder: relationship to ®bromyalgia and other syndromes of chronic fatigue and chronic muscle pain. Baillieres Clin Rheumatol 1994;8:839±856. Hudson JI, Pope Jr HG. The relationship between ®bromyalgia and major depressive disorder. Rheum Dis Clin North Am 1996;22:285±303. Lechner ME, Vogel ME, Garcia-Shelton LM, Leichter JL, Steibel KR. Selfreported medical problems of adult female survivors of childhood sexual abuse. J Fam Pract 1993;36:633±638. Leserman J, Li Z, Drossman DA, Hu YJ. Selected symptoms associated with sexual and physical abuse history among female patients with gastrointestinal disorders: the impact on subsequent health care visits. Psychol Med 1998;28:417±425. Lesse S. Variations in the autonomic faciocephalgia syndrome in men and women. Headache 1963;3:106. Leventhal JM. Research strategies and methodologic standards in studies of risk factors for child abuse. Child Abuse Negl 1982;6:113±123. Linton SJ. A population-based study of the relationship between sexual abuse and back pain: establishing a link. Pain 1997;73:47±53. Loftus E. The reality of repressed memories. Am Psychol 1993;48:518± 537.

K.G. Raphael et al. / Pain 92 (2001) 283±293 Longstreth GF, Mason C, Schreiber IG, Tsao-Wei D. Group psychotherapy for women molested in childhood: psychological and somatic symptoms and medical visits. Int J Group Psychother 1998;48:533±541. Marbach JJ, Lennon MC, Link BG, Dohrenwend BP. Losing face: sources of stigma as perceived by chronic facial pain patients. J Behav Med 1990;13:583±604. McBeth J, Macfarlane GJ, Benjamin S, Morris S, Silman AJ. The association between tender points, psychological distress, and adverse childhood experiences: a community-based study. Arthritis Rheum. 1999;42:1397±1404. Moeller TP, Bachmann GA, Moeller JR. The combined effects of physical, sexual, and emotional abuse during childhood: long-term health consequences for women. Child Abuse Negl 1993;17:623±640. Mullen PE, Walton VA, Romans-Clarkson SE, Herbison GP. Impact of sexual and physical abuse on women's mental health. Lancet 1988;1:841±845. Neisser U. Cognitive psychology, . New York: Appleton Century Crofts, 1967. Radke-Yarrow M, Campbell JD, Burton RV. Recollections of childhood: a study of the retrospective method. Monogr Soc Res Child Dev 1970:135. Raphael KG, Cloitre M. Does mood-congruence or causal search govern recall bias? A test of life event recall. J Clin Epidemiol 1994;47:555± 564. Rapkin AJ, Kames LD, Darke LL, Stampler FM, Naliboff BD. History of physical and sexual abuse in women with chronic pelvic pain. Obstet Gynecol 1990;76:92±96. Rimsza ME, Berg RA, Locke C. Sexual abuse: somatic and emotional reactions. Child Abuse Negl 1988;12:201±208. Robins LN, Helzer JE, Cottler L, Goldring E. National Institute of Mental Health diagnostic interview schedule, version III revised (DIS-III-R). St. Louis, MO: Washington University, 1989. Schofferman J, Anderson D, Hines R, Smith G, White A. Childhood psychological trauma correlates with unsuccessful lumbar spine surgery. Spine 1992;17:S138±S144. Schofferman J, Anderson D, Hines R, Smith G, Keane G. Childhood psychological trauma and chronic refractory low-back pain. Clin J Pain 1993;9:260±265. Schulsinger F, Mednick SA, Knop J. Longitudinal research: methods and uses in behavioral sciences. Boston, MA: Martinus Nijhoff, 1981. Stanton-Hicks M, Baron R, Boas R, Gordh T, Harden N, Hendler N, et al.

293

Complex regional pain syndromes: guidelines for therapy. Clin J Pain 1998;14:155±166. Straus MA. Measuring intrafamily con¯ict and violence: the con¯ict tactics (CT) scales. J Marriage Fam 1979;41:75±86. Talley NJ, Boyce PM, Jones M. Predictors of health care seeking for irritable bowel syndrome: a population based study. Gut 1997;41:394±398. Taylor ML, Trotter DR, Csuka ME. The prevalence of sexual abuse in women with ®bromyalgia. Arthritis Rheum 1995;38:229±234. Walker E, Katon W, Harrop-Grif®ths J, Holm L, Russo J, Hickok LR. Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse. Am J Psychiatry 1988;145:75±80. Walker E, Katon W, Hansom J, Harrop-Grif®ths J, Holm L, Jones ML, et al. Medical and psychiatric symptoms in women with childhood sexual abuse. Psychosom Med 1992;54:658±664. Walker EA, Keegan D, Gardner G, Sullivan M, Benstein D, Katon WJ. Psychosocial factors in ®bromyalgia compared with rheumatoid arthritis: II. Sexual, physical and emotional abuse and neglect. Psychosom Med 1997;59:572±577. Walling MK, Reiter RC, O'Hara MW, Milburn AK, Lilly G, Vincent SD. Abuse history and chronic pain in women: prevalences of sexual and physical abuse. Obstet Gynecol 1994;84:193±199. Widom CS. Child abuse, neglect and adult behavior: Research design and ®ndings on criminality, violence, and child abuse. Am J Orthopsychiatry 1989a;59:355±367. Widom CS. Does violence beget violence? A critical examination of the literature. Psychol Bull 1989b;106:3±28. Widom CS. Understanding the consequences of childhood victimization. In: Reese RM, editor. Treatment of child abuse, Baltimore: Johns Hopkins University Press, 2000, pp. 339±361. Widom CS, Morris S. Accuracy of adult recollections of childhood victimization Part II: childhood sexual abuse. Psychol Assess 1997;9:34±46. Widom CS, Shepard RL. Accuracy of adult recollections of childhood victimization: part I: childhood physical abuse. Psychol Assess 1996;8:412±421. Widom CS, Weiler BL, Cottler LB. Childhood victimization and drug abuse: a comparison of prospective and retrospective ®ndings. J Consult Clin Psychol 1999;67:867±880. Williams LM. Recall of childhood trauma: A prospective study of women's memories of child sexual abuse. J Consult Clin Psychol 1994;62:1167± 1176.