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Chronic Pain In Adulthood Linked To Adverse Childhood Experiences

Chronic Pain In Adulthood Linked To Adverse Childhood Experiences


This study aimed to elucidate the complex interplay between adverse childhood experiences (ACEs), anxiety, and chronic pain in adults through a systematic literature review (SLR) and meta-analysis. The narrative synthesis of findings revealed a substantial association between ACEs, anxiety, and chronic pain in adults, with 79% of the selected studies reporting a moderate to strong correlation. Among the ACEs, prevalent experiences included sexual abuse, physical abuse, emotional abuse, emotional neglect, and physical neglect.


Meta-analyses further corroborated these findings, demonstrating moderate associations between anxiety and chronic pain, as well as between ACEs and anxiety. Specifically, individuals who experienced ACEs were approximately twice as likely to present with chronic pain during adulthood. These results underscore the significant impact of early-life adversity and anxiety on chronic pain experiences later in life.


The study concludes that understanding the relationship between ACEs, anxiety, and chronic pain is crucial for informing clinical practice and developing targeted interventions. Moreover, the identification of anxiety as a potential mediator suggests avenues for further research to explore underlying mechanisms. Overall, this systematic review and meta-analysis contribute valuable insights to the existing literature, highlighting the interconnectedness of ACEs, anxiety, and chronic pain in adult populations.


Anxiety, historically defined with various interpretations, encompasses cognitive features like “apprehensive expectation.” Although mild anxiety is deemed biologically adaptive, distinguishing it from distressing pathological anxiety necessitating intervention remains crucial. Traumatic experiences often trigger maladaptive anxiety, impacting brain function and health. Limited research has directly linked anxiety to chronic pain, with existing studies primarily focusing on depression and post-traumatic stress disorder (PTSD). Adverse childhood experiences (ACEs), including violence, abuse, and neglect, profoundly affect development, mental health, and physical health, potentially leading to chronic pain.


The economic burden of chronic pain on productivity and healthcare costs is substantial, exceeding that of several non-communicable diseases. Early-life adversity, such as maltreatment, alters amygdala development, increasing sensitivity to environmental threats and anxiety levels. Anxiety disorders often coexist with chronic pain, mediating hypervigilance and exacerbating pain experiences. ACEs significantly impact the form, severity, and extent of chronic pain in adults, potentially involving neuroanatomical reorganization and neuroinflammation.


While inflammatory markers are elevated in PTSD and anxiety disorders, the relationship between inflammation and anxiety-related symptoms remains inconsistent. Despite links between ACEs and chronic pain, the independent role of anxiety in this pathway remains under-investigated. This systematic review aims to explore the associations between ACEs, anxiety, and chronic pain, bridging the current gap in understanding by summarizing existing evidence on these relationships. By elucidating these associations, this review seeks to inform interventions and treatments addressing the complex interplay between ACEs, anxiety, and chronic pain in adults.


The systematic literature review (SLR) conducted an extensive search on various topics including childhood adversity, trauma outcomes, comorbidities, chronic pain, adverse childhood experiences (ACEs), and neurophysiological aspects of anxiety and trauma. Chronic pain, defined as lasting more than three months, was a focal point of investigation, alongside the psychological effects of childhood trauma and stress. The search encompassed the last 20 years of literature and included electronic databases such as PubMed, MEDLINE, PsycInfo, and PsycArticles. Primary studies in English exploring the relationship between anxiety, childhood trauma, and chronic pain were included in the review.


The selection strategy involved rigorous screening using Rayyan software, with multiple reviewers involved in the process to ensure quality and accuracy. Eligibility criteria were established based on Population, Exposure, Controls, Outcomes, Setting, and Study designs (PECOS) principles, targeting adults with chronic pain and/or anxiety who had experienced childhood trauma. Observational, correlational, cross-sectional, interventional, and longitudinal studies were considered, while exclusion criteria filtered out studies involving individuals under 18 years of age without anxiety, chronic pain, or childhood adversity.


Quality appraisal was conducted using the Joanna Briggs Institute (JBI) tool, chosen for its broad applicability to various study types. Data extraction focused on primary outcomes including chronic pain, childhood trauma history, and anxiety, with attention to variations in pain intensity and types of ACEs. Narrative synthesis of findings was performed, supplemented by meta-analyses to explore associations between ACEs, anxiety, and chronic pain.


To ensure data protection, measures were taken to secure all relevant data in accordance with applicable laws and regulations, with access restricted to authorized personnel only.


In summary, the SLR provided a comprehensive overview of the literature on the interplay between childhood trauma, anxiety, and chronic pain, employing robust methodologies to extract and analyze relevant data while safeguarding confidentiality and integrity throughout the process.


The study conducted a rigorous meta-analysis to delve into the intricate relationships among adverse childhood experiences (ACEs), anxiety, and chronic pain across a broad spectrum of research literature. After meticulously screening a sizable pool of articles and selecting 52 studies of high quality based on the JBI checklist, the meta-analysis uncovered significant associations shedding light on the complex interplay between ACEs, anxiety, and chronic pain.


The analysis unearthed a compelling link between ACEs and chronic pain, revealing that individuals who underwent ACEs were nearly twice as likely to grapple with chronic pain during adulthood, as evidenced by an overall odds ratio (OR) of 1.99 (95% CI=[1.53, 2.60], p<0.01). This finding underscores the enduring impact of childhood adversities on later physical health outcomes and underscores the importance of addressing early-life traumas in comprehensive pain management strategies.


Furthermore, the correlation meta-analysis uncovered a nuanced but noteworthy relationship between the frequency of ACEs and the intensity of chronic pain. The data revealed a small yet statistically significant positive correlation, suggesting that a higher occurrence of ACEs was associated with heightened chronic pain intensity (overall correlation of r=0.17, 95% CI=[0.11, 0.23], p<0.001). This finding underscores the cumulative effect of childhood adversities on pain experiences in adulthood and underscores the need for tailored interventions to address these interconnected issues effectively.


Turning to the association between anxiety and chronic pain, while an OR meta-analysis wasn’t feasible due to the available studies’ constraints, a correlation meta-analysis provided valuable insights. It highlighted a moderate positive association between anxiety levels and chronic pain indices, indicating that elevated anxiety symptoms were correlated with increased pain intensity (overall correlation of r=0.30, 95% CI=[0.14, 0.45], p<0.01). This finding underscores the intricate relationship between mental health and pain experiences and emphasizes the importance of addressing psychological factors in pain management interventions.


Moreover, the meta-analysis delved into the relationship between ACEs and anxiety, uncovering a significant positive moderate association. The data revealed that a higher frequency of ACEs was correlated with heightened anxiety symptoms (overall correlation of r=0.26, 95% CI=[0.15, 0.36], p<0.01). This finding underscores the pervasive impact of childhood adversities on mental health outcomes and emphasizes the need for holistic approaches to address the psychological sequelae of early-life traumas.


Overall, these findings contribute valuable insights into the complex interplay between ACEs, anxiety, and chronic pain, highlighting the need for multidisciplinary interventions that address the interconnected nature of these factors. By understanding and addressing childhood adversities and their psychological ramifications, healthcare professionals can develop more effective strategies for managing chronic pain and promoting overall well-being across the lifespan.


The systematic review findings underscore a robust association between childhood adversities (ACEs), anxiety, and chronic pain experiences in adults. Meta-analyses confirm moderate-sized significant associations between ACEs and anxiety, as well as between anxiety and chronic pain. Participants with ACEs exhibit nearly double the likelihood of experiencing chronic pain in adulthood. This correlation suggests that early-life adversities play a pivotal role in shaping adult health outcomes, with heightened rates of chronic pain observed among individuals reporting ACEs.


The review highlights variations in the prevalence of ACEs, with sexual abuse emerging as a notable focus despite being less commonly reported in some datasets. This discrepancy may stem from differences in study design, sample characteristics, or variations in ACE definitions. Furthermore, the inclusion of neglect categories alongside abuse in ACE measurement signifies a shift toward a more comprehensive understanding of adversity’s impact. Such nuanced assessments offer valuable insights into the complex interplay between neglect, anxiety, and chronic pain.


Despite the established associations, some methodological limitations, such as self-report measures prone to recall bias, underscore the need for cautious interpretation. However, studies incorporating a broad range of chronic pain outcomes enhance the robustness of findings.


Practically, the review emphasizes the imperative of incorporating ACE screenings into clinical practice, particularly among individuals presenting with anxiety and chronic pain. Early identification of ACEs can inform tailored treatment approaches, potentially mitigating the long-term societal and economic burdens associated with adverse childhood experiences.


Moving forward, future research should explore the mediating role of anxiety in the ACE-chronic pain relationship and investigate novel treatment modalities informed by a deeper understanding of trauma’s impact on pain perception. Moreover, efforts to enhance provider comfort with trauma-informed care and streamline ACE screenings in healthcare settings can facilitate more holistic patient support and improve treatment outcomes.


In conclusion, this review underscores the interconnectedness of ACEs, anxiety, and chronic pain in shaping adult health trajectories. By recognizing and addressing early-life adversities, healthcare providers and policymakers can pave the way for more comprehensive and effective interventions, ultimately promoting improved well-being and quality of life for individuals affected by these experiences.


Dalechek DE, Caes L, McIntosh G, Whittaker AC. Anxiety, history of childhood adversity, and experiencing chronic pain in adulthood: A systematic literature review and meta-analysis. Eur J Pain. 2024 Jan 8. doi: 10.1002/ejp.2232. Epub ahead of print. PMID: 38189218.

Lead author of this study:
Danielle E. Dalechek: Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK. Division of Psychology, Faculty of Natural Sciences, University of Stirling, Stirling, UK.

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