Childhood maltreatment, trauma, and pain: trauma-related symptoms as mediators in a high-risk group

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Childhood maltreatment, trauma, and trauma-related symptoms contribute to pain in individuals with a history of Residential Youth Care, with posttraumatic stress disorder and dissociation as potential mediators.

Abstract

Introduction:

A history of childhood maltreatment (CM) and trauma-related symptoms has been associated with the development of pain conditions. Individuals raised in Residential Youth Care (RYC) often report significant exposure to CM, high rates of posttraumatic stress disorder (PTSD), and an increased risk for various adverse health outcomes, making them a high-risk group for pain symptoms. Objectives: This study examines the role of CM, trauma, and symptoms of PTSD and dissociation for pain indicators.

Methods:

As part of the 10-year follow-up project, N = 157 individuals (68.15% women) with a history of RYC were recruited. Pain symptoms were assessed using standardized questions from a large-scale population-based study in Norway, recording headache, pain lasting at least 3 months, pain intensity, as well as continuous muscle and joint pain. Childhood maltreatment was measured using the Maltreatment and Abuse Chronology of Exposure scale, and dissociative symptoms through self-report online survey. Trauma load and symptoms of PTSD were evaluated using clinician-administered interviews based on the PTSD Checklist, aligned with Diagnostic and Statistical Manual of Mental Disorders-5 criteria.

Results:

We confirmed associations between CM, trauma load and pain intensity, and body pain distribution in a high-risk group, while we did not find associations for headache. Symptoms of PTSD and dissociation predominantly mediated the relationship between CM/trauma load and pain symptoms.

Conclusion:

A history of CM and trauma-related symptoms are crucial for understanding pain symptoms in individuals transitioning to adulthood after RYC. Posttraumatic stress disorder and dissociation symptoms may contribute to development and exacerbation of pain symptoms and may be a target for intervention.

1. Introduction

Children and adolescents with a history of Residential Youth Care (RYC) are a high-risk group due to severe and broad exposure to childhood maltreatment (CM), resulting in significant disparities in both physical and mental health outcomes,^{6,17,36,43,45,57,63,72,79} and reduced quality of life.^24,35 Research links CM and trauma-related symptoms to the development of pain.^9,38,45,69 To date, no studies have focused on pain symptoms in individuals with a history of RYC during their transition into young adulthood—an underrepresented population at increased risk for extensive CM, trauma exposure, and enduring mental and physical health challenges. However, preliminary evidence indicates a connection between the amount of CM exposure and chronic pain in youth in foster care.³¹

A review and meta-analysis⁴⁷ across 22 countries found an 11.6% prevalence of chronic pain (>3 months in the past year) in young adults. Prevalence varied by pain condition but not by sex, location, or assessment method, highlighting chronic pain in young adults as a public health concern. Headache disorders, marked by recurrent headaches, contribute to disability, reduced quality of life, and financial and societal burdens.⁷⁶ Migraine and tension-type headaches are leading causes of outpatient and emergency visits, remaining a significant public health issue.⁷ The overall point-prevalence of headache in European countries was 53% (61% in women, 45% in men).⁶⁶ In Norway, approximately 15% experienced migraines, with 4% suffering from chronic headache.⁶⁵

Over 30 years ago, Felitti¹⁵ linked childhood sexual abuse to recurrent headaches, depression, and gastrointestinal distress. Later research highlighted the co-occurrence of maltreatment types, shifting focus to cumulative risk.¹⁶ Studies consistently show a dose–response relationship between CM and somatic health issues, further influenced by the type and timing of exposure.⁵⁰ Building on Beal et al.,³ we define maltreatment specifically as child abuse and neglect,⁶⁷ excluding factors such as socioeconomic status or family dysfunction, which are part of the broader childhood adversity definition. In addition, we assess traumatic experiences across the lifespan using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria, which cover a wider range of events, including for instance natural disasters, adult violence, and accidents.

A meta-analysis found that individuals with CM have a higher risk of chronic pain in adulthood,¹² a finding supported by recent reviews.^38,45 Notably, a study from the British Birth Cohort showed that childhood exposure to separation, institutional care, or maternal death significantly increased the risk of chronic widespread pain at age 45.³⁴

Surveys across 10 countries demonstrated that exposure to 3 or more childhood adversities is associated with chronic headaches.⁵⁸ Similarly, Canadian and US studies linked increasing early life stressors, particularly emotional abuse and neglect, to higher odds of migraines.^28,70 Research in Czech adults³⁹ and studies from Norwegian adolescents^64,65 are in line with these findings. In a clinical sample of Norwegian adolescents with a history of mental health treatment, exposure to sexual abuse, bullying, or multiple types of interpersonal violence was associated with significantly higher headache frequency.²⁶ Recent meta-analyses^44,62 confirmed an increased risk of migraines in individuals exposed to CM compared with those unexposed, although it remains unclear whether higher levels of exposure further amplify the likelihood of headaches.

Research shows that early life stress alters biological pathways related to nociception, increasing vulnerability to trauma symptoms and dysregulating pain sensitivity.^74,77 Youth with chronic pain also report high psychological stress, posttraumatic stress disorder (PTSD) symptoms, and CM, linking pain processing and stress exposure.⁴⁸ Studies emphasize the impact of CM on neural structure and function, highlighting the need to explore how specific types and timing of CM affect adult pain.^{9,30,46,67,68} Recent evidence suggests that early and middle childhood may constitute sensitive periods for the development of physical multimorbidity.⁵⁰ Emerging findings further indicate that exposure to adverse experiences between the ages of 10 and 12 years is associated with an increased risk of chronic pain in adulthood.⁵³

Given the high prevalence of mental disorders in adults with a history of RYC,³⁵ it is crucial to include mental health indicators—particularly trauma-related symptoms such as PTSD and dissociation—when analyzing the link between CM, traumatic experiences, and pain symptoms. Posttraumatic stress disorder has been found to mediate the relationship between childhood abuse and physical complaints.⁵⁵ There is some evidence that loneliness, psychological distress,⁶⁵ PTSD and emotional dysregulation,⁵¹ other mental problems^2,37,52 and sex^8,20 might influence the relationship between CM, trauma exposure, and pain symptoms. A recent study similarly indicates that the association between CM and chronic pain is predominantly mediated by biopsychosocial factors, with psychological mechanisms playing a particularly central role.⁷⁸ Research on the relationship between dissociation and pain symptoms is still developing, with findings suggesting both protective and amplifying effects of dissociation on pain perception. Dissociative symptoms may act as a psychological defense mechanism, reducing acute pain perception.¹³ However, dissociative symptoms can also be triggered by acute pain,¹⁸ potentially amplifying the risk for ongoing experience of pain symptoms.⁵⁴

The overall aim of this study was to explore how exposure to adverse experiences (CM and trauma load), symptoms of PTSD, and dissociation are associated with pain symptoms in young adults (21–29 years of age) with a history of living in RYC. The research will address the following questions: (1) Is CM, trauma load, symptoms of PTSD, and dissociation related to pain symptoms (pain in the past 3 months, intensity of pain, continuous pain in muscles and joints, body pain distribution, occurrence of headache and days with headache in the past month)? (2) Are specific types of CM and the timing of exposure associated with pain symptoms? (3) Are symptoms of PTSD and/or dissociation mediating the relationship between CM or trauma load and pain symptoms (pain intensity and body pain distribution)?

2. Methods

2.1. Design, participants, and settings

This study is based on a sample from a longitudinal design with 2 time points: T1 (baseline, conducted between 2010 and 2014)³⁵ and T2 (10-year follow-up, conducted between 2021 and 2022). At T1, adolescents aged 12 to 20 years residing in RYC facilities in Norway were invited to participate. At T2, these baseline participants were recontacted and invited to engage in a follow-up study involving a phone interview (psychologist or medical doctors) and an electronic self-report survey, yielding a response rate of 52% from baseline participants and a total of N = 157 participants (see for further recruitment details Ref. 25). For this study, only T2 data were used from N = 107 women and n = 50 men. On average, participants were M = 25.4 (SD = 1.6) years old. Most participants, 145 (92.4%), were born in Norway. Participants received a gift card (500 NOK = 44 EUR) after they completed the telephone interview. All participants were also included in a lottery for a larger value gift-card (10.000 NOK = 875 EUR).

2.2. Measures in the online survey

Sex, age, and country of birth (Norway) were assessed through the online survey. Socio-economic status was evaluated based on participants' highest level of education attained and their current educational status.

2.2.1. Headache and pain symptoms

Standardized questions from the HUNT (Helseundersøkelsen i Trøndelag) 4 Study were used to assess headache and pain symptoms. The HUNT study^40,42 includes large total population-based cohorts from the 1980s, covering 125,000 Norwegian participants; HUNT1 (1984–1986), HUNT2 (1995–1997), HUNT3 (2006–2008), and HUNT 4 (2017–2019). The HUNT questionnaires can be downloaded from the HUNT website.⁴⁹ Pain items from HUNT capture key internationally recommended domains for pain assessment, such as intensity, duration, and body distribution, allowing for a multidimensional analysis of pain.¹⁴

Headache was assessed through 3 aspects: presence, type, and intensity. Participants were first asked, “Have you had headaches in the last 12 months?” with response options “yes” or “no.” If “yes,” they were then asked about the type of headache (“Migraines” or “Other”). To measure number of days with headaches, participants were asked, “How many days per month do you have a headache?” with options “Less than 1 day = 0,” “1 to 6 days = 1,” “7 to 14 days = 2,” or “More than 14 days = 3.” A graded ordinal variable (0–3) was constructed based on these responses.

Individuals were asked: “Do you have pain lasting more than 3 months?” and “Do you have pain lasting more than 6 months?” with “yes” or “no” responses. The 6-month item was excluded as it deviates from standard chronic pain timeframes. Pain intensity was assessed by asking, “How strong has your pain been in the last 4 weeks?” with responses “no pain = 0”, “very mild = 1,” “mild = 2,” “moderate = 3,” “strong = 4,” “very strong = 5.” This was used to assess pain intensity.

Individuals were asked, “Have you had muscle or joint pain for at least 3 months in the past year?” with a “yes” or “no” response. If “yes,” they were asked to specify the pain locations, including 13 body areas (neck, chest, upper back, lower back, thigh, calf, jaw, shoulders, elbows, hips, wrists, knees, and ankles/feet) (see Fig. 1 for locations and descriptive statistics). The total number of affected body parts was summed to create a “body pain distribution” score, ranging from 0 to 13.

Figure 1.

This figure illustrates the 13 body locations along with the number and percentage (n, %) of reports in the current sample.

The HUNT4 headache items have demonstrated good validity against expert clinical interviews.²⁷ The HUNT4's body pain sides and chronicity questions show acceptable reliability.¹¹

The Norwegian version of Maltreatment and Abuse Chronology of Exposure (MACE-55) scale¹⁹ uses 55 items to assess exposure to the following 10 types of maltreatment before age 18: parental verbal abuse, parental nonverbal emotional abuse, parental physical maltreatment, emotional neglect, physical neglect, witnessing interpersonal violence to parents, witnessing violence to siblings, peer verbal/emotional abuse, peer physical bullying, and sexual abuse. Each item is scored as either “yes” or “no,” with additional assessment of the timing for each item spanning ages 1 to 18. Eight of the items ask for positive experiences, and responses are reversed based on the timing before analysis (absence of the essential experiences of at least one age). For each of the 10 subscales, a sum score was calculated by summing the items within the subscale and then interpolating the total to a standardized range of 0 to 10. The severity of CM was calculated by summing the scaled scores of all 10 subscales, yielding a possible range of 0 to 100.¹⁹ The MACE-55 demonstrated excellent test–retest reliability for the total score and good to excellent reliability for its 10 subscales. Convergent validity with the Childhood Trauma Questionnaire was moderate to high for both total and subscale scores.

The Shutdown Dissociation Scale (Shut-D),^59,60 Norwegian translation by Jozefiak, IPH, NTNU, is a brief structured interview for assessing symptoms of dissociation as a consequence of exposure to trauma based on the defense cascade model. It consists of 13 items, with a 4-point Likert scale (0 = not at all; 3 = several times a week/often) yielding a sum score (range 0–39). The scale showed excellent internal reliability as well as test–retest reliability, high convergent validity, and satisfactory predictive and discriminatory validity. A sum score of ≥8 indicates clinically relevant dissociative symptoms.^59,60 Unlike previous studies, this scale was assessed through self-report rather than clinician interview.

2.3. Measures from the interview

The Stressful Life Events Screening Questionnaire,²¹ Norwegian version by Norwegian Centre for Violence and Traumatic Stress Studies, is a 15-item self-report screening measure designed to assess lifetime exposure to a variety of traumatic event types. Item 9 in the Norwegian version asks for being victim of physical violence in adulthood. The original questionnaire demonstrated good test–retest reliability, adequate convergent validity, and effectively distinguished between Criterion A and non-Criterion A events.²¹ Regardless of the frequency of each event type, we calculated lifetime exposure to the number of distinct traumatic event types, referred to as “trauma load,” with a potential range from 0 to 15.

The PTSD Checklist (PCL-5),⁷⁵ translated at the Norwegian Centre for Violence and Traumatic Stress Studies, is a 20-item self-report measure assessing DSM-5 PTSD symptoms over the past month on a 5-point scale (0–4). Total scores range from 0 to 80. The Norwegian version of the PCL-5 was created using an iterative process of translation and back-translation, following established guidelines.⁷³ The PCL-5 demonstrates strong internal consistency, reliability, and validity.⁵ Multiple language versions of the PCL-5 have been validated, showing consistently strong psychometric properties.^32,41

2.4. Statistical analysis

Analyses were performed using R (version 4.3.1). Point-biserial correlations were calculated for variables involving at least one binary measure, while Pearson correlations were computed for continuous variables for the first 2 aims. Missing data were partially excluded from the analysis. For aim 3, the mediating role of symptoms of PTSD and dissociation in the relationship between CM or trauma exposure, and pain intensity or body pain distribution was analyzed using R package “mediation.”³³ All models were computed using the mediate function, with scores standardized before analysis to enhance interpretability and facilitate comparison of effect sizes. The significance of indirect effects was assessed through bootstrapping, and the proportion of mediation was calculated as the ratio of the indirect effect to the total effect. To correct for multiple testing, the Benjamini–Hochberg procedure was applied to control the false discovery rate at 0.05. This correction was conducted separately for each research aim, and within Research Aim 2, separately for the different types and timing of CM.⁴

2.5. Ethics

At baseline, all participants provided written informed consent; for those younger than 16 years, guardian consent was also required.²³ At follow-up, the young adults had to give their digital informed consent. Data were stored in collaboration with the NTNU IT-department and the Services of Sensitive Data at the University of Oslo in a deidentifiable form. The study has been approved by the Norwegian Regional Ethical Research Committee (502016/REK Midt) and the Norwegian Agency for Shared Services in Education and Research (Sikt-ref: 790618).

3. Results

3.1. Sample characteristics

The average age of first out-of-home placement by the Child Welfare Service was M = 12.5 years (SD = 4.0). A significant proportion of participants, 111 (70.7%), had discontinued the education they had planned to complete, and 99 (63.1%) did not graduate from high school. Fewer than half of the participants, 65 (40.1%), were employed at least part-time, while 23 (14.6%) remained in education, and 2 (1.3%) were in military service. The remaining 70 (44.6%) were neither in employment, nor in education, nor in training.

On average, the severity of CM was M = 44.66 (SD = 17.59), and participants were exposed to an average of M = 6.30 (SD = 3.16) different types of traumatic events throughout their lifetime. More than 40% of the participants (n = 62 of 146, 42.4%) met the criteria for current PTSD based on the DSM-5, and n = 63 (of 145, 43.44%) reported symptoms of dissociation above the pathological cutoff. Of 156 participants, n = 81 (51.6%) reported chronic pain lasting at least 3 months. In addition, n = 105 (67.3%) reported headaches in the past 12 months, including n = 37 with migraines and n = 68 with other types.

3.2. Associations between childhood maltreatment, trauma load, posttraumatic stress disorder symptoms, dissociation, and indicators of pain

Small to moderate effect size correlations were observed between measures of pain symptoms (current pain over the past 3 months, pain intensity, continuous pain in muscles and joints, and the number of pain locations) and severity of CM, trauma load, and trauma-related symptoms (r ranged between r = 0.26 to r = 0.44). No significant associations were found between any variables and headache occurrence in the past year or number of headache days. For detailed correlation coefficients and 95% CIs, see Table 1.

Table 1.

Descriptive statistics and correlation coefficients (95% confidence interval) between measures of exposure (childhood maltreatment, trauma load), symptoms of posttraumatic stress disorder/dissociation, and indicators of pain.

	M (SD)	Current pain (past 3 mo) in n (%)	†Pain intensity (past 4 wk)	‡Continuous pain in muscles and joints (for 3 mo) in n (%)	‡Body pain distribution	§Headache last year in n (%)	†Number of days with headache
M (SD) or n (%)		81 (51.6)	2.07 (1.62)	80 (51.6)	2.95 (3.70)	105 (67.3)	0.92 (0.86)
Severity of CM (MACE SUM)	44.66 (17.59)	0.27*** [0.12, 0.41]	0.26*** [0.11, 0.40]	0.26*** [0.10, 0.40]	0.32*** [0.17, 0.46]	0.00 [−0.15, 0.16]	0.13 [−0.03, 0.29]
‖Trauma load (SLESQ)	6.30 (3.16)	0.35*** [0.20, 0.48]	0.30*** [0.15, 0.45]	0.27** [0.12, 0.42]	0.29** [0.13, 0.44]	0.08 [−0.09, 0.24]	0.09 [−0.07, 0.25]
¶PTSD symptoms (PCL-5)	25.64 (20.14)	0.35*** [0.20, 0.48]	0.37*** [0.22, 0.51]	0.31*** [0.15, 0.45]	0.37*** [0.22, 0.50]	0.14 [−0.03, 0.29]	0.08 [−0.09, 0.24]
‖Symptoms of dissociation (Shut-D)	10.70 (7.86)	0.37*** [0.23, 0.51]	0.41*** [0.26, 0.54]	0.44*** [0.30, 0.57]	0.44*** [0.30, 0.56]	0.12 [−0.04, 0.28]	0.17 [0.00, 0.32]

*P < 0.05, **P < 0.01, and ***P < 0.001 based on the Benjamini–Hochberg procedure controlling the false discovery rate at 0.05. In addition, significant correlations are highlighted in bold.

^†n = 153.

^‡n = 155.

^§n = 156.

^‖n = 145.

^¶n = 146.

CM, childhood maltreatment; MACE, Maltreatment And Abuse Chronology Of Exposure; MACE SUM, severity of childhood maltreatment; PTSD, posttraumatic stress disorder; SLESQ, Stressful Life Events Screening Questionnaire; PCL-5, Posttraumatic Stress Disorder Checklist based on the DSM-5; Shut-D, Shutdown Dissociation Scale.

3.3. Associations between types of childhood maltreatment, timing of exposure, and indicators of pain

The severity of CM showed the strongest correlations with current pain over the past 3 months, pain intensity, continuous pain in muscles and joints, and the number of pain locations, with small to moderate effect sizes ranging from r = 0.21 to r = 0.32 (Table 2). Types of CM were also correlated with pain symptoms, although the associations were weaker, reflecting small effect sizes. Current pain over the past 3 months was associated with parental nonverbal emotional abuse and peer physical abuse. Small correlations were observed between pain intensity and parental nonverbal emotional abuse, and physical abuse as well as peer physical abuse. While the distribution of body pain exhibited a pattern of small associations with parental verbal abuse emotional and physical abuse by peers, no significant associations were found between headache frequency in the past year and numbers of headache days with specific types of CM (see Table 2).

Table 2.

Descriptive statistics and correlation coefficients (95% confidence interval) between types of childhood maltreatment and indicators of pain.

	M (SD)	Current pain (past 3 mo) in n (%)	†Pain intensity (past 4 wk)	‡Continuous pain in muscles and joints (for 3 mo) in n (%)	‡Body pain distribution	§Headache last year in n (%)	†Number of days with headache
M (SD) or n (%)		81 (51.6)	2.07 (1.62)	80 (51.6)	2.95 (3.70)	105 (67.3)	0.92 (0.86)
Severity of CM (MACE SUM)	44.66 (17.59)	0.27** [0.12, 0.41]	0.26* [0.11, 0.41]	0.26* [0.10, 0.40]	0.32** [0.17, 0.46]	0.00 [−0.15, 0.16]	0.13 [−0.03, 0.29]
Parental verbal abuse (PVA SUM)	7.16 (3.58)	0.18 [0.02, 0.33]	0.19 [0.03, 0.34]	0.20* [0.05, 0.35]	0.22* [0.06, 0.36]	0.10 [−0.06, 0.26]	0.15 [−0.01, 0.30]
Parental nonverbal emotional abuse (PNVEA SUM)	5.09 (2.75)	0.21* [0.06, 0.36]	0.24* [0.08, 0.38]	0.19 [0.03, 0.34]	0.19 [0.03, 0.34]	0.03 [−0.13, 0.19]	0.17 [0.01, 0.32]
Parental physical abuse (PPA SUM)	3.38 (3.12)	0.18 [0.02, 0.33]	0.23* [0.07, 0.37]	0.18 [0.03, 0.33]	0.26* [0.11, 0.41]	0.07 [−0.09, 0.23]	0.04 [−0.12, 0.20]
Physical neglect (PN SUM)	5.21 (2.81)	0.19 [0.04, 0.34]	0.15 [−0.01, 0.30]	0.14 [−0.02, 0.29]	0.21* [0.05, 0.35]	−0.07 [−0.22, 0.09]	0.06 [−0.10, 0.22]
Emotional neglect (EN SUM)	6.97 (2.66)	0.11 [−0.04, 0.27]	0.12 [−0.04, 0.27]	0.06 [−0.10, 0.22]	0.13 [−0.03, 0.28]	−0.01 [−0.17, 0.14]	0.10 [−0.05, 0.26]
Sexual abuse (SEXA SUM)	1.85 (2.59)	0.16 [−0.001, 0.30]	0.11 [−0.05, 0.26]	0.15 [−0.001, 0.31]	0.20 [0.04, 0.34]	0.03 [−0.13, 0.19]	0.04 [−0.12, 0.19]
Witnessed violence toward siblings (WITS SUM)	1.30 (2.18)	0.09 [−0.07, 0.24]	0.10 [−0.06, 0.26]	0.03 [−0.13, 0.19]	0.11 [−0.05, 0.26]	−0.11 [−0.26, 0.05]	0.05 [−0.11, 0.21]
Witnessed violence toward parents (WITP SUM)	2.92 (2.72)	0.11 [−0.04, 0.27]	0.03 [−0.13, 0.19]	0.10 [−0.06, 0.25]	0.14 [−0.02, 0.29]	−0.07 [−0.22, 0.09]	−0.01 [−0.17, 0.15]
Peer emotional abuse (PEERE SUM)	7.78 (3.31)	0.18 [0.02, 0.32]	0.19 [0.03, 0.33]	0.21* [0.06, 0.36]	0.18 [0.03, 0.33]	0.00 [−0.16, 0.16]	0.16 [−0.001, 0.31]
Peer physical bullying (PEERP SUM)	2.98 (2.87)	0.21* [0.06, 0.36]	0.24* [0.08, 0.38]	0.25* [0.10, 0.39]	0.32* [0.17, 0.45]	−0.02 [−0.18, 0.14]	0.02 [−0.14, 0.18]

*P < 0.05, **P < 0.01, and ***P < 0.001 based on the Benjamini–Hochberg procedure controlling the false discovery rate at 0.05.

^†n = 153.

^‡n = 155.

^§n = 156.

CM, childhood maltreatment; MACE, Maltreatment And Abuse Chronology Of Exposure.

At the descriptive level, the age-dependent severity of CM exhibited considerable variation, with higher mean scores observed around adolescence (Fig. 2A). While significant correlations were found between all age-dependent levels of CM severity and current pain reported over the past 3 months, the correlation for CM severity at ages 4 to 6 were not significant (Fig. 2B). For pain intensity, all age-dependent severities of CM showed significant correlations, except for CM at age 4 (Fig. 2C). For current pain in joints and muscles, only the age-dependent severity of CM during ages 8 to 11 was significantly associated (Fig. 2D). The distribution of body pain showed significant correlations with all age-dependent CM severities, except for CM at ages 4 and 5 (Fig. 2E). No significant correlations were observed for the occurrence of headache over the past year (Fig. 2F). However, a significant association was found between the number of days with headaches and the age-dependent severity of CM at ages 12 to 15 and 17 (Fig. 2G).

Figure 2.

Panel (A) shows the descriptive mean scores of the age-dependent severity of childhood maltreatment (CM), highlighting variations based on timing. Panels (B–G) display the correlation strength and 95% confidence intervals for the respective pain variables: (B) current pain (past 3 months), (C) pain intensity, (D) continuous pain in muscles and joints, (E) body pain distribution, (F) headache in the past year, and (G) days with headache. If the 95% confidence interval includes the zero line, the correlation is not statistically significant.

3.4. Mediating role of posttraumatic stress disorder symptoms and dissociation in the childhood maltreatment/trauma load and pain relationship

All results of the mediation analysis are presented in Figure 3 (for pain intensity) and Figure 4 (for body pain distribution), with age and sex considered as covariates. Tables S1 and S2, http://links.lww.com/PR9/A378 in the Supplement list all numerical values. The relationship between the severity of CM and pain intensity was fully mediated by PTSD symptoms and dissociative symptoms, explaining 42.1% and 60.5% of the total effect (Figs. 3A and B). Similarly, the relationship between trauma load and pain intensity was fully mediated by PTSD symptoms and dissociative symptoms, accounting for 49.9% and 54.5% of the total effect (Figs. 3C and D). The relationship between the severity of CM and body pain distribution was partially mediated by PTSD symptoms, which accounted for 33.5% of the total effect. By contrast, dissociation symptoms fully mediated the relationship between CM severity and body pain distribution, explaining 49.7% of the effect (Figs. 4A and B). In addition, the relationship between trauma load and body pain distribution was fully mediated by PTSD and dissociation symptoms, accounting for 50% and 61.4% of the total effect, respectively (Figs. 4C and D).

Figure 3.

Direct (ADE, average direct effect), indirect, and mediation effects (ACME, average causal mediation effect) between the severity of childhood maltreatment (CM) (A and B) or trauma load (C and D) and PTSD (A and C) or symptoms of dissociation (B and D) and the outcome pain intensity are shown using standardized coefficients and 95% confidence intervals. All mediation analysis included covariates of age and sex. Mediation analysis (A) is based on a sample size of n = 142, mediation analysis (B) on n = 143, mediation analysis (C) on n = 142, and mediation analysis (D) on n = 134. PTSD, posttraumatic stress disorder.

Figure 4.

Direct (ADE, average direct effect), indirect, and mediation effects (ACME, average causal mediation effect) between the severity of childhood maltreatment (CM) (A and B) or trauma load (C and D) and PTSD (A and C) or symptoms of dissociation (B and D) and the outcome body pain distribution are shown using standardized coefficients and 95% confidence intervals. All mediation analysis included covariates of age and sex. Mediation analysis (A) is based on a sample size of n = 144, mediation analysis (B) on n = 143, mediation analysis (C) on n = 143, and mediation analysis (D) on n = 134. PTSD, posttraumatic stress disorder.

4. Discussion

Childhood maltreatment and trauma are common among young adults with a history of RYC, identifying them as a high-risk group shaped by adversity. High rates of PTSD, dissociation, and disengagement from work or education reflect their lasting psychological and socioeconomic challenges. Chronic pain is also markedly elevated, affecting 51.6% of this group compared with 11.6% in the general young adult population.⁴⁷ Similarly, headaches in the past year were reported by 67.3%, exceeding the 53% prevalence among European adults.⁶⁶

By focusing on an underrepresented sample, we demonstrated associations between CM, trauma load, and pain symptoms^9,38,45,79 in individuals with a history of RYC. Despite the high prevalence of headache, no significant link emerged between CM, trauma load, or trauma-related symptoms and headache. This contrasts with findings in other populations,^34,39 but is consistent with another recent study.⁷⁸ Previous studies link CM to headaches, but in our highly exposed sample,¹ a ceiling effect may explain the lack of a significant association. Beyond overall CM severity, types of emotional and physical abuse, neglect, and peer-related maltreatment were associated with pain indicators, although generally with small to moderate effect sizes. Most age periods, except around age 4, were significantly linked to pain, with slightly stronger effects for joint and muscle pain (CM at ages 8–11) and headache days (CM in adolescence). This may reflect the cumulative burden of early and persistent CM in this high-risk group. The findings highlight the importance of both type and timing of CM exposure, extending previous research that focused mainly on cumulative scores,³¹ with few studies addressing developmental timing in detail.⁵³ We have confirmed the association between PTSD symptoms and pain outcomes in a high-risk group, as detailed in a recent review.³⁸ We add to the limited literature linking dissociative symptoms with elevated and chronic pain.^13,54 Although experimental studies show paradoxical pain responses, our findings reveal that PTSD and dissociation both relate positively to pain outcomes,¹³ and may represent a transdiagnostic phenomenon underlying altered pain processing.⁵⁶ In young adults with a history of RYC, PTSD and dissociation symptoms showed to mediate the effect of CM/trauma exposure on pain intensity and body pain distribution. These findings are consistent with previous research in diverse populations,^55,57,78 supporting the robustness and generalizability of the observed mediating role across different samples. This mediation likely reflects adversity-induced dysregulation of physiological arousal, impaired affective modulation, and peritraumatic pain intrusions; alternatively, pain itself may act as an internal trigger—mechanisms that collectively contribute to the amplification and generalization of bodily pain experiences.^9,51,71 Furthermore, as CM, socioeconomic adversity, and unhealthy lifestyle behaviors frequently co-occur in populations with lower educational attainment,²² these factors as beyond the scope of this study may represent mediators and/or shared risk pathways. This hypothesis warrants systematic examination in future longitudinal and intervention studies.¹⁷ The mediating role of trauma-related symptoms advances our understanding of how past adversity translates into current pain experiences and highlights potential intervention targets to address both psychological and physical health.

4.1. Clinical implications

The findings reinforce evidence linking CM, trauma, and psychological consequences with pain, highlighting the need for interdisciplinary research and practice as emphasized by the Lancet Psychiatry Commission's blueprint for improving physical health in people with mental illness.¹⁷ Integrating awareness of psychological and physical factors, along with targeted diagnostic assessments for CM exposure, is crucial in general practice, pain-specialized treatment teams, and RYC-related work. The findings stress trauma's complex impact on both psychological and physical health, guiding trauma-informed and integrative treatments for pain management. Trauma-focused therapies such as Cognitive Behavioral Therapy¹⁰ and Narrative Exposure Therapy,⁶¹ especially for those with broad exposure to CM and traumatic experiences, are effective in reducing trauma-related symptoms and show promise for pain symptoms.

4.2. Strengths, limitations, and generalizability

The study's strengths include examining multiple forms of CM and trauma-related symptoms linked to pain outcomes in an underrepresented young population. Applying the Benjamini–-Hochberg procedure to control the false discovery rate further strengthens the robustness of our findings. Identifying PTSD and dissociation as mediators underscores the mind–body link, providing valuable insights for targeted therapeutic interventions, although conclusions are limited by the small sample and cross-sectional design. Pain symptoms and their distribution were assessed through self-report, as physical examinations were not feasible due to budget limitations. To enhance interpretability, we recommend assessing clinical pain diagnoses as well as the use of analgesics and pain-specific treatments in future studies. However, pain remains a subjective experience, regardless of clinical examination.²⁹ The study's 52% response rate (see also Ref. 25) is a limitation, although it is satisfactory given the high burden of adversities. Attrition analysis showed that participants who completed the follow-up had a higher baseline prevalence of mental disorders, suggesting potential selection bias. While the findings may be applicable to other high-risk populations with similar backgrounds of significant CM and trauma exposure, such as psychiatric inpatients and individuals with chronic pain and mental health issues, further exploration in these samples is necessary to confirm their generalizability.

5. Conclusion

A history of CM and trauma-related symptoms is crucial for understanding pain symptoms in individuals during their transition to adulthood after RYC. Posttraumatic stress disorder and dissociation symptoms may contribute to development and exacerbation of pain representing key targets for intervention and personalized treatment.

Supplemental digital content

Supplemental digital content associated with this article can be found online at http://links.lww.com/PR9/A378.