INTRODUCTION
A history of childhood trauma is prevalent among adults with chronic pain and is associated with greater pain-related burden and poorer clinical outcomes.1 The childhood trauma and posttraumatic stress disorder (PTSD) literature suggests that trauma-related symptoms, such as avoidance and emotional dysregulation, may attenuate response to behavioral pain treatments.1,2 With growing interest in trauma-specific treatments for chronic pain, it remains unclear whether general behavioral pain interventions are less effective for patients with high levels of childhood trauma. The present secondary analysis examined whether childhood trauma differentially impacts response to behavioral pain treatments in chronic low back pain. We hypothesized that childhood trauma would moderate treatment response.
METHODS
Data were drawn from a randomized clinical trial of adults with chronic low back pain comparing 8-session Cognitive Behavioral Therapy (CBT), 1-session Empowered Relief (ER), and 1-session Health Education (HE; no skills). CBT and ER include pain neuroscience education, action plans, and self-regulatory skills such as cognitive strategies and relaxation techniques to reduce pain- and stress-related arousal and improve emotion regulation and pain self-efficacy.3 The parent trial was institutional review board approved, preregistered (NCT03167086; May 22nd 2017) with first participant enrolled on June 8th 2017, and adherent to CONSORT guidelines.3
Participants completed the 28-item Childhood Trauma Questionnaire (CTQ)4 at baseline (Cronbach’s α=0.95 in this sample), and total scores were dichotomized using established cutoffs4 to relatively low (≤51) versus high (>51) childhood trauma to provide a clinical interpretable group comparison and preserve statistical stability, while sensitivity analyses used the CTQ total score as a continuous variable. Pain intensity, pain interference, physical function, fatigue, sleep disturbance, depression, anxiety, pain catastrophizing, and pain self-efficacy were assessed at baseline and post-treatment months 1 and 3. Repeated-measures mixed-model analyses of variance (ANOVAs) in SPSS 31.0 tested the childhood trauma × treatment × time interaction.
RESULTS
Participants (N=218; 50% female; Mage=49.78, SDage=14.06; 60.6% White) were randomized to CBT (n=75), ER (n=76), or HE (n=67). Mean CTQ total score was 43.12 (SD=17.30; range=25–119), with 62.4% (n=136) classified as low childhood trauma and 37.6% (n=82) as high childhood trauma. No significant demographic differences were observed between trauma groups or attrition groups. Higher CTQ total score correlated with worse baseline symptoms of pain interference, physical function, fatigue, sleep disturbance, depression, anxiety, pain catastrophizing (Pearson’s r ranges −0.17 to 0.27; all p<.05), except pain intensity (r=0.08; p=0.21) and pain self-efficacy (r=−0.07; p=0.29).
Contrary to our hypothesis, no significant childhood trauma × treatment × time interactions were observed (all p values>.05; Table 1). CBT and ER participants improved significantly over time relative to HE, regardless of childhood trauma level (Figure 1). Findings were unchanged in sensitivity analyses using CTQ as a continuous variable. Sensitivity analysis restricted to CBT and ER participants with severe childhood trauma (CTQ≥69; n=19) showed significant improvements in pain intensity, interference, catastrophizing, and fatigue (all p values<.05; ηp2 range=0.27–0.42), indicating substantial within-group changes.
Table 1.
Repeated-Measures Mixed-Model ANOVA Results for Time, Treatment Group, and Childhood Trauma Effects Across Pain-Related Outcomes (N=218)
| Outcome | Time | Time × Treatment | Time × Trauma | Time × Treatment × Trauma | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| F | p | ηp 2 | F | p | ηp 2 | F | p | ηp 2 | F | p | ηp 2 | |
| Pain Intensity | 34.45 | <.001 | 0.18 | 3.91 | 0.005 | 0.05 | 0.07 | 0.92 | 0.001 | 0.41 | 0.78 | 0.005 |
| Pain Interfere | 43.15 | <.001 | 0.22 | 5.20 | <.001 | 0.06 | 1.03 | 0.36 | 0.007 | 0.23 | 0.91 | 0.003 |
| Physical Fx. | 23.62 | <.001 | 0.13 | 2.39 | 0.05 | 0.03 | 0.37 | 0.69 | 0.002 | 0.54 | 0.70 | 0.007 |
| Fatigue | 25.11 | <.001 | 0.14 | 1.60 | 0.17 | 0.02 | 0.12 | 0.86 | 0.001 | 0.20 | 0.92 | 0.003 |
| Sleep Disturb | 9.00 | <.001 | 0.06 | 2.76 | 0.03 | 0.03 | 0.16 | 0.86 | 0.001 | 0.53 | 0.71 | 0.007 |
| Depression | 14.02 | <.001 | 0.08 | 0.90 | 0.47 | 0.01 | 0.81 | 0.45 | 0.005 | 0.74 | 0.56 | 0.009 |
| Anxiety | 14.39 | <.001 | 0.08 | 2.24 | 0.07 | 0.03 | 0.84 | 0.43 | 0.005 | 0.59 | 0.66 | 0.008 |
| PCS | 78.26 | <.001 | 0.32 | 6.45 | <.001 | 0.07 | 0.19 | 0.83 | 0.001 | 0.19 | 0.92 | 0.002 |
| PSEQ | 34.04 | <.001 | 0.18 | 4.91 | 0.001 | 0.06 | 1.06 | 0.34 | 0.007 | 1.06 | 0.38 | 0.013 |
Note. Physical Fx. = Physical Function, Sleep Disturb=Sleep Disturbance, PCS: Pain Catastrophizing Scale, PSEQ: Pain Self-Efficacy Questionnaire.
Figure 1. Representative outcome trajectories by treatment group and childhood trauma level.
(A) Pain intensity and (B) pain catastrophizing mean scores are displayed at baseline, 1-month, and 3-month follow-up for low childhood trauma (CTQ ≤ 51) and high childhood trauma (CTQ > 51) groups. Overlapping 95% confidence intervals are not shown for visual clarity (see Supplementary Table 1 for details). Across both outcomes, CBT and ER demonstrated greater improvement over time compared with HE, with largely parallel treatment trajectories observed across low and high childhood trauma groups. These visual patterns are consistent with the nonsignificant childhood trauma × treatment × time interactions identified in repeated-measures mixed-model ANOVA analyses.
DISCUSSION
Childhood trauma was generally associated with greater baseline symptom burden. Contrary to our hypothesis, participants with higher levels of childhood trauma reported benefitting from the behavioral pain treatments. Prior work in chronic fatigue syndrome suggested that childhood trauma does not diminish behavioral treatment response;5,6 our results provide similar evidence for chronic pain. Although longer-term follow-up is needed, limited evidence from 6- and 12-month follow-up studies suggests that treatment effects are sustained among individuals with childhood trauma histories.5,6
Limitations include: (1) potential underpower and dichotomizing CTQ scores may have reduced power to detect interaction effects, though CTQ score modeled as a continuous variable yielded similar results; (2) the absence of trauma-specific inclusion criteria and PTSD assessment as active PTSD symptoms (e.g., avoidance, hypervigilance) may influence treatment engagement and response; (3) findings are limited to individuals with chronic low back pain and to the CBT and ER interventions. Future research should examine these associations in larger, more trauma-severe clinical samples and across a broader range of behavioral interventions and pain conditions.
Supplementary Material
ACKNOWLEDGEMENTS
Funding:
We acknowledge funding from NIH T32 DA035165 (SK), NIH K24 DA053564 (BDD), and NIH K24 NS126781 (SM).
Disclosures:
Stanford University owns the copyright and trademark to Empowered Relief. Stanford University receives fees for Empowered Relief CME/CEU interprofessional clinician certification workshops; BDD receives no personal monies for Empowered Relief or for clinical certifications. BDD is principal investigator for NIH grants and PCORI contracts to Stanford University involving Empowered Relief and CBT. BDD has authored or coauthored five pain treatment books for patients and clinicians and receives royalties for four. BDD is chief science advisor to AppliedVR and this is a compensated role that is unrelated to the current study. BDD is a former scientific member of the NIH Interagency Pain Research Coordinating Committee, former member of the Centers for Disease Control and Prevention (CDC) Opioid Workgroup, the Pain Advisory Group of the American Psychological Association, and served on the Board of Directors of the Institute for Brain Potential and the American Academy of Pain Medicine.
SM receives research funding from the NIH, Food and Drug Administration, and Patient-Centered Outcomes Research Institute (administered through Stanford University).
Abbreviation:
- PTSD
posttraumatic stress disorder
- CBT
Cognitive Behavioral Therapy
- ER
Empowered Relief
- HE
Health Education
- CTQ
Childhood Trauma Questionnaire
- ANOVA
analyses of variance
Footnotes
Conflicts of Interest: All authors have no conflicts of interest to declare.
Ethics Approval:
The parent trial was approved by Stanford University’s institutional review board and registered with ClinicalTrials.gov (Identifier NCT03167086). Written informed consent was obtained from all participants (aged 18 years or older) prior to enrollment.
REFERENCES
- 1.Tidmarsh LV, Harrison R, Ravindran D, Matthews SL, Finlay KA. The influence of adverse childhood experiences in pain management: mechanisms, processes, and trauma-informed care. Frontiers in Pain Research. 2022;3:923866. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Bosco MA, Gallinati JL, Clark ME. Conceptualizing and treating comorbid chronic pain and PTSD. Pain research and treatment. 2013;2013(1):174728. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Darnall BD, Roy A, Chen AL, et al. Comparison of a single-session pain management skills intervention with a single-session health education intervention and 8 sessions of cognitive behavioral therapy in adults with chronic low back pain: a randomized clinical trial. JAMA network open. 2021;4(8):e2113401. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Bernstein DP, Fink L, Handelsman L, Foote J. Childhood trauma questionnaire. Assessment of family violence: A handbook for researchers and practitioners. 1998; [Google Scholar]
- 5.Heins MJ, Knoop H, Lobbestael J, Bleijenberg G. Childhood maltreatment and the response to cognitive behavior therapy for chronic fatigue syndrome. Journal of psychosomatic research. 2011;71(6):404–410. [DOI] [PubMed] [Google Scholar]
- 6.De Venter M, Illegems J, Van Royen R, Moorkens G, Sabbe BG, Van Den Eede F. Differential effects of childhood trauma subtypes on fatigue and physical functioning in chronic fatigue syndrome. Comprehensive psychiatry. 2017;78:76–82. [DOI] [PubMed] [Google Scholar]
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