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Nov
29

Childhood abuse can have a multitude of negative health implications, and, as well as affecting an individual’s mental health and social development, has been linked to chronic pain later in life. Kelli Hooks reports on the long-term sequelae of child abuse and the importance of trauma-informed practice.

According to figures from the Blue Knot Foundation, one in every four Australians is a survivor of childhood trauma, including abuse. Recent research undertaken by the Foundation found that more than 80 per cent of those who suffered abuse as a child—including sexual, physical, emotional or neglect—experience multiple health consequences as a result. 

Blue Knot Foundation President Dr Cathy Kezelman AM notes that alongside the significant mental health implications of childhood trauma, including a high prevalence of conditions such as anxiety and depression, as well as negative impacts on interpersonal relationships, childhood abuse can also have profound physical health repercussions in adulthood. Physical implications may stem from coping strategies deployed around the time of the abuse or may be indicative of unresolved trauma. 

‘When someone has been abused or traumatised as a child, it affects the very development of their core sense of self,
their sense of self-worth, their self-esteem, their relationship to others and their relationship to the world,’ Cathy says.
‘It also has physical health repercussions. Some of the strategies people use to cope become risk factors for later adult health issues. For example, smoking, substance abuse and overeating can all have long-term repercussions on health, but they were arguably what helped people to survive their childhood.

‘Chronic pain conditions such as fibromyalgia and medical presentations which are very hard to pinpoint, such as
headaches, neck pain, back pain ... may relate to the way the body is expressing trauma that has not been worked through.’ 

Research has established that even those whom have suffered severe and pervasive early trauma can recover provided they receive the right support. For healthcare practitioners involved in the treatment of people affected
by complex trauma, Cathy points to the importance of implementing trauma-informed practice, which revolves around five essential principles: safety, trustworthiness, collaboration, choice and empowerment. 

‘It can often be very hard for survivors to trust people, and obviously touch can be very difficult, particularly for survivors who have been sexually or physically abused. In a situation where you are approaching the body, touching the body, manipulating the body, for people who are sensitised to that, it’s really quite critical,’ she says. 

‘It’s important for people to feel as safe as they can, so build a relationship of trust before delving in. Safety is so vital—people can’t start processing their trauma until they feel safe. Survivors often come from a place of being disempowered so it’s also very important that they have a major say in what they feel they need and want, and that they
have choices.’ 

The sensitisation survivors of trauma may possess can impact their tolerance for relatively minor stressors and,
consequently, they may exhibit, and respond with, extreme forms of arousal—either hyperarousal or hypoarousal.
Cathy emphasises the value of practitioners being cognisant of traumatic stress reactions and how they can affect a
patient’s presentation. 

‘People who’ve been abused are often allergic to stressors, they’re often hypervigilant, waiting for the next assault, or they can be quite shut down. Hyperarousal and hypoarousal are both stress responses and can happen episodically. Someone may present as being agitated and sweaty with a rapid heart rate, and then, at another point in that consultation, may appear spaced out and shut down. It’s important to be aware of all of those possible signs.’ 

To assist practitioners in providing optimal care in this space, the Blue Knot Foundation has developed practice
guidelines for the treatment of complex trauma, which are the accumulation of 20 years of national and international research in the field. The guidelines notably focus on the sensitivities and vulnerabilities of survivors. The Foundation also offers trauma-informed training for those working in this complex area of care. 

One such healthcare professional is psychiatrist Dr Michelle Atchinson, a private practitioner with 20 years’ experience and an interest in psychiatric problems arising out of traumatic stress. A large proportion of Michelle’s clientele have been war service veterans and, more recently, she recalls treating a refugee from Iran who had suffered significant past trauma which impacted her ability to recover from a minor physical injury she sustained later in life. 

‘She’d had family killed in front of her, she’d spent time in refugee camps and was finally in Australia, where she felt safe; then she had a motor vehicle accident. It was quite minor but she never really recovered … it reactivated all of the other trauma that she’d held inside,’ Michelle says. 

And it is in the case of such presentations, whereby the patient is not responding to regular treatment for their physical ailment, or their pain appears to be out of proportion to the cause, that Michelle stresses the value of clinicians taking a comprehensive developmental history, including a trauma history check, in their initial evaluations. 

‘Often with people who have had childhood trauma, their body is less resilient to coping with trauma later in life. For example, with people who have had a minor car accident but have sustained a very severe psychiatric condition out of it, often you can look at their history and see that they aren’t coping now because of something that happened to them earlier in their life,’ Michelle notes.

‘If people present with a somatic problem and, when you fix it, another somatic problem jumps up … and the person keeps presenting with pain that isn’t helped by usual treatment, that’s when you’ve got to step back and question whether there is something more psychological going on rather than just a physical process. There may be a past trauma that’s made the person more vulnerable.’ 

In some cases, a patient’s pain presentation may also be indicative of the form of abuse they have suffered in the past. Michelle underlines the need for practitioners to be aware of such correlations during assessment. 

‘For women with chronic pelvic pain … often if you go into their history, you will find that they are victims of sexual abuse. There’s a link between the sort of abuse that people have suffered and their presentation now with unexplained physical symptoms.’

Michelle points to the significance of identifying trauma early, encouraging practitioners to also be aware of the signs
and symptoms of abuse in their younger patient population. With only 38 per cent of victims reporting abuse, and with almost 200 000 Australian children suspected of being harmed, or at risk of harm from abuse (according to the latest statistics from the Australian Institute of Health and Welfare), it is crucial for those providing care for children to
speak up if they suspect abuse is occurring. 

‘Children don’t tell you what’s going wrong—they show you what’s going wrong. Look out for behavioural changes. Children are more likely to present with stomach pain or headaches than telling someone that they are being abused. So, if you’re working with children, be very mindful of physical complaints that don’t seem to have a physical basis or aren’t responding to treatment—take them very seriously,’ she says. 

The correlation between prolonged childhood abuse and physical conditions in adulthood has been reinforced by a range of research in the last several decades, with past studies indicating that childhood abuse is a risk factor for the development of chronic pain and other difficult-to-manage physical illnesses. Complex post-traumatic stress disorder (CPTSD) has also been linked to chronic pain conditions, and the younger the child is when trauma occurs, the more likely they are to develop CPTSD, Michelle notes. 

‘Repeated traumatic experiences in childhood can affect your stress hormones and the way your body responds to stress as a child, and you’ll carry that through to adulthood. People with CPTSD have often had childhood trauma and somehow their body is less resilient to coping with trauma later in life. 

‘A number of studies have looked at the rates of physical illness in children and people who are survivors of childhood
abuse. There are a whole range of medical conditions that are more prevalent in those people; not just chronic pain but things like asthma, rheumatoid arthritis and diabetes as well.’ 

Chair of the national Pain group Lester Jones, APAM, has worked with survivors of torture and other trauma, and reiterates the well-established link between childhood trauma and poor health outcomes later in life, such as chronic pain. According to Lester, more recent research in the area seeks to identify a biological explanation for the correlation, with a particular focus on the reactivity of the neuro-immuneendocrine system. 

‘Largely, that’s about there being a multidirectional network of these systems in terms of communication about things like stress and danger. One of the suggestions from the literature is that stress responses may become over-reactive or underactive. There is a bit of a paradox between how people present in situations, but there is some dysregulation in their stress response system. What we’re suggesting with the research coming out about the immune system is that there’s a similar thing happening there,’ he says. 

Lester proposes that one of the major breakthroughs in recent literature exploring the impact of traumatic experiences in childhood is an understanding that the immune system is in direct communication with neural synapses. 

‘In brain research, that’s essentially defined as a tetrapartite synapse which involves four components: two nerve cells and two glial cells. And that’s the really revolutionary information we need to start bringing in factors from early childhood experiences and focusing on how they might alter the immune system and the repercussions later in life,’ he says. 

‘What we are looking for is changes in the reactivity of the sensitivity of the neuro-immune interactions—the system
is being primed to look out for danger but also react to any threatening event. The understanding is that our patterns
of immune function and the way that the immune and the endocrine system work is established in childhood and persists through our lives but with the potential to be modified along the way. And there’s a suggestion that there’s more of a critical period in the early years.’ 

Lester has worked with researchers in this area, and recently authored a chapter on the topic in an upcoming book, Psychologically-informed Physiotherapy. In his chapter, ‘Stress, pain and recovery: neuro-immuneendocrine
interactions and clinical practice’, Lester discusses novel research in this area in a physiotherapy context. 

‘The chapter is really trying to describe what we know about normal communication between the neuro-immune-endocrine systems, and then looking at what might happen if we put this system under more load or stress,’ he says. ‘There’s a term we’re starting to see in physiotherapy literature, allostatic overload, which is essentially where a system is constantly in a state of trying to adjust to stresses and there’s some impact on the functioning of those systems if the load gets too much.’ 

In a clinical setting, Lester echoes the importance of practitioners being mindful of their patient’s background and the impact that past experiences may have on their current presentation. 

‘Learn about the person’s life story and be understanding. Even though someone might have had an experience many years ago, it could still have an impact on how they present, particularly in terms of the severity of their symptoms or evidence that their system might be over-applying protection. So you might see lots lots of muscle spasm and reactivity to things you might not think would be normally a cause for reaction,’ he says. 

‘Learn about how stress systems are affected by prior experiences—a patient may be in a state where they are over-expressing their stress. It’s also about learning that there are things we need to be aware of and that, in some cases, we can trigger a negative response in someone by the questions we ask. We need to have clear strategies to manage clients with past trauma, including how to support someone if they have a negative reaction to our interactions.’

Comments

Cathy
# Cathy
Tuesday, 6 December 2016 8:09 PM
I am a Physiotherapist AND a survivor of severe childhood sexual abuse, and I am so so heartened by this article!

Even though I have over 20 years experience as a Physiotherapist, it has only been over the past 4 years that I have truly come to understand the connection between the (early) childhood trauma and somatic symptoms, which for me have been wide and varied.

As a teenager and through my twenties, I became used to a pattern of presenting to a doctor with physical symptoms, undergoing tests and finding the results were completely. This was very frustrating, and after a while I was beginning to think that I was a hypochondriac!

After starting treatment with a Psychiatrist - and with the benefit of knowledge gained from my profession - I realised somewhere in the back of my mind that there was an underlying psycho-somatic component to my symptoms, although I did not really understand what the connection was. Instead, I used that vague knowledge to look at my symptoms objectively and determine if they made sense (for example, that pain in my calf is NOT a DVT because it is not hot or swollen, I have no recent history of risk factors such as air travel and no pain on ankle dorsiflexion!). I immediately went from being a frequent flyer at my GP to not visiting one for years at a time.

Then around four years ago, an event triggered the recovery of some long-repressed memories (I thought I had a good recollection of events, but knew there was a 5 year gap in my childhood). These memories presented themselves predominantly as somatic symptoms (various pains and sensory issues, tinnitus, dizziness/vertigo and even physical stigmata).
In working through these memories (I am fortunate enough to have a fantastic Psychiatrist), I was able to match physical symptoms to past events - almost like putting together the pieces of a puzzle, only I had to find the pieces first! Whilst I still experience a range of somatic issues, knowing where they come from has been very comforting and they have been easier to control.

As a Physiotherapist working in the disability field, I have seen these physical manifestation of trauma frequently. I am often alarmed at the lack of understanding regarding this amongst many health professionals. Instead, labels such as "disengaged", "unmotivated", "anxious", "inconsistent" or "functional" are used (with negative connotations) to explain lack of progress and/or behavioural observations. This is why I am so grateful that the APA has produced a guide to trauma-informed care for Physiotherapists :).

Finally, I would like to share a poem I wrote whilst going through this process - I hope it gives a bit of an insight into somatic symptoms!

MY BODY KNOWS
My body knows the story
My body keeps the score
Of memories so scary
They haunt forever more

My body knows the dialogue
That I have never heard
It doesn’t breathe a sound of it
It doesn’t have the words

My body knows the truth
And screams to let it out
But the messages get muddled
With things all mixed about

My body knows the force
Of being torn to pieces
It bears the many scars
And keeps the many secrets

My body knows the horror
Waiting in the dark
But it’s not sure it should tell me
In case I fall apart

My body knows the story
My body keeps the score
And I don’t have a say in it
No say in it at all



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Testimonials

“Blue Knot Foundation has a key role to play in the building of community capacity in care provision to those who have experienced childhood abuse and trauma in any environment.”

NIALL MULLIGAN Manager, Lifeline Northern Rivers

“I think Blue Knot Foundation is a fantastic support organisation for people who have experienced childhood trauma/abuse, for their families/close friends and for professionals who would like to learn how to more effectively work with these people.”

Psychologist Melbourne

“It's such a beautiful thing that you are doing. Helping people to get through this.”

ANONYMOUS

“It was only last September when I discovered the Blue Knot Foundation website and I will never forget the feeling of support and empathy that I received when I finally made the first phone call to Blue Knot Helpline, which was also the first time I had ever spoken about my abuse.”

STEVEN

"At last there is some sound education and empathetic support for individuals and partners impacted by such gross boundary violations.”

TAMARA

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