What is the association between childhood adversity and subsequent chronic pain in adulthood? A systematic review

Inflammatory reactivity is unrelated to childhood adversity or provoked modulation of nociception

ABSTRACT

Adversity in childhood elevates the risk of persistent pain in adulthood. Neuroimmune interactions are a candidate mechanistic link between childhood adversity and persistent pain. We aimed to clarify whether immune reactivity is associated with provoked differences in nociceptive processing in adults with a range of childhood adversity. Pain-free adults (n = 96; 61 female; median [range] age: 23 [18-65] years old) with a history of mild to severe childhood adversity underwent psychophysical assessments before and after in vivo neural provocation (high-frequency electrical stimulation) and, separately, before and after in vivo immune provocation (influenza vaccine administration). Psychophysical assessments included the surface area of secondary hyperalgesia after neural provocation and change in conditioned pain modulation (test stimulus: pressure pain threshold; conditioning stimulus: cold water immersion) after immune provocation. Immune reactivity was operationalised as interleukin-6 and tumour necrosis factor-α expression after in vitro lipopolysaccharide provocation of whole blood. We hypothesised associations between immune reactivity and (1) childhood adversity, (2) induced secondary hyperalgesia, and (3) vaccine-associated change in conditioned pain modulation. We found that provoked expression of proinflammatory cytokines was not statistically associated with childhood adversity, induced secondary hyperalgesia, or vaccine-associated change in conditioned pain modulation. The current findings from a heterogenous sample cast doubt on 2 prominent ideas: that childhood adversity primes the inflammatory system for hyper-responsiveness in adulthood and that nociceptive reactivity is linked to inflammatory reactivity. This calls for the broader inclusion of heterogeneous samples in fundamental research to investigate the psychoneuroimmunological mechanisms underlying vulnerability to persistent pain.

The mediating role of anxiety between child abuse and pain among a sample of Lebanese adults

Pain is defined as an unpleasant sensory and emotional experience in response to a noxious stimulus. Nowadays, it is increasingly prevalent among adults and may be influenced by past experiences such as child abuse, trauma or psychiatric conditions like anxiety. Thus, this study aims to evaluate the mediating effect of anxiety between child abuse and pain among a sample of Lebanese adults. This cross-sectional study was conducted between March and April 2024. Participants were selected using a snowball sampling method from various Lebanese governorates, and completed a self-administered online questionnaire via Google Forms. All adults over the age of 18 were eligible to participate. The questionnaire included sociodemographic questions, the short form of McGill pain questionnaire, the generalized anxiety disorder-7 (GAD-7), and the child abuse self report scale (CASRS-12). A total of 507 Lebanese adults completed the questionnaire. The mean age was 26.80 ± 10.29 years and 73.2% were female. The results showed that anxiety partially mediated the association between child abuse and pain. Higher levels of child abuse were significantly associated with greater anxiety, which in turn was significantly associated with increased pain. Child abuse was directly associated with higher pain levels. The study highlights the relationship that child abuse has on pain in adults and its relationship with anxiety. Future research delving into the relationship between child abuse and chronic pain in adulthood is essential to better understand the underlying pathways and support effective prevention and intervention strategies.

Childhood maltreatment and chronic "all over" body pain in adulthood: a counterfactual analysis using UK Biobank

ABSTRACT

Evidence linking adverse childhood experiences and chronic pain in adulthood is largely cross-sectional, potentially subject to recall bias and does not allow exploration of mediating pathways. We analysed a large population-based cohort (UK Biobank) using a causal framework, to determine if childhood maltreatment is related to chronic "all over" body pain in adulthood. We used doubly robust estimation with inverse probability weights to estimate the difference in risk of chronic pain "all over" between those exposed/not exposed to childhood maltreatment (abuse or neglect). In addition, we looked at interaction with adult stressful life events and examined mediation using inverse odds weighting in a generalized linear model. Using cases with complete data (n = 118,347), the risk of chronic "all over" body pain was higher in the exposed (6.3%, 95% confidence interval [CI] 6.0%-6.5%) than in the unexposed (4.0%; 95% CI 3.8%-4.2%). This difference remained in analyses stratified by sex. Conversely, when analyses were repeated with a negative control exposure, childhood sunburn, risk differences were 0.8% in women (95% CI 0.3%-1.3%) and 0.5% in men (95% CI 0.1%-0.9%). Childhood maltreatment and adult life events had similar effects, and there was a supra-additive risk (1.2%; 95% CI 0.6-1.7) when experiencing both. In mediation analyses, the total effect was a relative risk of 1.57 (95% CI 1.49-1.66), while the estimated indirect effect via all mediators was relative risk 1.16 (95% CI 1.14-1.18). Reducing childhood maltreatment would likely prevent cases of chronic widespread pain in adulthood. Stressful adult events and mediators may offer opportunities for intervention.

Inflammatory reactivity is unrelated to childhood adversity or provoked modulation of nociception

Adversity in childhood elevates the risk of persistent pain in adulthood. Neuroimmune interactions are a candidate mechanistic link between childhood adversity and persistent pain. We aimed to clarify whether immune reactivity is associated with provoked differences in nociceptive processing in adults with a range of childhood adversity. Pain-free adults (n=96; 61 female; median (range) age: 23 (18-65) years old) with a history of mild to severe childhood adversity underwent psychophysical assessments before and after in vivo neural provocation (high-frequency electrical stimulation) and, separately, before and after in vivo immune provocation (influenza vaccine administration). Psychophysical assessments included the surface area of secondary hyperalgesia after neural provocation and change in conditioned pain modulation (test stimulus: pressure pain threshold; conditioning stimulus: cold water immersion) after immune provocation. Immune reactivity was operationalised as IL-6 and TNF-α expression after in vitro lipopolysaccharide provocation of whole blood. We hypothesised associations between immune reactivity and (1) childhood adversity, (2) induced secondary hyperalgesia, and (3) vaccine-associated change in conditioned pain modulation. We found that provoked expression of pro-inflammatory cytokines was not statistically associated with childhood adversity, induced secondary hyperalgesia, or vaccine-associated change in conditioned pain modulation. The current findings from a heterogenous sample cast doubt on two prominent ideas: that childhood adversity primes the inflammatory system for hyper-responsiveness in adulthood and that nociceptive reactivity is linked to inflammatory reactivity. This calls for the broader inclusion of heterogeneous samples in fundamental research to investigate the psychoneuroimmunological mechanisms underlying vulnerability to persistent pain.

Adverse Childhood Experiences and Urogenital Pain: Examining the Mediating Effects of Negative Affect and Pain Catastrophizing

BACKGROUND : Adverse childhood experiences (ACE) are associated with later psychological and somatic problems, including the emotional sequelae of adverse events (depression, anxiety, and catastrophizing) and outcomes such as chronic pain intensity and pain-related functioning. ACE have rarely been studied in women with pelvic, urogenital, and/or bladder pain (PUBP).

AIMS

Thus, we examined how childhood adversities are related to psychological and pain-related outcomes in adult women. We also tested whether negative affect and pain catastrophizing mediated the relationship between ACE and pain-related outcomes.

METHODS

A consecutive series of 310 adult women who presented at a tertiary urology center and reported PUBP completed an intake packet, which included the ACE Questionnaire as well as measures of psychological mediators and pain-related outcomes.

RESULTS

Elevated ACEs were significantly associated with higher pain interference and vaginal insertion pain, as well as significantly related to negative affect (depression and anxiety) and pain catastrophizing. Both negative affect and pain catastrophizing were found to mediate the relationship of ACE to pain intensity and interference; however, only pain catastrophizing mediated the relationship between ACE and vaginal insertion pain.

CONCLUSIONS

These results suggest that ACEs may impact some pain-related outcomes in women with PUBP by influencing negative affect and pain catastrophizing. Thus, these processes are important targets for intervention in individuals with PUBP and a history of adverse childhood events.

TRIAL REGISTRATION

This study does not require a clinical trial registration because it is not a clinical trial.

Impact of adverse childhood experiences on analgesia-related outcomes: a systematic review

BACKGROUND

There is well-established evidence linking adverse childhood experiences (ACEs) and chronic pain in adulthood. It is less clear how ACE exposure might influence the response to chronic pain treatment. In this systematic review, we synthesise the literature assessing the impact of ACE exposure on outcomes relating to the use, benefits, and harms of analgesic medications (analgesia-related outcomes).

METHODS

We searched seven databases from inception to September 26, 2023, for studies investigating adverse events in childhood (<18 yr) and any analgesia-related outcome during adulthood (≥18 yr). Title/abstract screening, full-text review, data extraction, and risk of bias assessment were performed independently by two authors. Given the high degree of study heterogeneity, a narrative synthesis was performed.

RESULTS

From 7531 records, 66 studies met inclusion criteria, involving 137 395 participants. Analgesia-related outcomes were classed into six categories: use of analgesics (n=12), analgesic side-effects (n=4), substance misuse (n=45), lifetime drug overdose (n=2), endogenous pain signalling (n=4), and other outcomes (n=2). No studies assessed the effect of ACE exposure on the potential benefits of analgesics. ACE exposure was associated with greater use of analgesic medication, higher incidence of analgesic medication side-effects, greater risk and severity of substance misuse, greater risk of drug overdose, and greater risk of attempted suicide in opioid dependency.

CONCLUSIONS

Adverse childhood experience exposure is associated with poor analgesia-related outcomes, so individual assessment adverse childhood experiences is important when considering the treatment of chronic pain. However, significant gaps in the literature remain, especially relating to the use and harms of non opioid analgesics.

SYSTEMATIC REVIEW PROTOCOL

CRD42023389870 (PROSPERO).

Impact of Early-Life Adversity on Cannabis Use: Exploring the Mediating and Moderating Effects of Chronic Pain

Background: Although research suggests that early-life adversity (ELA) and cannabis use are linked, researchers have not established factors that mediate or modify this relationship. Identifying such factors could help in developing targeted interventions. We explored chronic pain as a potential mediator or moderator of this relationship. Methods: Using an online study, we collected cross-sectional data about ELA, cannabis use, and chronic pain to test whether ELA (adverse childhood experiences total score) is associated with cannabis use, and to examine pain as a potential mediator or moderator. Cannabis use was examined two ways: times used per day, and categorized as non-, some, or regular use. Chronic pain was measured as present/absent and as the number of painful body locations (0-8). Analyses used linear and multinomial regression. Results: ELA, chronic pain, and cannabis use were common among respondents. ELA was strongly associated with both measures of cannabis use. The number of painful body locations modestly mediated the association of ELA with cannabis use, reducing the magnitude of regression coefficients by about 1/7. The number of painful body locations modified the association between ELA and cannabis use (p≤0.006), while chronic pain presence/absence (a less-informative measure) had only a nonsignificant modification effect (p≥0.10). When either ELA or pain was high, the other was not associated with cannabis use; when either ELA or pain was low, more painful locations or higher ELA (respectively) was associated with more intense cannabis use. Conclusion: These exploratory findings suggest the importance of ELA and chronic pain as factors contributing to cannabis use, and of accounting for these factors in developing treatment and prevention strategies addressing cannabis use.

Impact of adverse childhood experiences on sensory thresholds in adults living with multimorbidity and chronic pain (the ACE-MAP study): protocol for an observational feasibility study

INTRODUCTION

Exposure to adverse childhood experiences (ACEs) is associated with a range of poor long-term health outcomes, including multimorbidity and chronic pain. Epidemiological evidence underpins much of this relationship; however, psychophysical testing methods, such as quantitative sensory testing (QST), may provide valuable insights into potential mechanisms. Previous studies have shown inconsistent links between ACEs and QST, but the QST profiles of people with multimorbidity have not been reported. We hypothesise that exposure to ACEs is associated with lowered QST thresholds (ie, experience of pain with milder stimuli) and that this association is stronger in adults with multimorbidity and/or chronic pain. The ACE-MAP study is a cross-sectional feasibility study with the primary aim of assessing the feasibility and acceptability of the proposed study procedures. The secondary aim is to generate preliminary data to understand the impact of ACEs on QST thresholds.

METHODS AND ANALYSIS

We plan to recruit 40 participants, with 10 in each of the following groups: (1) chronic pain with multimorbidity; (2) chronic pain without multimorbidity; (3) multimorbidity without chronic pain; and (4) controls. Participants will complete a series of questionnaires (including on ACEs, chronic pain and long-term conditions) and will then take part in QST assessments. The primary study outcomes will include measures of feasibility and acceptability of the proposed study design. The secondary study outcomes will include exploratory analysis on the relationship between ACEs and QST thresholds.

ETHICS AND DISSEMINATION

The study was approved by the Scotland B Research Ethics Committee (reference: 24/SS/0031). Results from the study will be presented at scientific conferences, published in a peer-reviewed journal and shared with patients and members of the public through other media streams.

TRIAL REGISTRATION NUMBER

ISRCTN10049430.

An Analysis on the Impact of Childhood Adversity, Anxiety, and C-Reactive Protein on Adult Chronic Pain in the Midlife in the United States (MIDUS) Study

OBJECTIVE

This study used the Midlife-Development in the United States (MIDUS) dataset to a) examine relationships between reported childhood adversity (CA), anxiety, and pain; b) assess associations between CAs, anxiety, C-reactive protein (CRP) levels, and pain; and c) explore how CAs, anxiety, and CRP are associated with pain medication consumption.

METHODS

Data were from Project-4 of MIDUS-II (n = 1225), which utilized Project-1 demographics and supplemental chart review. For objectives 1-2, structural equational modeling (SEM) followed by general linear modeling (GLM) regression was conducted. For objective 3, all variables from the objective 1-2 dataset were used as possible independent variables for the exploratory regression.

RESULTS

For objectives 1-2, CRP was significantly correlated with anxiety, emotional abuse, physical neglect, and chronic pain (n = 1173). The SEM (n = 1173) indicated that CAs, anxiety, and CRP all played a role in predicting chronic pain. Regression results (n = 1173) indicated that gender, total income, and highest education were significant predictors of chronic pain. Significant interactions to explain chronic pain included physical abuse/emotional neglect, emotional abuse/physical abuse, physical abuse/minimization, physical neglect/education, CRP/income, and CRP/education. For objective 3 (n = 600), there were no significant main effects, but a large variety of interactions contributed to predicting pain medication consumption. CAs interacting significantly to explain this included emotional abuse/physical abuse, physical abuse/emotional neglect, physical abuse/minimization, and sexual abuse/minimization. There were also significant interactions between CRP/income and CRP/education.

CONCLUSIONS

Based on a large US sample, sociodemographics played a meaningful role in predicting chronic pain in adults, and CRP was significantly correlated with anxiety, emotional abuse, physical neglect, multiple sociodemographic variables, and chronic pain. The influence of CAs on predicting long-term medication use for chronic pain was complex and warrants further study.

The effects of neighborhood disadvantage and adverse childhood experiences on conditioned pain modulation in adults with chronic low back pain

Chronic low back pain (cLBP) remains a major health crisis worldwide. Current conceptualizations of cLBP utilize the biopsychosocial model, yet research on social factors remains limited. Adverse childhood experiences (ACEs) are a risk factor for a variety of chronic health problems, including cLBP. However, the extent to which socioeconomic context might influence associations between ACEs and cLBP remains unclear. Socioeconomic factors such as healthcare access and living conditions, which cluster at the neighborhood level, may affect how ACEs relate to cLBP in adulthood. This study examined (1) the relationship between ACEs and conditioned pain modulation (CPM), and (2) the moderating effect of area-level deprivation index (ADI) in a sample of community-dwelling adults with cLBP. 183 adults with cLBP (53% female, 62.8% non-Hispanic Black) reported on ACEs, ADI, sociodemographics, and completed experimental testing of conditioned pain modulation (CPM). Greater ACEs were associated with a less efficient CPM response for individuals residing in low neighborhood deprivation (p < 0.01). ACEs were not significantly associated with CPM for those residing in average (p = 0.31) or high deprivation (p = 0.15). Our findings suggest that a history of ACEs is associated with diminished ability to inhibit pain, especially among individuals living in less deprived neighborhoods. The association between ACEs and CPM was weakest for the portion of our sample residing in neighborhoods with the most deprivation. People from disadvantaged backgrounds may experience numerous psychosocial stressors that hinder CPM, making it difficult to assess the specific impact of ACEs on CPM. TRIAL REGISTRATION: This study utilized baseline data collected as part of a parent trial titled "Examining Racial and SocioEconomic Disparities in Chronic Low Back Pain" (ERASED - ClinicalTrials.gov ID: NCT03338192). PERSPECTIVE: This study demonstrates that early life adversity is associated with abnormal endogenous pain modulation, particularly for participants who live in neighborhoods characterized by less deprivation.

Gastrointestinal symptoms in abused nonpatient women

BACKGROUND

Severely abused nonpatient women report a high number of gastrointestinal (GI) symptoms and GI syndromes. Little is known about whether the abuse‒symptom relationship varies across different life, social, and community conditions.

OBJECTIVE

To comparatively assess the timing, type and severity of physical and/or sexual abuse and GI symptoms of nonpatient women who contacted a lawyer for legal support with those who sought shelter in antiviolence centers.

SUBJECTS AND METHODS

Forty-six lawyer controls (LCs) (aged 29-80 years) and 67 women (aged 18-58 years) sheltered in antiviolence (V) centers completed an identical anonymous questionnaire with medical and abuse sections. The severity of abuse was assessed with the 0-6 Abuse Severity Measure (ASM). The associations between abuse characteristics and the number of symptoms were assessed with the Poisson regression model.

RESULTS

Among the LC women, 65% experienced physical and/or sexual abuse in childhood and/or adulthood, whereas 100% of the V women did. In both groups, most women experienced combined sexual and physical abuse in childhood and adulthood. The ASM was < 2 in 57% of the LC and 18% of the V women. LC and V women reported an average of 4.9 and 4.6 GI symptoms, respectively. In both groups, women who had been both sexually and physically abused reported a greater number of GI symptoms. Childhood and adulthood abuse were associated with more GI symptoms only in V women. LC women with ASM > 2 reported more GI symptoms than those with an ASM of < 2 (median; IQR: 6.5; 3-11 vs 3; 1-7, p = 0.002). V women with ASM > 5 reported significantly more GI symptoms than control women with ASM < 5 (median; IQR: 6; 4-8 vs 4.5; 2-8, p < 0.001).

CONCLUSIONS

In abused "nonpatient" women, the combination of physical and sexual abuse, childhood and adulthood abuse and higher severity scores were associated with a greater number of GI symptoms, irrespective of the social and economic setting.

When thinking about pain contributes to suffering: the example of pain catastrophizing

ABSTRACT

The extensive literature on the potent role negative thoughts about pain have on the experience of pain and pain-related suffering has documented associations with important neurobiological processes involved in amplifying nociceptive signals. We focus this review on pain catastrophizing (pCAT)- appraisals of pain as threatening, overwhelming, and unmanageable- and review the evidence that these thoughts are learned in childhood through experience and observation of others, particularly caretakers and parents. For children who have learned pCAT, repeated exposures to pain over time activate pCAT and likely contribute to further amplification of pain through changes in the neurobiological pain regulatory systems, which overlap with those regulating the stress response. We propose that repeated pain and stress exposures throughout childhood, adolescence, and into adulthood alter the neurobiology of pain via a repetitive positive feedback loop that increases risk for heightened pain sensitivity over time with repeated exposures. At some point, often precipitated by an acute episode of pain and possibly influenced by allostatic load, pCAT contributes to persistence of episodic or acute pain and exacerbates pain-related suffering. This developmental trajectory is not inevitable, as the impact of pCAT on pain and pain-related suffering can be influenced by various factors. We also present future directions for work in this area.

Childhood trauma, PTSD/CPTSD and chronic pain: A systematic review

BACKGROUND

Despite the growing body of literature on posttraumatic stress disorder (PTSD) and chronic pain comorbidity, studies taking into account the role of childhood exposure to traumatic and adverse events remains minimal. Additionally, it has been well established that survivors of childhood trauma may develop more complex reactions that extend beyond those observed in PTSD, typically categorized as complex trauma or CPTSD. Given the recent introduction of CPTSD within diagnostic nomenclature, the aim of the present study is to describe associations between childhood trauma in relation to PTSD/CPTSD and pain outcomes in adults with chronic pain.

METHODS

Following PRSIMA guidelines, a systematic review was performed using the databases Pubmed, PsychInfo, Psychology and Behavioral Sciences Collection, and Web of Science. Articles in English or French that reported on childhood trauma, PTSD/CPTSD and pain outcomes in individuals with chronic pain were included. Titles and abstracts were screened by two authors independently and full texts were consequently evaluated and assessed on methodological quality using JBI checklist tools. Study design and sample characteristics, childhood trauma, PTSD/CPTSD, pain outcomes as well as author's recommendations for scientific research and clinical practice were extracted for analyses.

RESULTS

Of the initial 295 search records, 13 studies were included in this review. Only four studies explicitly assessed links between trauma factors and pain symptoms in individuals with chronic pain. Findings highlight the long-term and complex impact of cumulative childhood maltreatment (e.g., abuse and neglect) on both PTSD/CPTSD and chronic pain outcomes in adulthood.

CONCLUSION

This review contributes to current conceptual models of PTSD and chronic pain comorbidity, while adding to the role of childhood trauma and CPTSD. The need for clinical and translational pain research is emphasized to further support specialized PTSD/CPTSD treatment as well as trauma-informed pain management in routine care.

An ecosystem of accepting life with chronic pain: A meta-ethnography

Background

Chronic pain is a highly prevalent long-term condition, experienced unequally, impacting both the individual living with pain, and wider society. 'Acceptance' of chronic pain is relevant to improved consultations in pain care, and navigating an approach towards evidence-based, long-term management and associated improvements in health. However, the concept proves difficult to measure, and primary qualitative studies of lived experiences show complexity related to our socio-cultural-political worlds, healthcare experiences, and difficulties with language and meaning. We framed acceptance of chronic pain as socially constructed and aimed to conceptualise the lived experiences of acceptance of chronic pain in adults.

Methods

We conducted a systematic search and screening process, followed by qualitative, interpretive, literature synthesis using Meta-ethnography. We included qualitative studies using chronic pain as the primary condition, where the study included an aim to research the acceptance concept. We conducted each stage of the synthesis with co-researchers of differing disciplinary backgrounds, and with lived experiences of chronic pain.

Findings

We included 10 qualitative studies from Canada, Sweden, The Netherlands, Ireland, UK, Australia and New Zealand. Our 'lines of argument' include a fluid and continuous journey with fluctuating states of acceptance; language and meaning of acceptance and chronic pain, a challenge to identity in a capitalist, ableist society and the limits to individualism; a caring, supportive and coherent system. The conceptual framework of the meta-ethnography is represented by a rosebush with interconnected branches, holding both roses and thorns, such is the nature of accepting life with chronic pain.

Conclusion

Our findings broaden conceptualisation of 'acceptance of chronic pain' beyond an individual factor, to a fluid and continuous journey, interconnected with our socio-cultural-political worlds; an ecosystem.

Anxiety, history of childhood adversity, and experiencing chronic pain in adulthood: A systematic literature review and meta-analysis

BACKGROUND

When considering factors that may impact chronic pain experiences in adulthood, adverse childhood experiences (ACEs) and anxiety should be considered. The literature on the associations between these 3 variables remains unclear.

OBJECTIVE

To summarize the existing literature on the relationship between ACEs and anxiety on chronic pain experience in adults, and examine the association between ACEs and anxiety.

METHODS

A systematic literature review (SLR) and meta-analysis was used to examine adults (≥18) with a reported history of ACEs, self-reported and/or diagnosed anxiety, and chronic pain. The SLR included quality appraisal according to the Joanna Briggs Institute tool.

RESULTS

The narrative summary indicated a significant association between ACEs, anxiety, and chronic pain experiences in adults. Of 52 selected studies, 79% reported a moderate-strong association. For ACE prevalence, the majority reported experiencing sexual abuse (50% [SD 16.01]), followed by physical abuse (46% [SD 20.7]). Other ACEs included emotional abuse (33% [SD 17.17]), emotional neglect (25% [SD 21.02]), and physical neglect (23% [SD 22.44]). Meta-analyses showed moderate associations between anxiety and chronic pain (r = 0.30; 95% CI = [0.14, 0.45], p < 0.01) and between ACEs and anxiety (r = 0.26; 95% CI = [0.15, 0.36], p < 0.01), and that participants who experienced ACEs are around twice as likely to present chronic pain during adulthood (OR = 1.99; 95% CI = [1.53, 2.60], p < 0.01).

CONCLUSION

The results of the SLR and meta-analysis indicated that ACEs and anxiety influence chronic pain experience in adults. Given the relationship between ACEs and anxiety, there would be value in exploring this as a potential mediator in future studies.

SIGNIFICANCE

There was an unmet need to summarize the existing literature on the relationship between ACEs and anxiety on chronic pain experience in adults and the association between ACEs and anxiety. The results of this systematic review and meta-analysis indicated that both ACEs and anxiety influenced chronic pain experience in adults and helped to inform the diverse literature on these potential relationships to date.

Overview: Chronic Pain and Cannabis-Based Medicines

Chronic pain is primarily conceptualized as a disease in its own right when it is associated with emotional distress and functional impairment. Pathophysiologically, dysfunction of the cortico-mesolimbic connectome is of major importance, with overlapping signals in the nociceptive and stress systems. The endocannabinoid system plays an important role in the central processing of nociceptive signals and regulates the central stress response. Clinically, there is moderate evidence that cannabis-based medicines (CBM) can contribute to a significant reduction in pain, especially the associated pain affect, and improvement in physical function and sleep quality in a proportion of patients with chronic pain. The analgesic effect appears to be largely independent of the cause of pain. In this context, CBM preferentially regulates stress-associated pain processing.

Broadening the Scope of Resilience in Chronic Pain: Methods, Social Context, and Development

PURPOSE OF REVIEW

A wellspring of new research has offered varying models of resilience in chronic pain populations; however, resilience is a multifaceted and occasionally nebulous construct. The current review explores definitional and methodological issues in existing observational and clinical studies and offers new directions for future studies of pain resilience.

RECENT FINDINGS

Definitions of pain resilience have historically relied heavily upon self-report and from relatively narrow scientific domains (e.g., positive psychology) and in narrow demographic groups (i.e., Caucasian, affluent, or highly educated adults). Meta-analytic and systematic reviews have noted moderate overall quality of resilience-focused assessment and treatment in chronic pain, which may be attributable to these narrow definitions. Integration of research from affiliated fields (developmental models, neuroimaging, research on historically underrepresented groups, trauma psychology) has the potential to enrich current models of pain resilience and ultimately improve the empirical and clinical utility of resilience models in chronic pain.

Hidden family rules: perspective on a dysfunctional paternalistic system and the persistence of pain

This article explores how paternalistic control and power reside within the family system and how this may influence pain and its persistence. Drawing upon clinical case studies and existing literature, this exploration emphasises the role of paternal dysfunction in creating emotional memory images and delves into how this may influence the chronification and treatment resistance of pain (i.e., making pain "sticky"). We argue that a dysfunctional paternalistic family system, often characterised by authoritarian dynamics, emotional neglect, and abuse, results in adverse experiences and emotional memory images that create a fertile ground for the entrenchment and propagation of psychosomatic symptoms, including pain. Further, the paper emphasizes the potential intergenerational effects of such a scenario, where inherited "Family Rules" drive maladaptive coping mechanisms, which contribute to the persistence of psychological and physiological distress across generations. Understanding these complexities offers new perspectives on treating psychological disorders and their physiological ramifications. It also highlights the urgency of addressing dysfunctional familial dynamics in psychotherapeutic interventions for both immediate and long-term psychophysiological health outcomes.