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Journal of Interpersonal Violence

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Original Research

Chronic Pain Personification Following Child Abuse: The Imprinted Experience of Child Abuse in Later Chronic Pain

Noga Tsur, PhD1

AbstractChild abuse has been shown to increase the risk for chronic pain. The illness personification theory implies that individuals tend to ascribe humanlike characteristics to chronic pain, and that this personification is embedded in the way they cope with their chronic condition. Recent findings demonstrate that individuals who experienced interpersonal violence tend to personify chronic pain in a way that resonates with past abusive experience. Although findings prevail to the link between trauma and the experience of the body, the personification of chronic pain among individuals who experienced child abuse has not been examined before. This article includes two studies that tested whether child abuse is implicated in abusive chronic pain personification in a young adult female sample (Study 1) and among females who experienced child abuse (Study 2). In both studies, self-report measures of child abuse, posttraumatic stress (PTS) symptoms, complex posttraumatic symptoms (disturbances of self-organization [DSO]), and abusive chronic pain personification were administered. Structural equation modeling was utilized to assess the hypotheses. The findings of the two studies showed a significant association between child abuse and pain

1Tel Aviv University, Israel

Corresponding Author:Noga Tsur, Bob Shapell School of Social Work, Tel Aviv University, Ramat Aviv, Tel Aviv 69978, Israel. Email: [email protected]

944529 JIVXXX10.1177/0886260520944529Journal of Interpersonal ViolenceTsurresearch-article2020

2022, Vol. 37(5-6) NP2516 –NP2537

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personification. Whereas PTS symptoms did not mediate this link (Study 1), DSO symptoms mediated this association (Study 2). The findings of these studies support the understanding that the experience of interpersonal violence is engraved in the experience of the body, as reflected in abusive chronic pain personification. Disturbances in self-organization seem to underlie this process, thus pertaining to the link between the experience of the body, self, and interpersonal trauma.

Keywordschild abuse, chronic pain, pain personification, PTSD, complex PTSD (CPTSD), abusive chronic pain personification

Introduction

Child abuse refers to the infliction of physical, sexual, and/or emotional abuse toward a child (Scher et al., 2001; Todahl et al., 2021). Extensive lit-erature has revealed the long-term ramifications of child abuse for physical and mental health (Afifi et al., 2009, 2014; Annerbäck et al., 2012). Perhaps the most conspicuous documented psychopathology ramification of child abuse is encapsulated in posttraumatic stress disorder (PTSD; Dworkin et al., 2017; Ullman & Filipas, 2005), with an estimated lifetime prevalence of about one third of victims (Gilbert et al., 2009). In addition, it has been shown that individuals who were subjected to ongoing interpersonal abuse, such as child abuse, may develop more complex and multifaceted reactions that extend beyond those observed in PTSD (Cloitre, 2020). These reactions are commonly encapsulated in complex posttraumatic stress disorder (CPTSD; Herman, 1992; van der Kolk et al., 2005), reflecting a trauma-related disor-der that, aside from PTSD symptoms, also includes disturbances in self-orga-nization (DSO; Cloitre et al., 2009). These disturbances are manifested in three main dimensions (Cloitre et al., 2018). The first dimension, negative self-concept, is often observed in beliefs about self as worthless or a failure. A second dimension refers to interpersonal relatedness, such as feeling dis-tant from others or difficulty in being emotionally close to others. The third dimension reflects affective dysregulation, often seen as difficulties in calm-ing oneself when feeling disturbed, or in feeling emotional numbness (Brewin et al., 2017). These disturbances in self-organization are inherently linked with the nature of child abuse, entailing incoherent experiences of living in an abusive environment, where love and hurt often coexist (Herman, 1992), sometimes reflected in attachment trauma (Berthelot et al., 2015; Schuder & Lyons-Ruth, 2004). Indeed, findings have shown CPTSD to be among the most prevalent malicious consequences of early interpersonal trauma

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(Messman-Moore & Bhuptani, 2017; van der Kolk, 2017), including child abuse (Cloitre et al., 2009; Hyland et al., 2017). Findings further indicate that, whereas the association between child abuse and PTSD is direct, the association between child abuse and DSO symptoms is explained by dys-functional emotion regulation (Knefel et al., 2019) and sense of coherence (Sölva et al., 2020).

Individuals who experienced child abuse have been shown to be at greater risk of suffering from chronic health conditions (Flaherty et al., 2006; Leeb et al., 2011), such as arthritis, asthma, and heart disease (Leeb et al., 2011; Springer et al., 2007) as well as engaging in poor health behaviors, such as smoking and substance use (Rodgers et al., 2004). One of the most common debilitating chronic conditions is chronic pain, which has been shown to be linked with previous exposure to interpersonal violence and trauma (Kendall-Tackett, 2001), as well as PTSD (Asmundson & Katz, 2009; Lõpez-Martínez et al., 2014; McFarlane, 2010; Sharp & Harvey, 2001). Particularly, findings indicate that individuals who experienced child abuse tend to report more pain compared with individuals who did not experience child abuse (Sachs-Ericsson et al., 2007). A meta-analytical study showed a significant link between child abuse and fibromyalgia (Häuser et al., 2014). Other such find-ings imply that, among women, retrospective reports of child abuse were associated with chronic pain in adulthood (Walsh et al., 2007).

Chronic Pain Personification

A growing body of knowledge reveals that interpersonal trauma is not merely implicated in the functioning of the body, but also in the ways in which trau-matized individuals perceive, interpret, and experience their bodily signals (van der Kolk, 2015). Such findings reveal that individuals who were exposed to interpersonal trauma tend to perceive bodily signals as catastrophic and frightening, potentially indicating serious dreadful conditions and conse-quences (Tsur et al., 2018). Stemming from these understandings, and com-bined with the illness personification theory (Schattner et al., 2008; Shahar & Lerman, 2013), a new research arena has emerged, which sheds light on the ways in which individuals who experienced trauma personify their bodily signals. According to the Illness Personification theory, first concieved by Shahar and colleagues (Schattner et al., 2008; Schattner & Shahar, 2011; Shahar & Lerman, 2013), individuals tend to ascribe humanlike characteris-tics to illness-related symptoms in a way that is relevant to the self (Shahar & Lerman, 2013). As such, individuals tend to develop a sort of “relationship” with their chronic medical condition, reflecting the narrative in which the self interacts with the illness (Schattner & Shahar, 2011; Shahar & Lerman,

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2013). This way, chronic pain, or any other chronic illness, is no longer merely construed as a physical condition, but rather becomes an internal phe-nomenon, entailing personal designations and meanings. An example of such personification arises from Schattner et al. (2008), who depicted the words of a woman coping with systemic lupus erythematosus: “I’m like some bull-dozer. I mean if, God forbid, something happens, I just go to war—I won’t let it (the illness) defeat me” (p. 468).

Recently, the illness personification theory has been applied within the trauma research arena. These studies inspected whether the personification of chronic conditions resonates with the experience of past violating abuse. The finding showed that, 35 years post captivity, ex-prisoners of war who were subjected to severe torture during captivity tended to ascribe torturing char-acteristics to their chronic pain (Tsur et al., 2017). Specifically, as compared with controls, torture survivors tended to describe their current chronic pain in a way that resonates with the experience of interpersonal violence, choos-ing words such as “killing,” “terrifying,” “evil,” “beating,” “penetrating,” and so on (see Tsur et al., 2017, for the full word list). Presumably, chronic pain personification may derive from the resemblance between the experi-ence of interpersonal violence and chronic pain, with both reflecting an uncontrollable, internal experience of suffering and pain. The findings further indicated that PTSD mediated the association between torture and pain per-sonification, potentially pointing to the underlying mechanism whereby pain personification evolves (Tsur et al., 2017, 2020).

Considering the high prevalence of chronic pain following child abuse (Flaherty et al., 2006), a question arises as to whether chronic pain among individuals who experienced child abuse is personified in such abusive instances. A few findings provide indirect indications for such processes, revealing that individuals who experienced child abuse tend to perceive pain as catastrophic (e.g., Pieritz et al., 2015) and report on increased psychoso-matic symptoms (Lamela & Figueiredo, 2013). However, examinations of chronic pain personification among individuals who experienced child abuse have not been conducted to date.

This article depicts two studies that aimed to examine chronic pain per-sonification following child abuse and the potential intervening effects of PTSD and CPTSD in these processes.

Study 1

The aim of this study was to test whether individuals who experienced child abuse tend to ascribe abusive characteristics to chronic pain. That is, this study assessed whether child abuse was associated with abusive chronic pain

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personification and whether posttraumatic stress (PTS) symptoms mediated this link. Considering the limited knowledge on pain personification among individuals who experienced child abuse, combined with an understanding that social forces influence the way men and women perceive their body in general (Calogero et al., 2011; Gapinski et al., 2003), and that body image (Demarest & Allen, 2000; Gibson & Helme, 2001) and chronic pain (Molton et al., 2008; Tsang et al., 2008) vary across age and gender, this study was conducted in young adult women.

Method

Participants and Procedure

The current sample consisted of 214 young adult women. Participants were recruited through personal reference and online posts. Inclusion criteria were (a) ages between 18 and 35 years, (b) women, and (c) fluent in Hebrew. Recruitment included a short description of the study, indicating its purpose to learn about women’s perceptions of themselves and their body, and its link with close relationships and past stressful experiences. Table 1 presents the sample characteristics. The study was approved by the institutional review board and all participants signed a consent form.

Measures

Child abuse was measured using the Childhood Trauma Questionnaire (CTQ; Bernstein et al., 2003). The CTQ consists of 28 items that refer to five mal-treatment forms, namely, sexual abuse, physical abuse, emotional abuse, physical neglect, and emotional neglect. For this study, the items reflecting physical abuse, sexual abuse, and emotional abuse (and not neglect) were used. Participants were asked to rate whether the items were true to them on a 5-point Likert-type scale with responses ranging from 1 (never true) to 5 (very often true), for example, “hit severely enough that bruises were noticed” (physical abuse), “was touched sexually” (sexual abuse), and “was called names by family members” (emotional abuse). Three different scores reflect-ing the three forms of abuse were calculated. Previous findings reveal the scales’ validity (Bernstein et al., 2003), as well as the Hebrew version (Talmon & Ginzburg, 2017). Cronbach’s alphas for the current sample were accept-able; .8 for physical abuse, .83 for sexual abuse, and .72 for emotional abuse.

PTS symptoms were assessed using the International Trauma Questionnaire (ITQ; Cloitre et al., 2018), which is a self-report diagnostic measure of PTSD as defined by the International Classification of Diseases, Version 11 (ICD-11).

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The scale consists of six items that represent three PTSD clusters (i.e., reexpe-riencing, avoidance, and sense of threat). Participants were asked to rate the extent to which a symptom has been bothering them over the past month on a Likert-type scale, ranging from 0 (not at all) to 4 (extremely). Example items include “having upsetting dreams that replay part of the experience or are clearly related to the experience,” “Avoiding internal reminders of the experi-ence (for example, thoughts, feelings, or physical sensations),” and “Being ‘super-alert,’ watchful, or on guard.” Previous findings revealed the scale’s validity (Cloitre et al., 2018) and the Hebrew version supported the validity of the ITQ (Ben-Ezra et al., 2018; Gilbar et al., 2018). Cronbach’s alpha for the current sample was high: .84.

Abusive Chronic Pain Personification Scale (pain personification, in short) was derived from the Hebrew version of the McGill Pain Questionnaire (MPQ; Melzack, 1975). The MPQ comprises 78 pain descriptors. Participants are usually asked to choose the words that best describe their experience of pain. The questionnaire can provide a separate measure of the sensory, affec-tive, and cognitive/evaluative dimensions of chronic pain as well as a mea-sure of the total pain experience. To examine abusive personification, a separate dimension was identified from the words listed in the MPQ, com-prising 37 words describing pain related to interpersonal torment and/or abuse, for example, whipping, terrifying, suffocating, agonizing, and killing. This unique dimension was tested for its validity and was shown to be signifi-cantly distinct from the original sensory, affective, and cognitive/evaluative

Table 1. Study 1 Sample Characteristics.

Variable N = 194

Age, M (SD) 26 (3.03)Years of education, M (SD) 14.32 (1.61)Family status % (N) Single 61% (130)

Married 13.6% (29)In a relationship 24.9% (53)Divorced 0.5% (1)

Place of birth % (N) Israel 97.7% (209)Other 2.3% (5)

Child abuse, M (SD) Physical abuse 5.44 (1.59)Sexual abuse 5.6 (1.98)Emotional abuse 6.68 (2.4)

PTS symptoms, M (SD) 1.91 (0.87)

Note. PTS = posttraumatic stress.

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dimensions by way of its associations with exposure to trauma and PTSD (Tsur et al., 2017, 2020). The magnitude of the Abusive Chronic Pain Personification Scale was calculated based on the number of words chosen by the participant (range = 0–37).

Data Analyses

Demographics and correlation tests were conducted using SPSS Version 25. Structural equation modeling (SEM), using AMOS 22 software package (Arbuckle, 2013), was conducted to test the theoretical model. Specifically, this method was used to assess (a) the association between child abuse, PTS symptoms, and abusive personification, and (b) the indirect effect from child abuse to abusive personification through the mediation of PTS symptoms. Using SEM, the direct and indirect effects of the latent constructs were exam-ined simultaneously, as well the extent to which the hypothesized model’s structure fits the data. A latent variable of child abuse was indicated by its three measures: physical abuse, sexual abuse, and emotional abuse. PTS symptoms and abusive personification were indicated by their measured scores. Five thousand bootstrap samples were used to test whether the medi-ated effects were significant.

Several complementary fit indices were used to examine the overall quality and fit of the hypothesized model to the data: comparative fit index (CFI), Tucker–Lewis index (TLI), and root mean square error of approximation (RMSEA). A model is considered to have a good fit to the observed data when CFI and TLI values are 0.95 and above (Schreiber et al., 2006), and adequate when they are 0.9 and above (Hooper et al., 2008). In addition, a model is considered to have a good fit when RMSEA is 0.05 and below, and adequate when it is between 0.1 and 0.05 (Hooper et al., 2008).

There were some missing values in the data. Little’s (1988) missing com-pletely at random (MCAR) model revealed that the data were missing com-pletely at random, χ2(47) = 28.30, p = .99. Hence, missing data were replaced with maximum likelihood estimations based on all variables in the model, a procedure referred to as full information maximum likelihood (FIML), by running models in AMOS 22 (Arbuckle, 2013).

Results and Discussion

As can be seen in Table 1, the average age of participants was 26 years and the majority were born in Israel. Most participants were single (61%) and to

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a lesser extent were in a relationship (24.9%) or married (13.6%). A total of 203 participants (94.9%) reported having good or excellent health. Chronic pain was reported by 33 participants (15.3%).

Table 2 presents the Pearson correlations between the study variables. As can be seen, the three child abuse types were significantly correlated with each other (i.e., physical abuse, sexual abuse, and emotional abuse). PTS symptoms were significantly correlated with sexual and emotional abuse, and a trend was found between PTS symptoms and physical abuse (p = .065). Pain personification was significantly correlated with physical abuse and emotional abuse. A trend was found for the correlation between pain personification and sexual abuse (p = .077).

The Associations Between Child Abuse, PTS Symptoms, and Abusive Chronic Pain Personification

A structural model was conducted to examine the research model with the covariates of age and years of education. The fit indices of the model indi-cated a good fit between the model and the data, with χ2/df = 1.41, CFI = 0.98, TLI = 0.96, RMSEA = 0.044, 90% confidence interval [0, 0.088]. The results of the SEM are depicted in Figure 1, with a presentation of the standardized estimates of the direct effects. As can be seen, the model yielded the following direct effects: As hypothesized, child abuse was sig-nificantly positively associated with PTS symptoms. That is, the higher the level of child abuse, the higher the PTSD symptoms. Contrary to the hypothesis, PTS symptoms were not significantly associated with pain per-sonification. However, a significant direct effect was found between child abuse and pain personification, revealing a significant association between

Table 2. Intercorrelations Between the Variables in Study 1 and Study 2.

MeasuresPhysical Abuse

Sexual Abuse

Emotional Abuse

PTS Symptoms

DSO Symptoms

Chronic Pain Personification

Physical abuse 1 .32*** .63*** .14 — .18*Sexual abuse .16* 1 .27** .17* — .077Emotional abuse .67*** .32*** 1 .24** — .21**PTS symptoms .25** .42*** .38*** 1 — .13DSO symptoms .17* .31** .34*** .6*** 1 —Chronic pain personification

.34 .14 .24** .21** .27** 1

Note. Results above the diagonal reflect intercorrelations in Study 1 and results below the diagonal reflect intercorrelations in Study 2. PTS = posttraumatic stress; DSO = disturbances of self-organization.*p < .05. **p < .01. ***p < .001.

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them (β = .27, p = .006). That is, the higher the level of child abuse, the higher the abusive personification of pain personification. The hypothe-sized indirect effect between child abuse and pain personification through the mediation of PTS symptoms was not significant (p = .26).

These findings imply that, although child abuse was significantly associ-ated with abusive pain personification, this association was not mediated by PTS symptoms. The findings may be explained by the sample characteris-tics, which reflect a relatively young and healthy group of young adult women. In addition, it is possible that some PTS symptoms relate to previ-ous traumatic experiences other than, or in addition to, child abuse. Finally, as presented earlier, the literature has revealed that early interpersonal trauma is often implicated in CPTSD, which, in addition to PTSD symp-toms, includes symptoms reflecting self-regulatory disturbances, as seen in a negative self-concept, problems with interpersonal relatedness, and affec-tive dysregulation (Cloitre et al., 2009, 2018). Thus, it is possible that for individuals who experienced child abuse, it is rather the self-regulatory symptoms, and not PTSD symptoms, which explain the association between child abuse and pain personification.

Study 2

This study was conducted to answer the questions that arise from the findings of Study 1. Specifically, the aims of Study 2 were (a) to assess the association between child abuse and chronic pain personification within a sample of trau-matized women who experienced child abuse, and (b) to elaborate on the

Figure 1. Model testing the association between child abuse and chronic pain personification, and the mediation of PTS symptoms.Note. PTS = posttraumatic stress.

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underlying mechanism of the link between child abuse and personification by adding the disturbances in self-organization symptoms (DSO) of CPTSD as another potential mediating factor. Specifically, both PTS symptoms and DSO symptoms were tested as simultaneous mediators in the association between child abuse and abusive personification of chronic pain among women who experienced child abuse.

Method

A sample of 160 women who reported having been sexually abused in their childhood participated in this study. Data were collected through social media platforms such as Facebook and WhatsApp. Inclusion criteria were (a) age between 18 and 60 years, (b) fluent in Hebrew, and (c) reported experiencing child sexual abuse. The study was approved by the institutional review board and all participants signed a consent form.

Measures

Child abuse was measured using the CTQ (Bernstein et al., 2003), as described in Study 1. Cronbach’s alphas for the current sample were acceptable; .83 for physical abuse, .83 for sexual abuse, and .89 for emo-tional abuse.

Complex Posttraumatic Stress (CPTS) symptoms were assessed using the ITQ (Cloitre et al., 2018). The ITQ is a self-report measure that assesses PTSD or CPTSD symptoms in accordance with the ICD-11. The scale consists of six items that represent the three PTSD clusters (i.e., reexperiencing, avoidance, and sense of threat) and another six items that represent the three disturbances in self-organization (DSO) clusters, that is, affective dysregulation (“When I am upset, it takes me a long time to calm down”), negative self-concept (“I feel worthless”), and disturbances in relationships (“I feel distant or cut-off from people”). Participants were asked to rate the extent to which a symptom has been bothering them over the past month on a Likert-type scale, ranging from 0 (not at all) to 4 (extremely). Previous findings revealed the DSO scale’s interpretability, homogeneity, and its link with functional impairment (Shevlin et al., 2018); the full scale’s validity (Cloitre et al., 2018; Karatzias et al., 2017); as well as the validity of the Hebrew version (Ben-Ezra et al., 2018; Gilbar et al., 2018). Cronbach’s alphas of PTS symptoms for the current sam-ple were .85 and .89 for DSO symptoms, indicating high reliability.

The Abusive Chronic Pain Personification Scale (Tsur et al., 2017, 2020) was derived from the Hebrew version of the MPQ (Melzack, 1975), as reported in Study 1.

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Data Analyses

Data analyses in Study 2 were very similar to Study 1 and therefore are pre-sented in brief. Demographics and correlation tests were conducted using SPSS Version 25. SEM, using AMOS 22 software package (Arbuckle, 2013), was conducted to test the theoretical model. Specifically, this method was used to assess (a) the association between child abuse, CPTS symptoms, and abusive personification; (b) the indirect effect from child abuse to abu-sive personification through the mediation of PTS symptoms; and (c) the indirect effect from child abuse to personification through the mediation of DSO symptoms. The direct and indirect effects of the latent constructs were tested simultaneously, as well as tested how well the hypothesized model’s structure fits the data. A latent variable of child abuse was indicated by its three measures: physical abuse, sexual abuse, and emotional abuse. PTS symptoms, DSO symptoms, and abusive personification were indicated by their measured scores. Five thousand bootstrap samples were used to test whether the mediated effects were significant.

Several complementary fit indices were used to examine the overall quality and fit of the hypothesized model to the data, as reported in Study 1. There were some missing values in the data: The minimal covariance coverage in the variance-covariance matrix used in the analyses was .81. Little’s (1988) MCAR model revealed that the data were missing com-pletely at random, χ2(16) = 10.64, p = .83. Hence, missing data were replaced with maximum likelihood estimations based on all variables in the model, a procedure referred to as, by running models in AMOS 22 (Arbuckle, 2013).

Results and Discussion

As can be seen in Table 3, the average age of participants was 31.72 and the majority were born in Israel. Most participants were married (40.6%) and, to a lesser extent, single (33.8%) or in a relationship (20.7%). A total of 104 participants (65.4%) reported having good or excellent health. Chronic pain was reported by 54 participants (34.2%).

Table 2 presents the Pearson correlations between the study variables. As can be seen, the three child abuse types were significantly correlated with each other (i.e., physical abuse, sexual abuse, and emotional abuse). Both PTS symptoms and DSO symptoms were significantly correlated with each other, as well as with all types of child abuse. Pain personification was sig-nificantly correlated with emotional abuse and a trend was found with sexual abuse (p = .079).

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The Associations Between Child Abuse, PTS Symptoms, DSO Symptoms, and Abusive Chronic Pain Personification

A structural model was conducted to examine the research model with the covariates of age and years of education. The fit indices of the model indicated a good fit between the model and the data, with χ2/df = 1.4, CFI = 0.99, TLI = 0.97, RMSEA = 0.05, 90% confidence interval [0, 0.113]. The results of the SEM are depicted in Figure 2, with a presenta-tion of the standardized estimates of the direct effects.

Table 3. Study 2 Sample Characteristics.

Variable N = 194

Age, M (SD) 31.72 (8.39)Family status % (N) Single 33.8% (54)

Married 40.6% (65)In a relationship 20.7% (33)Divorced 5% (8)

Place of birth % (N) Israel 88.1% (140)Other 11.9% (20)

Child abuse, M (SD) Physical abuse 9.38 (4.91)Sexual abuse 15.6 (5.73)Emotional abuse 13.62 (6.29)

PTS symptoms, M (SD) 3.09 (1.05)DSO symptoms, M (SD) 3.01 (1.09)

Note. PTS = posttraumatic stress; DSO = disturbances of self-organization.

Figure 2. Model testing the association between child abuse and chronic pain personification, and the mediation of PTS symptoms and DSO symptoms.Note. PTS = posttraumatic stress; DSO = disturbances of self-organization.

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The model yielded the following direct effects: As hypothesized, child abuse was significantly positively associated with PTS symptoms and with DSO symptoms. That is, the higher the level of child abuse, the higher the PTS and DSO symptoms. PTS symptoms were not significantly associated with pain personification. However, DSO symptoms were significantly asso-ciated with pain personification. A significant direct association was found between child abuse and pain personification (β = .14; p = .03). That is, the higher the level of child abuse, the higher the abusive personification of pain personification.

To examine the mediation of PTS symptoms and DSO symptoms in the association between child abuse and pain personification, a test of indirect effects was performed. The indirect effect between child abuse and pain personification through the mediation of PTS symptoms was not significant (p > .05). However, the indirect effect between child abuse and pain per-sonification through the mediation of DSO symptoms was significant (indi-rect effect = .71; p = .005), revealing that DSO significantly mediated this association.

The findings of this study reveal that child abuse is significantly associ-ated with abusive chronic pain personification. In addition, whereas PTS symptoms were not found to mediate the association between child abuse and pain personification, DSO symptoms were found to mediate this association. Taken together, the findings of Study 1 and Study 2 imply that child abuse may be implicated in the ways in which later chronic pain is personified. In addition, whereas DSO may be involved in the underlying mechanism of this association, PTS symptoms seem irrelevant to this process.

General Discussion

The findings of this study postulate new insights regarding the way women with a history of child abuse perceive, experience, and relate to later chronic pain. Particularly, the findings show significant associations between the experience of child abuse and the tendency to personify chronic pain as abu-sive. In addition, the findings imply that whereas PTS symptoms do not mediate the association between child abuse and pain personification, DSO symptoms do in fact mediate this association. These findings may denote the possibility that the relationship with the perpetrator is reconstructed, poten-tially projected onto the “relationship” with chronic pain.

The findings imply that the underlying mechanism of the link between child abuse and abusive personification of pain is embedded in DSO, including the three DSO symptoms. DSO symptoms reflect difficulties in self-organization, spanning over affective, cognitive, and interpersonal dimensions (Brewin et al., 2017; Cloitre, 2020). The current findings

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imply that self-disorganization may also be linked to bodily dimensions, as reflected in torturing personification. The experience of the body has been shown to be an inherent constituent of identity and self-in-relationships formation, with the embodiment of other person’s signals through neuro-logical mirror-matching mechanisms (Gallese, 2003; Lamm et al., 2011). Although such processes normally occur at early development within infant–caregiver relationships, alterations may take place following expo-sure to repeated interpersonal violence in older ages and during adulthood (Lahav et al., 2015; Mikulincer et al., 2011). Indirect support of such understandings may be seen in findings demonstrating that DSO symp-toms are linked with chronic pain prevalence (Teodorescu et al., 2015). However, more research is needed to clarify the link between DSO symp-toms and chronic pain in general, and pain personification in particular.

Interestingly, the current findings are different from previous findings, which found that PTSD mediated the link between exposure to interpersonal violence and pain personification (Tsur et al., 2017, 2020). Several explana-tions may explain these dissimilarities. In previous findings, abuse took place when the participants were adults and the abuse was not executed by a care-giver. As such, although the relationship between the capturer and the pris-oner of war reflects a complicated pathological bond, it is different from abuse that occurs with an attachment figure, one who is responsible for sup-plying the needs of the child and, most importantly, to protect the child from danger. In addition, previous investigations of chronic pain personification following trauma were conducted in a male sample, whereas the current stud-ies include only female participants. As such, it is possible that some of the differences are derived from the multifaceted factors that constitute gender differences and their link with the experience of the body following trauma (see “Diversity concerns” section).

Diversity Concerns

Several diversity matters should be considered when interpreting the results of the current investigation. First, the study was conducted within a sample of young adult women (Study 1), and in a sample of women all of whom were abused as a child (Study 2). Extensive literature pinpoints to the role of social forces, such as objectification (Calogero et al., 2011; Chow & Tan, 2018) and medicalization of women’s health (Purdy, 2001), as intervening in the way women experience their bodily signals. Indeed, previous investigations yielded mixed findings regarding gender differences in the way bodily sig-nals are perceived and interpreted. That is, some findings indicate that women tend to be higher in a catastrophic and frightful orientation toward the body

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(Keogh & Birkby, 1999; Sullivan et al., 2000). Nevertheless, other findings did not demonstrate such significant gender differences in orientation to bodily signals (Thompson et al., 2008). Further research is needed to clarify the complicated links between trauma, the experience of the body, gender, and social forces.

Alongside the interaction between social factors and gender, cultural matters may significantly intervene in the way individuals perceive and experience their body. It has been argued that the binary Western Cartesian dualistic perception of mind and body impedes the perception of the body as an integral part of the self (Mehling et al., 2009, 2012). As such, bodily manifestations are viewed on a functional bases, a “vehicle for self” that should be examined and treated solely in “objective” medical efforts, “clean” from psychosocial contaminates. Consumer culture and new media technologies are also suggested to play a role in the construction of the body and the way it looks in means of social status (Featherstone, 2010), the person’s “business card” (Orbach, 2019). Eastern cultures, on the con-trary, view the body, mind, cognition, and emotion as indistinctive entities, espousing a more integrative perception of human health and functioning (Chan et al., 2002). Future investigations should include cultural contexts and their effects on the link between trauma, the experience of the body, and pain personification.

Clinical Implications

Extensive literature uncovers the high comorbidity of PTSD and chronic pain (Asmundson & Katz, 2009; Lõpez-Martínez et al., 2014; Sharp & Harvey, 2001). Although widely documented, the underlying mechanism of this comorbidity is yet to be uncovered. The current findings propose a new direction for exploring the link between child abuse and pain percep-tion, potentially contributing to the illumination of its underlying mecha-nisms. In addition, the literature points to the significant role of pain perception for successful coping with chronic pain (Keefe et al., 1989; Sullivan, 2012), health-related quality of life (Keeley et al., 2008; McPeak et al., 2018), as well as chronic pain intensity (Peters et al., 2005; Roelofs et al., 2004). Considering the well-documented high risk for suffering from chronic pain following child abuse (Häuser et al., 2014; Kendall-Tackett, 2001; Sachs-Ericsson et al., 2007; Walsh et al., 2007), the current findings offer a new frame for targeting these processes among child abuse survivors. Taken together, this study may provide a new pathway for preventing and treating the multifaceted biopsychosocial derivatives of child abuse.

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Limitations

The findings of this study should be considered in light of several limita-tions. First, it should be noted that although well-validated measures were used in this study (Bernstein et al., 2003; Cloitre et al., 2018; Tsur et al., 2017), some bias may have resulted from self-reporting of child abuse his-tory and C/PTS symptoms. Second, the two studies were conducted in a single time-point, and therefore, one should be cautious with concluding causality. Third, one should consider the sample characteristics when inter-preting the results. Specifically, Study 1 and Study 2 are somewhat different with respect to the developmental stage of participants. However, although the age range in Study 2 was larger (age 18–60 years), the mean age was relatively young (M = 31.2; SD = 8.39), potentially resulting from recruit-ment method, as older adults may be less likely to engage in social media. Thus, future studies should account for men also, as well as elaborate on the potential intervening effect of age and developmental stages on pain per-sonification following child abuse. Finally, several additional factors may have affected the results. One such factor is the type of child abuse experi-enced. Notably, participants in Study 2 were recruited on the bases of expe-riencing child sexual abuse. As often reported in the literature (Debowska et al., 2017), participants in this sample also reported on exposure to emo-tional and physical abuse. Nevertheless, further elaboration on the type of abuse is encouraged. Additional important factors that should be tested are the age in which the abuse took place, chronicity of C/PTSD, as well as overall health.

Conclusion

Despite these limitations, this study provides a glimpse into an understudied phenomenon, pertaining to the personification of pain following child abuse. The findings imply that early interpersonal trauma is not merely a psychoso-cial phenomenon but is rather deeply carved within the perception and expe-rience of the body. As such, posttraumatic chronic pain should be viewed and treated as inherently linked with the experience of the abuse, rather than a physiological derivative. Future investigations should elaborate on the phe-nomenon of chronic pain personification following interpersonal violence, and its link with mental and physical health and well-being.

Acknowledgments

The author would like to thank Prof. Karni Ginzburg, Prof. Carmit Katz, and Prof. Golan Shahar for their contribution and generosity.

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Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publica-tion of this article.

ORCID iD

Noga Tsur https://orcid.org/0000-0001-9801-2234

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Author Biography

Noga Tsur, PhD, is a faculty member in the School of Social Work at Tel Aviv University. Her main research interest focuses on the subjective perception and orien-tation toward bodily signals following trauma. She also studies the link between chronic pain, trauma, and posttraumatic orientation toward bodily signals. She com-pleted her doctorate under the supervision of Prof. Karni Ginzburg in the School of Social Work, Tel Aviv University. She was a postdoctoral fellow in Prof. Golan Shahar’s Lab at Ben Gurion University, in Prof. Zahava Solomon’s Lab at Tel Aviv University, and Prof. Ellen Langer’s Lab at Harvard University.

, https://doi.org/10.( – ), –36 17 18 8538 8558.

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