ACEs and the Epidemiology of Psychophysiologic Disorders

A new paper (on-line only at the moment) (1) reports a prospective epidemiological study thaexamines the association between Adverse Childhood Experiences (ACEs) and the subsequent occurrence of painful medical conditions.  The role that mood and anxiety disorders play in this association is also carefully assessed.

The paper begins with a review of literature that reports the strong association between ACEs and subsequent painful medical conditions in adults in both prospective and retrospective studies.  This association persists throughout the life span.  The authors also report studies that associate ACEs with premature mortality and with inflammatory conditions including cardiovascular disease, diabetes and autoimmune disorders.  Another strong association they report is between ACEs and depression and anxiety that, like the others, persists across the life span.  Finally, they note that painful conditions, anxiety and depression are all linked to ACEs though the nature of their interaction has not been clear and that served as the rationale for this research.
Specifically, the authors are interested in whether depression/anxiety mediate or moderate the development of painful conditions.  The term mediation means ACEs cause the depression/anxiety which then leads to the painful condition.  Moderation means the depression/anxiety affect the pain independent of the effect of ACEs.  These interactions are not mutually exclusive and can be visualized as follows:
Mediation:     ACEs –> Depression/Anxiety –> Pain
Moderation:  ACEs –> Pain <– Depression/Anxiety
The data they report  come from two National Co-Morbidity Surveys done ten years apart using 158 experienced interviewers to assess 5000 people in their homes.  They recorded ACEs, criteria for depression and anxiety, and presence of painful conditions subsequent to the initial survey (either new onset or persistence of a prior condition).

To focus on the key results, they confirmed a linear association between the number of ACEs and the number of painful conditions.  People with 4 or more ACEs had twice as many painful conditions as those with no ACEs.  Strong associations were also found between ACEs and (in descending order by strength of association) PTSD, Depression, Social Phobia, Generalized Anxiety Disorder, Panic, and bipolar disorder.  Of people with 4 or more ACEs, over 40% had PTSD and over 40% had depression.
Using sophisticated statistical techniques, the authors looked for mediation and moderation effects.  They were able to show that Depression/Anxiety did function as a mediator for the effect of ACEs on the number of painful conditions.  That is, ACEs increased Depression/Anxiety which then led to a greater number of painful conditions.
When they looked for moderation effects they found a surprising result.  It turned out that ACEs led to an increased number of pain disorders primarily among those with a smaller number of mood disorders.  To express this another way, for those with high levels of ACEsthe subsequent development of mood/anxiety disorders contributed little to increasing the number of painful medical conditions.  
The authors speculate that individuals who experienced high levels of ACEs have limited reserve capacity from which to draw leading them to be more susceptible to painful medical conditions regardless of the presence or absence of anxiety/mood disorders. Thus, for those with high levels of ACEs, there is some ceiling effect such that the co-occurrence of mood/anxiety disorders does not substantially contribute to increased painful medical conditions.  The paper goes on to suggest that people with low levels of ACEs may have developed greater reserve capacity over time compared to those exposed to higher levels of ACEs.  However, when these individuals experience anxiety or mood disorders, their reserve capacity then becomes depleted, making the association between the anxiety/mood disorders and painful medical conditions stronger.
A question not yet answered by controlled trials is whether the long-term impact of ACEs can be lessened with treatment.  But my experience is that this can be done.  From 1984-2009 I interviewed over 4000 ACE survivors (2).  All were suffering from medically unexplained symptoms or a chronic functional syndrome.  Helping them to develop improved self-esteem, to recognize and then verbalize repressed emotions and to learn self-care skills was effective in relieving their symptoms.  In many cases this approach (along with related techniques) also led to improved outcomes for patients’ depression/anxiety, addictions, eating disorders, dysfunctional relationships and self-mutilation behavior.
The paper by Sachs-Ericsson et al is long and somewhat challenging to read but stands out for the prospective design, large sample size and high quality epidemiologic data.  Their findings confirm numerous other studies of ACEs, pain, depression and anxiety and their conclusions are well-supported by their data and other research.
1. Sachs-Ericsson NJ et al.  When Emotional Pain Becomes Physical: Adverse Childhood Experiences, Pain, and the Role of Mood and Anxiety Disorders.  J. Clin. Psychol. 00:1–26, 2017.  DOI: 10.1002/jclp.22444
2. Clarke, D. D.  Diagnosis and treatment of medically unexplained symptoms and chronic functional syndromes.  Families, Systems, & Health, Vol 34(4), Dec 2016, 309-316.  Special Section: Medically Unexplained Symptoms.

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