(Dr. Carol Burckhardt)
There is an increasing interest
in the role of childhood physical and sexual abuse as a cause of fibromyalgia (FM).
Beginning with two articles published simultaneously in Arthritis and Rheumatism,
the major research journal of the American College of Rheumatology, the debate over this
relationship has grown hot at times as researchers and clinicians have struggled with both
the data and their biases.
For openers, no one, for the most part, denies that abuse
occurs. Survey after survey confirms that a proportion of the adult population, both men
and women, has been abused during childhood. While percentages vary by type of sample, in
other words, community samples tend to have lower percentages than clinical samples, the
rates of sexual abuse range from 10% all the way up to 80-90% in some groups
(gastroesophageal reflux disease and irritable bowel syndrome). Physical abuse percentages
may be even higher depending on how the abuse is measured.
For the purposes of this essay, I will limit the discussion
to sexual abuse, primarily because it is generally recognized as the type of abuse that
produces the most long-standing sequelae. It is also the type of abuse for which there are
now standardized instruments for measurement, the most well-known of which is part of the
National Population Survey of Canada. The studies of FM patients have all used this
survey. That is an important point because one of the ways some people use to discredit a
study is to say that the instruments used to measure something are not reliable or valid.
They cant say that about any of the studies that have been published so far on FM
and sexual abuse or those that have been completed and are soon to be published.
First Ill summarize the findings of the two studies
that have been published. Taylor and colleagues (Arthritis and Rheumatism,
38:229-234) found that 65% of women with FM reported sexual abuse compared to 52% of
healthy controls. They also found that the abused group of FM patients reported more
symptoms such as pain, weakness, weight changes, and depression that did the FM patients
who had not been abused. Their conclusions were that sexual abuse was associated with more
severe symptoms of FM but didnt appear to be a causal factor.
Boisset-Pioro and colleagues (Arthritis and Rheumatism, 38:235-241)
found that 37% of their FM sample had experienced childhood sexual abuse compared to 22%
of their controls who were women with other rheumatic diseases. They concluded that there
was an association between FM and the severity of sexual abuse (e.g. multiple abuse
Several things are important to note about both of these
studies. First, they used clinical populations, that is, women who were seeking medical
care for their FM. So we can expect that the women were distressed enough by their FM
symptoms to seek care. Second, we know that people who have had many stressors in their
lives or who have psychiatric disorders are more likely to seek treatment and that they
are more likely to come from dysfunctional families where abuse is more likely to occur
(especially families in which a parent has alcoholism). Third, neither study provides any
proof of a causal relationship between sexual abuse and FM. This is a very important point
because recently there have been attempts by some professionals to say that sexual abuse
causes FM. There is no way that anyone could even begin to prove a causal link between
abuse and FM without doing very long-term studies of children who were watched over many
years to see who was abused and who developed FM as adults.
There is some very fascinating research underway in related
fields that may begin to shed some more light on this apparent relationship. Recently some
researchers in the area of gastrointestinal disorders (American Journal of Medicine, 97:108-118)
found that patients with these disorders who had been abused were also more likely to have
abnormal pain perception and environmental stressors. They also tended to blame themselves
for their pain.
Another body of research that is emerging and was
summarized in Scientific American (October, 1995) concerns brain changes in the
hippocampus part of the brain in patients who had suffered severe abuse. The researchers
hypothesize that changes in the hippocampus which deals with short-term and long-term
memory may be due to the flooding of that part of the brain with cortisol which is
released during stressful events.
Now perhaps I am making a large leap here, but it just
might be possible that childhood sexual abuse as a stressor may make some vulnerable
people more susceptible to brain changes in the pain perception parts of the brain.
Evidence is beginning to accumulate in FM research that there are changes in pain
perception in patients with FM and that there are brain changes in these patients also.
Thus, it is possible that childhood sexual abuse could be one of the factors that causes
FM through its effects on the hypothalamus-pituitary-adrenal axis which controls the
output of cortisol and other hormones. Obviously, there is no evidence that abuse alone
causes any disease or syndrome. However, it may be an significant factor for some
Whether or not sexual abuse is causally related to FM, it
is critical that patients with FM who have been abused recognize the possibility that
abuse history may contribute to their overall distress, self-blame, feelings of
powerlessness and lack of control. Lori Kondora, a nurse who interviewed adult women who
had been sexually abused as children (Health Care for Women International, 16:21-30),
found that while many women experienced low self-esteem, depression, addictive behaviors,
anxiety, pain and eating disorders, some women also experienced resilience, independence,
creativity, a deeper spirituality, and personal strength. Remembering was central to the
beginning of the healing process and telling their stories to others enhanced that