When past pain shapes the present body
IN PARTNERSHIP WITH UNLIKELY COLLABORATORSIllustrations by Jon McCormack
by Laura Onstot
Editor’s Note: This article explores some difficult and sensitive topics that may not be suitable for younger readers. We encourage thoughtful consideration and suggest reviewing the content before sharing it with children or younger audiences, as it may bring up challenging themes.
As a nurse, my mind is accustomed to the confines of the medical world. I like things that can be measured and quantified: lab values, medication doses, anatomical abnormalities. What makes me more nervous – what makes most healthcare providers nervous – is the unseeable.
Jon McCormack
Given my background, it’s not surprising that, until recently, I packaged each of my mental and physical health diagnoses into separate little boxes. Sure, I had migraines and polycystic ovarian syndrome, but those had nothing to do with my PTSD or depression. I assumed that while a person could have both mental and physical health ailments, they should be treated by different specialties, with little overlap.
It wasn’t until I left the confines of medicine and attended the 2024 Innovations in Psychotherapy conference as a grad student in licensed mental health counseling that I began to understand how limiting – and dangerous – my views had been.
Adverse Childhood Events
Dr. Nadine Burke Harris, a pediatrician and former Surgeon General of California, delivered the keynote address. She explained that childhood trauma doesn’t just affect mental health – it affects physical health too. She introduced the term ACEs (adverse childhood events), which include things like abuse, violence at home, or living with substance abuse or mental illness. ACEs are negative experiences that can change not only a child’s perception of the world and safety, but also the chemical, hormonal, and genetic makeup of their body.
Dr. Burke Harris didn’t coin the term ACEs; in fact, her work was based on research she discovered from the 1990s. Yes, back in the days when I was sporting a red fanny pack and blister-covered feet from my jelly sandals. The nineties were also when I began experiencing stomach pain and a reduced appetite that even concerned my “no need to go to the doctor unless you’re actively dying” parents.
It all began in 1985, when Kaiser Permanente’s chief of the Department of Preventive Medicine, Dr. Felitti, was investigating why patients in an obesity trial were dropping out, despite losing weight. By the end of his interviews with 286 dropouts, his team discovered that around 55% had been sexually abused as children. Whether they were conscious of their motivations or not, weight was a protective mechanism for them.
Jon McCormack
These staggering numbers inspired the epidemiological ACE study, which began in 1995. Rather than just looking at one adverse childhood experience (sexual abuse), The Adverse Childhood Experiences (ACE) Study looked at the most common adverse experiences: “psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned.” They found that as a person’s number of ACEs increased, so did their risk for: alcoholism, drug abuse, depression, suicide attempts, smoking, STDs, and obesity. They were also at risk of coronary artery disease, cancer, chronic lung disease, skeletal fractures, and liver disease.
If you’re curious about your own ACE score, NPR has an easy-to-take quiz. Their article reminds us that while an ACE score can provide helpful data about risk factors, it can’t predict the future, and it also doesn’t take into account positive early life factors that may be protective.
As Dr. Burke Harris explains in her TED talk, exposure to trauma early in life impacts the developing bodies and brains of children, changing brain structures like the nucleus accumbens (pleasure/reward center– think substance dependence), the prefrontal cortex (impulse control and executive function- think ADHD, or the ability to keep a room clean), and the amygdala (fear response).
Connection between ACEs and Chronic Pain
To begin to understand the connection between adverse childhood events and chronic pain conditions, you must understand the biology of stress. Dr. Burke Harris has a helpful analogy: Imagine you are out in the forest, and you come upon an angry bear. Immediately, your body will go into a fight-or-flight response. Your stress hormones will rise, and your immune system kicks into overdrive as your body prepares to fight the germs from a scratch or, more likely, a tooth puncture. This mechanism is vital for survival – and it is a good thing, as long as the “bear” doesn’t live at your house. If the bear follows you home every day, you will experience toxic stress.
Toxic stress is the biological response that occurs when a person is exposed to prolonged adverse events, causing a continual activation of the body's hormonal, inflammatory, chemical, and genetic stress response systems.
I asked Dr. Anto, a pediatric neurologist and researcher at Children’s Hospital of Philadelphia, to explain the biology behind why a higher ACE score can lead to increased development of migraines. She began by explaining the hypothalamic pituitary adrenal axis (the HPA axis) – a communication system our body uses to regulate stress hormones. She said, “Having exposure to an ACE early on increases the amount of toxic stress that a child experiences, and it kind of affects how that system [HPA axis] develops, and it can lead to a whole cascade of immunological as well as inflammatory downstream processes that affect how people develop chronic medical conditions.” She mentioned these early toxic stressors likely also affect the development of pain modulation systems in the brain.
When I caught Dr. Burke Harris for a quick Zoom interview, she brought up the ventral tegmental area. “With individuals who have experienced high doses of adversity, we see changes to the structure and function of those brain cells [ventral tegmental area], so that individuals experience less pleasure or less relief with the same dose of the endorphins. One of the ways that you see this, is increased risk of substance dependence, right? Higher and higher and higher doses of substances like opiates [are required] to get the same effect, and that's part of the reason why we see an individual with four more ACEs is 10 times as likely to develop opioid dependence than as a person with zero aces.” And the other way you see it play out is in people who exhibit high levels of thrill-seeking.
As Dr. Burke Harris summed it up, the connection between childhood adversity and chronic pain results from a combination of factors: changes in the structure and function of the brain, inflammatory system, and hormonal system. And unfortunately, not only are people who have higher ACE scores more likely to experience chronic pain, but they are also more likely to not get effective pain relief from both internal systems (endorphins) and external systems (opioids).
The science is complex, and this article only covers a snowflake on the tip of the iceberg. If you are interested in learning more, I would recommend watching Dr. Burke Harris’ viral TED talk, reading her book The Deepest Well, or checking out the CDC’s info page on ACEs.
Unpacking beliefs, finding new ground
In medicine, we have a tendency to blame the patient, saying things like, “She got diabetes because she was lazy and didn’t cook nutritious meals.” Or, “She’s a drug addict, so I doubt her shoulder actually hurts. She’s probably just seeking pain meds.” Or my favorite from floor nursing, “He tried to die on me.” There are common refrains I hear among lay people too: “She’s sick all the time.” Or, “She’s probably just using that migraine as an excuse.”
Dr. Burke Harris’ presentation introduced another possibility: It was not the patient’s fault. Perhaps the risk for diabetes began in childhood, when they were exposed to a stress so toxic that their body was chronically flooded with stress hormones, changing their brain structures and functions. It made so much sense, and it was something I had never once heard about in my seven years as a nurse.
My interest in this topic is personal. As a child, I had multiple “bears” follow me home every day. When I developed migraines, I assumed it was because I was weak – a message I absorbed from my upbringing. When I heard Dr. Burke Harris present, I realized the story I had been telling myself was wrong: I am not weak. The chronic stress hormones that flooded me as a child impacted the way my brain and body developed.
In my pediatric nursing class, the resounding mantra was, “Kids are so resilient.” And they are. Their bodies are capable of adapting to survive situations that many adults wouldn’t be able to. But reading this research and talking to the experts reminded me of a more ominous undertone: Toxic stress can literally impact how their body develops. It changes the brain and hormones, and can leave a person to live their lifetime in a body that pays the consequences for simply surviving.
This research gave me the peace of recognizing I can get rid of the BS narrative that I’m broken. My body adapted in incredible ways to survive. And it diminished that helpless feeling I get when I think about my migraines. I’ve been able to incorporate practices like yin yoga, meditation, and getting rid of caffeine to help level out my cortisol levels and reduce the frequency of my migraine attacks. Most importantly, this research gave me power – something I didn’t have as a child.
Five things you can do to help manage pain:
Somatic Therapy: Focuses on body awareness, helping you release stored tension and trauma to reduce pain and stress. (See our Somatic Mindfulness video series.)
Parts work / inner child work / Internal Family Systems therapy: Helps you understand and heal different parts of yourself that might be holding onto pain or trauma, creating a sense of balance and relief.
Mindfulness and meditation: Practices that can help you manage stress, lower anxiety, and improve your ability to cope with pain.
Gentle physical movement: Practices like Yoga and Tai Chi can improve body awareness, flexibility, and reduce pain by releasing physical tension.
Grounding techniques: Simple practices like deep breathing or focusing on your senses can help reduce the emotional intensity of pain and reconnect you to the present moment.
Laura Onstot is a freelance writer who specializes in mental health and parenting essays, investigative journalism, and interview articles. She transitioned her career from research nursing to freelance writing to stay at home with two children. As a registered nurse of over 10 years and a mom of 7 years, Laura uses her personal experience to ensure content hits the heart of the matter.
Jon McCormack is a Dublin-born illustrator with experience in editorial, advertising, and publishing. Storytelling and atmosphere are pivotal to his work, with inspiration derived from cinema, queer culture, sequential art, and absurd humor.