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This is an Accepted Manuscript of an article published in Psychology, Health & Medicine,
available online:
http://www.tandfonline.com/doi/full/10.1080/13548506.2015.1111393
Citations details of this paper:
Rzeszutek, M., Oniszczenko, W., Schier, K., Biernat-Kałuża, E., Gasik, R. (2015). Sex
differences in trauma symptoms, body image and intensity of pain in a Polish sample of
men and women suffering from chronic pain. Psychology Heath & Medicine. Advanced
online publication:
DOI: 10.1080/13548506.2015.1111393
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RUNNING HEAD: Trauma symptoms, body image & chronic pain
Sex differences in trauma symptoms, body image and intensity of pain in a Polish sample of
patients suffering from chronic pain
Marcin Rzeszutekª*, Włodzimierz Oniszczenkob, Katarzyna Schierb, Edyta Biernat-Kałużac,
Robert Gasikd
ªFaculty of Management and Finance, University of Finance and Management, Pawia 55, 01-
030, Warsaw, Poland, Tel: +48 22 53 65 430, Fax: +48 22 53 65 496,
e-mail: rzeszutek@vizja.pl
bFaculty of Psychology, University of Warsaw, Stawki 5/7, 00-183, Warsaw, Poland, Tel: +48
22 55 49 805, Fax: +48 22 63 57 991, e-mail: wlodek@psych.uw.edu.pl, kas@psych.uw.edu.pl
cORLIK Outpatient Clinic, Ostrobramska 101, 01 – 041,Warsaw, Poland, Tel: +48 22 46 56 660,
e-mail: edyta.bk@wp.pl
d Neuroorthopaedic Department, Institute of Rheumatology, Spartanska 1, 02-637,Warsow,
Poland, Tel:+48 22 844 42 4, e-mail: robert.gasik@ir.ids.pl
*To whom correspondence should be addressed
Faculty of Management and Finance, University of Finance and Management, Pawia 55, 01-030,
Warsaw, Poland, Tel: +48 22 53 65 430, Fax: +48 22 53 65 496,
e-mail: rzeszutek@vizja.pl
Acknowledgements
The work was supported by funding from the Faculty of Psychology, University of Warsaw
(BST 1712.01) awarded to the third author. The authors declare no conflict of interest.
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Abstract
The main goal of the current study was to investigate sex differences in the relationship between
the level of trauma symptoms appearing in posttraumatic stress disorder (PTSD) and intensity of
pain in a sample of 300 Polish patients suffering from chronic pain, specifically rheumatoid
arthritis and lower back pain. We also focused on participants’ body image with body esteem as
a mediator. To assess the intensity of pain among participants, we used the Numerical Rating
Scale (NRS-11). The level of trauma symptoms was assessed with the PTSD Factorial Version
Inventory (PTSD-F). To measure body image among participants, we used the Body Esteem
Scale (BES). The results of our study suggest that trauma symptoms and body image dimensions
were significant predictors of pain intensity among men suffering from chronic pain. Moreover,
trauma symptoms and age were significant predictors of pain intensity among women suffering
from chronic pain. Finally, we demonstrated that sex differentiates the reaction to chronic pain.
Keywords: chronic pain, trauma symptoms, body image, sex
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Sex Differences in Trauma Symptoms, Body Image, and Intensity of Pain in a Polish
Sample of Patients Suffering from Chronic Pain
Introduction
Chronic pain, defined as a persistent and recurrent pain lasting longer than three to six
months and continuing despite the healing of body tissues (IAEP, 1994), is a severely harmful
experience, which often predisposes an individual with chronic pain to psychiatric disorders,
such as sleep disorders (Smith & Haythornthwaite, 2004), depression (McWilliams et al., 2003),
and trauma symptoms such as those appearing in PTSD (Sharp & Harvey, 2001). On one hand,
chronic pain is one of the most commonly reported physical health complaints among people
who have experienced traumatic events (Gonzalez et al., 2013). On the other hand, other authors
have found that trauma symptoms in chronic pain patients may be linked to overwhelming pain,
precluding normal social functioning, causing disability and functional limitations, and posing a
risk of premature death (Beck & Clapp, 2011; Rzeszutek et al., 2015).
Body image is a multidimensional construct, defined as the mental representation of
one’s own body, which includes body-related self-perceptions and self-attitudes, such as
thoughts, feelings, beliefs, and behaviours (Cash & Pruzinsky, 2002). One of the important
elements of body image is body esteem, which refers to the affective dimension of the body
image (Franzoi & Shields, 1984). Body image, and body esteem in particular, may be related to
many psychiatric disorders, including eating disorders (Rayner et al., 2013), depression
(Jonsdottir et al., 2008), as well as PTSD (Weaver et al., 2014). In addition, experiences of
trauma can contribute to various disorders in terms of the perception and self-evaluation of one’s
body (Castle & Philips, 2002). Similarly, individuals suffering from chronic diseases
accompanied by pain display negative attitudes towards their bodies, for example, body
dissatisfaction or alienation (Bode et al., 2010).
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Women are more likely to be traumatised than men and are thus approximately twice as
likely as men to suffer from PTSD (Tolin & Foa, 2006). Alternately, although some authors have
observed a higher prevalence of chronic pain and greater pain sensitivity in women than in men
(Garcia et al., 2007), there are no unambiguous data on sex differences in regard to responses to
pain (Etherton et al., 2014). Finally, studies on sex differences in terms of body esteem are also
inconclusive. On one hand, women are found to be more dissatisfied than men with their
physical appearance (i.e. they are dissatisfied with their weight) (Grogan, 2007). However, other
studies have indicated that men are equally dissatisfied with their body weight (Lokken et al.,
2003).
Current Study
The main goal of the current study was to investigate sex differences in the relationship
between the level of trauma symptoms and intensity of pain, which was treated as the explained
variable, in a sample of 300 chronic pain patients while controlling for participants’ age and pain
duration. We also focused on participants’ body image with body esteem as a mediator. Due to
the exploratory nature of the research and the lack of unequivocal data in the existing literature
connecting sex differences to trauma symptoms, body image, and chronic pain, we did not
formulate formal hypotheses. Once again we want to underline the fact that our study is strictly
exploratory in nature.
Material and Methods
Participants and Procedure
The sample was comprised of 300 Polish patients suffering from chronic pain
(rheumatoid arthritis and low-back pain), recruited from the Institute of Rheumatology in
Warsaw and the Military Institute of Medicine in Warsaw. The sample was heterogeneous in
terms of pain cause and diagnosis because the main purpose of our study was to analyse
participants’ subjective experience of chronic pain as described by the biopsychosocial model of
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chronic pain, which views chronic pain not as a particular physical disease but as an ongoing
multifactorial process influenced by physical and psychosocial factors (Gatchel, 2007). This was
an anonymous, cross-sectional study, and participation was voluntary. Participants were asked to
complete a paper–pencil version of the measures. Table 1 presents basic demographics and
clinical data including pain, trauma and body image separately for men and women.
[Insert Table 1 about here]
Measures
To assess the intensity of pain among participants, we used the NRS-11, which measures
11 degrees of pain intensity on a scale from 0 to 10. The NRS-11 is a standard tool used in
research on chronic pain, with proven clinical relevance (Page et al., 2012).
To measure the level of trauma symptoms and traumatic events that patients experienced
in the past and could potentially lead to PTSD according to the DSM-IV (APA, 1994), we used
the PTSD-F (Strelau et al., 2002). This inventory contains 30 items, which are divided into three
scales: Intrusion/Arousal (15 items), Avoidance/Numbing (15 items), and a Global Trauma
Score (all items). The PTSD-F has satisfactory psychometric properties: the Cronbach’s α for the
Intrusion/Arousal scale, the Avoidance/Numbing scale, and the Global Trauma Score were .96,
.92 and .93, respectively.
To measure body image among participants, we used the BES (Franzoi & Shields, 1984).
This scale consists of 35 items that refer to the affective dimensions of body image. The BES
distinguishes three dimensions of body image separately for men (Physical Attractiveness, Upper
Body Strength, and Fitness) and for women (Sexual Attractiveness, Weight Control, and
Fitness). The tool has good psychometric properties—the Cronbach’s α reliability coefficient for
the men’s subscales were between .81 and .86 while for the women’s subscales they ranged from
.78 to .82.
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Results
Tables 2 and 3 present correlation coefficients between duration of pain, age, the PTSD-F
scales, the BES scales, and the level of pain among men and women suffering from chronic pain.
[Insert Table 2 about here]
[Insert Table 3 about here]
Table 4 shows that significant predictors of pain intensity among men were the Global
Trauma Score and body image dimensions. Significant predictors of pain intensity among
women were age and the Global Trauma Score (Table 5).
[Insert Table 4 about here]
[Insert Table 5 about here]
Figure 1 displays the mediation analysis following Baron and Kenny (1986). To assess
for mediation, the Sobel test was performed. The results indicate that the Fitness body image
scale (Z=2.466, p=0.013) as well as the Upper Body Strength body image scale (Z=2.456,
p=0.014) were significant, partial mediators of the link between the Global Trauma Score and
pain intensity among men.
[Insert Figure 1 about here]
Table 6 demonstrates that the sex of participants moderates the link between their Global
Trauma Score and pain intensity.
[Insert Table 6 about here]
Figure 2 indicates a positive relationship between trauma symptoms and pain intensity
among men and women with chronic pain. However, among men, the Global Trauma Score
explained approximately 26% of the variance in pain intensity (8% among women).
[Insert Figure 2 about here]
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Discussion
This study demonstrated that body image in terms of body esteem was negatively related
to the intensity of pain, but only among men, which was an intriguing finding. In men, body
image is closely connected to physical state, and men are thus able to control pain via physical
activity (Schier, 2010; Zając & Schier, 2011). Our results show that the role of body image
should be analysed in the context of optimal coping strategies differently for men and women.
Furthermore, we were surprised to find that the relationship between trauma symptoms
and pain intensity was stronger among men than among women as women are more likely to be
traumatised than men (Tolin & Foa, 2006). However, some authors have also observed greater
levels of posttraumatic symptoms and pain intensity in men than in women (Hart-Johnson &
Green, 2012; Spertus, 1999).
Finally, we observed that age correlated positively with intensity of pain, but only among
women, which was unexpected, as increasing age has been reported as a predictor for chronic
pain for both sexes (De Palma et al., 2011). Nevertheless, Cederbom et al. (2014) found greater
pain-related disability among older women, which may be linked to a high level of
catastrophising, which increases with age. In addition, female mean age was 50+, so menopausal
status might be important for their body and pain perception (Roberto & Reynolds, 2002).
Our study is not free of limitations. First, we did not provide a thorough assessment of
pain, especially pain location or pain treatment. Second, the cross-sectional design of the study is
limited for understanding causal processes and delineating the mediation mechanisms. Finally,
important covariates have not been taken into account, like marital and socioeconomic status,
past and current history of depression, or sleep problems. Despite these limitations, our research
adds to the literature by examining sex differences in the relationship between trauma and
chronic pain, including body image as a mediator. Trauma symptoms and body image should be
taken into account in psychotherapy accompanying pharmacotherapy of chronic pain.
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Tables
Table 1.
Demographic Characteristics, Data on the Course of Chronic Pain, the Level of Trauma Symptoms,
Information about the Traumatic Experiences from the Participants’ Past, and Body Image Dimensions in
the Sample of Men (N = 109) and Women (N = 191) Suffering from Chronic Pain.
Variables
Male (N = 109)
Female (N = 191)
Age
Range
M
SD
19-83
50.50
15.48
19-84
53.10
14.23
Pain intensity
Range
M
SD
0-10
6.33
2.16
0-10
6.66
1.84
Duration of pain (months)
Range
M
SD
4-768
166.39
143.93
4-660
145.78
125.02
Trauma symptoms
Intrusion/Arousal
Avoidance/Numbing
Global Trauma Score
M (SD)
34.95 (9.66)
35.01 ( 8.66)
69.95 (18.02)
M (SD)
36.21 (8.08)
34.27 (9.34)
70.48 (16.10)
Traumatic experiences from the
past
14
Death of a close person
Car accident
Accompanying life threatening
illness
Life threatening illness of close
relative
No answer
12
18
34
16
29
31
16
53
8
83
Body image dimensions M (SD)
Physical attractiveness 35.71 (9.91)
Upper Body Strength 28.01 (8.33)
Fitness 39.14 (11.86)
-
-
-
-
-
-
Sexual attractiveness 42.09 (11.29)
Weight control 28.96 (9.26)
Fitness 25.33 (7.95)
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Table 2.
Correlation Coefficients (Pearson’s r) Between Duration of Pain, Age, the PTSD-F Scales, the BES
Scales, and the Level of Pain Among Men Suffering From Chronic Pain (N=109).
Pain intensity
Duration of pain (months)
.06
Age
.11
Trauma symptoms
Intrusion/Arousal
.52**
Avoidance/Numbing
.47**
Global Trauma Score
.52**
Body image dimensions
Physical Attractiveness
-.42**
Upper Body Strength
-.40**
Fitness
-.48**
Note: ** p < .01.
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Table 3.
Correlation Coefficients (Pearson’s r) Between Duration of Pain, Age, the PTSD-F Scales, the BES
Scales, and the Level of Pain Among Women Suffering From Chronic Pain (N=191).
Pain intensity
Duration of pain (months)
.01
Age
.18*
Trauma symptoms
Intrusion/Arousal
.32**
Avoidance/Numbing
.24**
Global Trauma Score
.30**
Body image dimensions
Sexual Attractiveness
-.13
Weight Control
-.06
Fitness
-.08
Note: * p < .05; ** p < .01.
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Table 4.
Hierarchical Regression Analysis of Global Trauma Symptoms and Body Image Dimensions as a
Predictor of the Level of Pain Among Men Suffering From Chronic Pain (N=109).
Model
F
F Δ
R
R²
Predictor
Semipartial
correlation
Global Trauma
Score
38.39 (a)***
-
.51
.26
Global Trauma Score
.51***
+ Physical
Attractiveness
Upper Body
Strength
Fitness
16.07 (b)***
6.62***
.62
.38
Global Trauma Score
Physical
Attractiveness
Upper Body Strength
Fitness
.35***
-.08
-.15*
-.26**
Note: (a) df = 1/107, (b) df = 3/104, *** p < .001; ** p < .01; * p < .05.
18
Table 5.
Hierarchical Regression Analysis of Demographic Variables (Age), Global Trauma Symptoms and
Body Image Dimensions as a Predictor of the Level of Pain Among Women Suffering From Chronic
Pain (N=191).
Model
F
F Δ
R
R²
Predictor
Semipartial
correlation
Age
6.29(a)*
-
.18
.03
Age
.18*
+Global Trauma
Score
10.22 (b)***
13.73***
.31
.09
Age
Global Trauma Score
.10
.26***
Note: (a) df =1/ 188, (b) df =1/187; *** p < .001; * p < .05.
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Table 6.
Hierarchical Regression Analysis of Participant’ Sex as Moderating the Link Between the Level of Global
Trauma Score and the Intensity of Pain Among the Studied Sample (N=300).
Model
F
F Δ
R
R²
Predictor
Semipartial
correlation
+ Sex
Global Trauma
Score
27.59(a)***
-
.40
.16
Sex
Global Trauma
Score
-.07
.39***
+ Sex
x
Global Trauma
Score
20.27(b)***
4.90*
.41
.17
Sex
Global Trauma
Score
Sex
x
Global Trauma
Score
-.13*
.40***
.12*
Note: (a) df = 2/297; (b) df = 3/296; * p <.05; ***p<.001.
20
Note: *** p < .001. ; ** p < .01
Figure 1.
Relationship Between Global Trauma Score and the Intensity of Pain among Men Suffering from
Chronic Pain as Mediated by the Fitness and Upper Body Strength Body Image Scale.
Global Trauma
Score
Pain
Intensity
Body
image
-.39***
-.33***
.52*** (.38***)
Body image (Fitness)
Body image (Upper Body Strength)
-.37***
-.24**
.52*** (.42***)
21
Figure 2.
The Intensity of Pain as a Function of Global Trauma Score in Men and Women
Suffering From Chronic Pain
Trauma symptoms
Pain intensity
females
males
females
males
