Research has shown that trauma may not cause chronic pain, but it does make people more susceptible to developing chronic pain. People with chronic pain typically have at least double the rate of previous trauma as compared to the general population. The US Department of veterans Affairs has found that 15% to 35% of patients with chronic pain also have Post Traumatic Stress Disorder (PTSD).
What is trauma?
Before we can understand how trauma is linked to chronic pain, we need to understand what trauma is. Trauma can be defined as, “an event, series of events, or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening with lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” Principally a traumatic event is one which is potentially life threatening and which overwhelms the body’s natural coping mechanisms.
As a result of trauma individuals may suffer from a range of mental health conditions including post-traumatic stress disorder (PTSD), anxiety and depression.
The link between mind and body
The mind and body are connected and can influence each other in many ways. Stress and pain can create and perpetuating cycle. There are many ways in which stress worsens pain, including causing tense muscles and increasing inflammation. Trauma can cause stress, therefore contributing to the pain and stress cycle.
This means that when people experience a trauma which takes an emotional toll, it can also have physical effects. This doesn’t make chronic pain any less valid or mean that it’s ‘all in your head’ as stigma so often dictates. All pain is created by the brain. Chronic pain is just as valid as acute pain or any other physical health condition.
Symptoms of PTSD which can influence chronic pain
Patients with PTSD may experience a wide range of symptoms. Some of these symptoms can be linked to chronic pain, and many can have an influence on pain levels.
- Re-experiencing
Re-experiencing means that patients who have experienced trauma may ‘re-live’ aspects of their trauma, such as physical feelings, sights, sounds and smells, or emotions, as though they are actually happening again. This is involuntary and highly distressing.
When people re-experience their trauma, they are usually in a heightened emotional state, often in ‘fight, flight or freeze’. Consistently experiencing a heightened stress response can cause and exacerbate chronic pain.
- Disturbed sleep
Patients who have experienced trauma often find it difficult to have a restful sleep. This is often due to re-experiencing their trauma through nightmares. Those with chronic pain also tend to struggle with insomnia and non-restorative sleep. Lack of sleep can exacerbate chronic pain symptoms and make it harder for patients to cope effectively.
- Hypervigilance
People with PTSD may be easily startled, always on the lookout for potential danger (also known as hypervigilance). They can be very anxious and find it difficult to unwind. Hypervigilance can cause very tense muscles which can exacerbate chronic pain.
Pain hypervigilance is a common symptom of chronic pain and can strengthen the pain response. By being hypervigilant about pain, the brain is receiving feedback that it should continue producing pain messages. Since people with PTSD are already hypervigilant, they’re more likely to also become hypervigilant about their chronic pain.
- Inability to regulate emotions
The brain regions that regulate emotions, form memories and help focus attention, also help process and regulate pain. People with PTSD often have difficulty regulating emotions, especially distressing emotions. These difficulties can lead to maladaptive (unhelpful) coping behaviours. Research has shown that maladaptive coping behaviours worsen chronic pain and perpetuate the chronic pain cycle.
- Depression and anxiety
Depression and anxiety are often experienced alongside PTSD and as a symptom of chronic pain. People may struggle to practice good self-care or proactively manage their pain when they are in a negative mental state. Symptoms of depression can also exacerbate or lead to increased pain and impaired function (Morasco et al., 2013).
Anxiety has been found to be the most significant factor linking PTSD and chronic pain (Brennstuhl, Tarquinio & Montel, 2014) Hyperarousal and anxiety may make chronic pain patients more likely to develop catastrophising and fear avoidance behaviours. Catastrophising means that people are more likely to think negatively and worry excessively about their pain, which contributes to high stress levels. Fear avoidance means that chronic pain patients avoid activity for fear of worsening their pain symptoms. Avoidance of activity can cause the body to become deconditioned and lose fitness. This makes it more painful when people try to be active.
What treatments are available?
Psychological therapies are available which can treat mental illness and deal with trauma. There are many psychological therapies which are also very effective for chronic pain. A multidisciplinary approach to treating both trauma and chronic pain can bring highly effective outcomes for patients, giving them relief from both physical and mental symptoms.
Below are some of the therapies which may be suggested to treat trauma and chronic pain.
- Cognitive Behaviour Therapy (CBT)
CBT is a talking therapy which has proven results for both chronic pain and PTSD. The aim of the treatment is to change maladaptive thoughts and behaviours that serve to maintain and exacerbate the experience of both chronic pain and PTSD. Patients have demonstrated benefits from CBT techniques (exposure therapy, pacing, and activity scheduling) to alleviate both conditions (Shipherd et al., 2003). There is robust evidence that CBT is effective for PTSD. CBT helps to change unhelpful thinking and behaviours that are contributing to emotional difficulties.
At the Centre for Clinical Psychology we use Cognitive Processing Therapy (a form of CBT) to help people with PTSD and pain. CPT has been shown to improve physical functioning in those with chronic pain and other physical difficulties ( Song et al., 2020).
Pain management programmes
Pain management programmes aim to treat both mind and body. Psychological therapies are often an aspect of pain management programmes. When these therapies are combined with more manual treatments such as physical therapy, symptoms can be markedly reduced.
- Mindfulness
Mindfulness can help to reduce stress and regulate emotions, in turn reducing chronic pain symptoms. This helps to keep stress levels low and can help to deal with re-experiencing if you struggle with the effects of trauma.
If you are suffering from trauma and pain one of our clinical psychologists may be able to help.
References
Morasco, B. J., Lovejoy, T. I., Lu, M., Turk, D. C., Lewis, L., & Dobscha, S. K. (2013). “The relationship between PTSD and chronic pain: mediating role of coping strategies and depression.” Pain, 154(4), 609–616.
Brennstuhl, Marie-Jo & Tarquinio, Cyril & Montel, Sebastien. (2014). “Chronic Pain and PTSD: Evolving Views on Their Comorbidity.” Perspectives in Psychiatric Care. 51. 10.1111/ppc.12093
Murray J. McAllister, PsyD, (2017), “Trauma”. Institute For Chronic Pain.
PTSD: National Center for PTSD, (2019), “Chronic Pain and PTSD: A Guide for Patients”. U.S. Department of Veterans Affairs.
Shipherd JC, Beck JG, Hamblen JL, Lackner JM, Freeman JB. A preliminary examination of treatment for posttraumatic stress disorder in chronic pain patients: a case study. J Trauma Stress. 2003 Oct;16(5):451-7. doi: 10.1023/A:1025754310462.
Song, J., Johnson, C., Suvak, M. K., Shields, N., Lane, J., Monson, C. M., & Wiltsey-Stirman, S. (2020). Patterns of change in physical functioning and posttraumatic stress disorder with cognitive processing therapy in a randomized controlled implementation trial. European journal of psychotraumatology, 11(1), 1801166. https://doi.org/10.1080/20008198.2020.1801166
