Trauma and Chronic Pain are difficult to live with; they often occur together and exacerbate each other. This can make recovery more difficult and your experience with each condition worse. Some treatments can bring healing and reduce your suffering for both conditions.
How Trauma Can Influence Chronic Pain
Trauma and Chronic Pain can influence each other. Chronic pain is reported in 20 to 80% of individuals with a history of trauma. Additionally, 10 to 50% of individuals with PTSD report chronic pain.
People with chronic pain and a history of trauma tend to have worse functional status, report greater distress, and demonstrate worse responses to medical intervention. Similarly, worse PTSD symptoms in people with chronic pain are associated with higher levels of pain, disability, and psychological distress raising the possibility that the conditions may negatively influence each other. The presence of chronic pain and PTSD increases symptom severity in both conditions.
What Can Cause Chronic Pain and PTSD-like Symptoms?
The types of events and experiences that negatively affect chronic pain and PTSD-like symptoms are not confined to the traumatic events that meet the Criterion A qualification of the PTSD diagnosis. For a traumatic event to qualify for Criterion A there needs to be exposure to actual or threatened death, serious injury, or sexual violence and there are some qualifications for that exposure, such as directly experiencing or witnessing the event as well as some other qualifications around exposure of a traumatic event happening to a close family member or friend or exposure through a non-optional situation such as employment (such as dealing with human remains, crime scene photos). Individuals who react with fear, a perceived threat to survival, or react with horror to events below the Criterion A Threshold may still develop PTSD-like symptoms and have effects on their chronic pain or the development of chronic pain.
Adverse Childhood Experiences (ACEs)
When we are threatened, our bodies have what is called a stress response, which prepares our bodies to fight or flee. If an adult does not provide a calming influence to a child after an adverse experience (also called co-regulation), toxic stress can occur and damage crucial neural connections in the developing brain. This is because children often have not developed the skills to self-regulate and are reliant on adults for protection and to fulfil their needs. When children start to question if their parents are able to protect them or provide for them it can cause uncertainty that stresses their system in multiple ways.
What are Adverse Childhood Experiences?
These Adverse Childhood Experiences (ACEs) are damaging to adult mental and physical well-being, with lifelong consequences. Adverse Childhood Experiences may be defined as traumatic experiences occurring before the age of 18, and include (but are not limited to):
- Physical, emotional, and/or sexual abuse
- Physical and/or emotional neglect
- Familial or household dysfunction, such as parental incarceration, parental mental health disorder, and/or parental separation.
- Witnessing domestic violence or substance use
People rarely only experience one of these types of adversities as they usually experience more than one.
How are Adverse Childhood Experiences Related to Chronic Pain?
People with chronic pain often have high levels of adverse childhood experiences (4 or more). These types of early trauma seem to bring an increased risk of 2 to 3 times of later development of chronic pain. People with adverse childhood experiences can have a worse experience with chronic pain. Their experience of chronic pain is often more severe, more extensive, and more difficult to treat. The greater number of adversities a person experiences the worse this effect is. The more types of adverse childhood experiences, the greater the negative impact on development and pain experience in adult life.
Poor mental health can also be a contributory factor to chronic pain. Moreover, the negative impact of childhood adversity on mental health is well documented. People with more Adverse Childhood Experiences experience a greater mental health impact of anxiety and depression as well as fear of pain itself.
Specific Types of Trauma
Different types of trauma can affect the development of chronic pain in different ways. Research has shown that different patterns of pain can come from different types of trauma:
- Physical and/or sexual abuse tends to result in physical pain.
- Emotional abuse tends to result in widespread pain.
- Women develop pain from all forms of mistreatment (emotional abuse, physical abuse, physical neglect, bullying).
- Men tend to develop pain from physical and sexual abuse.
- Fibromyalgia is associated with prior psychological or physical trauma.
- Sexual abuse was linked to non-specific chronic pain and chronic pelvis pain.
Stress Response System
People with a history of childhood trauma and chronic pain have been shown to have a dysregulation of the central stress response system (hypothalamic pituitary adrenal [HPA] axis), which regulates the body’s response to stress. Unfortunately, in the event of significant traumatic exposures like adverse childhood experiences, this system may be chronically activated which results in increased “wear and tear” on the body. Over time, this chronic activation can negatively affect brain development, and impact learning, behaviours, and emotional functioning. Through these mechanisms, childhood trauma and ACES can result in poor physical and mental health in adulthood. Through the development of various chronic conditions, such as diabetes, heart disease, depression, and chronic pain.
People with PTSD often have the most extreme cases of HPA dysregulation. Notably, among those with increasing PTSD symptoms, rates of musculoskeletal and less understood pain conditions (e.g., fibromyalgia, pelvic pain, irritable bowel) increase appreciably.
When people have a mental illness or emotional distress, they are twice as likely to develop chronic pain. Mental distress is often more predictive than the severity of pain in establishing chronic pain and driving negative outcomes such as disability and healthcare costs.
Similarities Between Trauma and Chronic Pain
Negative affect and anxiety vulnerability are two personality features that may predispose individuals to chronic pain and PTSD symptoms and may be partially responsible for their comorbidity. Anxiety vulnerability is the tendency to respond with fear due to the assumption that certain symptoms are harmful. It may amplify the intensity of the initial emotional response to a traumatic event, thereby increasing the risk of developing either condition.
The symptom overlap between chronic pain and PTSD suggests that they may share underlying causes. Some of the symptoms they share include:
- Hyperarousal, which is increased alertness, anxiety, heart rate, and/or respiration.
- Emotional liability, which is sudden and intense changes in mood or affect.
- Somatic focus, which is a tendency to notice, focus on, and report physical symptoms.
- Biases in attention toward threatening stimuli, which is when someone has to tendency to perceive things as threatening or dangerous that may not be dangerous.
- Appraisal tendencies, which are patterns of appraisal such as always seeing things in a negative light (opposite of rose-coloured glasses).
- Heightened startle reaction,
- Trait fear, which is the tendency to experience fear in response to specific stimuli.
- Hypervigilance, which is being highly or abnormally alert to potential danger or threat (always being on-guard or on edge)
- Emotional numbing, which is being in a state of not feeling or expressing emotions.
- Stress response dysregulation
These conditions often involve a lowered physiological threshold for alarm responses and feelings of loss of control and unpredictability.
Impacts on the Brain
Both chronic pain and PTSD have similar activity in the hypothalamic-pituitary-adrenal (HPA) axis and the amygdala (involved in emotional control, memory, and learning), as well as structural and functional alterations in the anterior cingulate cortex, a brain region involved in attention and emotion.
Similarities in the Experience of PTSD and Chronic Pain
- Increased sensitivity to perceived threats
- Processed through and influenced by the Nervous system.
- Takes time and energy to cope with the symptoms.
- Becomes the focus of attention and energy and takes away from other tasks.
- Changes the relationship we have with our bodies.
- Affects the mind, heart, relationships, and work life.
- Engage in activities to protect or brace oneself.
- The environment and support system can affect how one deals with these conditions and how large the suffering is.
- Thoughts, feelings, and actions can affect how significant the pain and suffering are.
- Common human experiences of these conditions involve fear and lack of control.
- They are both incredibly demanding teachers who force sufferers to create boundaries, carefully manage themselves, and control their surroundings.
Both trauma and chronic pain involve attentional and reasoning biases toward potentially threatening stimuli. These biases can increase the suffering of the person. Catastrophizing, which can involve imagining the worst-case scenario, believing that you’re in a worse situation than you are or exaggerating your difficulties, is common with trauma and chronic pain and can increase the intensity of your pain or suffering. Often trauma and chronic pain sufferers can end up having selective and negative interpretations of things that evoke pain or fear.
Often people with trauma and chronic pain have heightened expectations or overestimations of how their condition has impacted them and the losses due to their condition. Furthermore, pain may serve as a traumatic cue, evoking fear and PTSD intrusion and hyperarousal, and vice versa.
Avoidant coping style, depressive symptoms, and fatigue are could lead to physical deconditioning, inactivity, and disability – all preventing fear extinction. This can prevent recovery as fear can maintain both conditions. PTSD-related anxiety may also directly influence pain perception.
Cognitive overload is a situation where one is given too much information at once, or too many simultaneous tasks, resulting in not being able to perform or process the information as it would otherwise happen if the amount was instead sustainable. It characterizes both conditions, and it leads limited capacity to employ adaptive coping strategies. Both trauma and chronic pain can lower your cognitive load capacity because of your pain and other symptoms.
How Trauma Can Complicate Chronic Pain Recovery
Effect on Conditions
Several vulnerabilities and processes may make an individual more prone to developing chronic pain following trauma. These vulnerabilities with the circumstances of the traumatic event can:
- Affect the emotional responses in the encounter, such as fear, anger, or disgust.
- Initiate cascades of cognitive bias, a systematic error in thinking that occurs when people are processing and interpreting information in the world around them and affects the decisions and judgments they make.
- Avoidance behaviour
- Autonomic responses, such as fight, flight, or freeze
- Muscular responsivity, which involves when muscles over- or under-respond to sensory input.
PTSD hyperarousal is associated with increased pain perception and dissociation with decreased pain perception. Combat-related PTSD is associated with increased pain thresholds, whereas accident-related PTSD is associated with decreased pain thresholds. Accident-related trauma is linked to an anxious and sensitizing reaction. Whereas combat-related trauma may lead to a dissociative and habituative reaction. Subjective pain reporting most often points in the direction of a more severe symptoms profile concerning pain, disability, and distress when comorbid PTSD and pain persist.
Effect on Treatment
Trauma can have negative consequences on the common treatments and relationships that are important for healing. Some of these challenges include:
- Trauma can affect a person’s capacity to trust healthcare professionals.
- Pain can impact access to coping strategies, such as coping strategies that involve positions or movements that increase pain.
- Common pain management strategies such as relaxation and mindfulness exercises can bring back trauma memories or trigger aspects of trauma.
- Often these strategies can make people with trauma feel uncomfortable relaxing a protective state. Generally, a sense of safety needs to be established before these strategies can be effective.
- May be hard to apply pacing strategies, due to a sense of worthlessness unless productive and feeling distress for taking breaks.
- May be hard to set boundaries if hyperaware of others’ displeasure, such as people who have people-pleasing tendencies.
The biological mechanisms behind pain sensitization and the development of chronic pain are complex but include regulatory mechanisms in the hypothalamic-pituitary-adrenal axis, inflammatory processes, immune system suppression, and fatigue. More complex interpersonal traumas such as physical and emotional abuse associated with war or sexual assault are of such a pervasive nature that the ability to trust others can be severely damaged, resulting in attachment insecurities that further increase the risk of developing long-term pain problems.
Treatment of Co-Occurring Trauma and Chronic Pain
Having knowledge and understanding of trauma and chronic pain can benefit sufferers and promote recovery. These conditions are both very complex and understanding how different things you think and do can have an impact on these conditions can help you reduce your pain and suffering from them.
Therapies Beneficial for Both Trauma and Chronic Pain
EMDR and Cognitive Processing Therapy are two evidenced-based PTSD therapies that can also be effective with chronic pain. EMDR also has chronic pain-focused protocols, which can make it easier for a therapist to move between the two conditions. Cognitive Processing Therapy (CPT) teaches the client a skill that can be applied to both thoughts relating to PTSD and chronic pain. Since trauma and chronic pain have similar mechanisms the treatment of trauma is likely to result in benefits with the chronic pain.
Most trauma therapies can be effective with chronic pain if the therapist is knowledgeable about chronic pain and can figure out how to make changes and bring aspects of chronic pain into the treatment. Integrating CBT techniques in the treatment of comorbid PTSD and chronic pain can also be effective.
What to Look for in a Therapist
When seeking treatment with a therapist for both trauma and chronic pain, it is important that the therapist is knowledgeable about chronic pain. Also, that the therapist knows the complexities of suffering with chronic pain including space for fatigue, challenges with pain, and challenges with the medical system. Unfortunately, some therapists who don’t have this knowledge can end up unintentionally gaslighting their clients through a lack of understanding and expectations of their clients.
The therapist may need to be flexible enough to adjust trauma treatment plans to incorporate aspects of chronic pain. Some therapists who are trained in chronic pain-specific treatments and therapies may be able to combine them with trauma therapies to give you the best possible outcome.
Trauma and chronic pain are difficult conditions to deal with and suffering from both can make the experience of each worse. There is hope and there are treatments that can improve the condition of both conditions.