How is Psychological Trauma Linked to Chronic Pain?
This article takes a look at the link between trauma and chronic pain. Discussion of types of trauma and the effects of trauma are included: please read with care if you are vulnerable.
The research available indicates that while trauma may not directly cause chronic pain, it certainly makes people more vulnerable to developing chronic pain. There are many studies which link chronic pain to trauma. The Institute for Chronic Pain states that up to 90% of women with fibromyalgia and up to 60% of patients with arthritis report trauma at some stage in their lives. As a point of comparison, 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 explains that 15% to 35% of patients with chronic pain also have Post Traumatic Stress Disorder (PTSD).
Let’s explore why emotional trauma is so deeply linked to chronic pain, and what we can do about it.
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.” Essentially a traumatic event is one which is potentially life threatening and which overwhelms the body’s natural coping mechanisms.
Anybody in any area of the world, of any gender or age can experience trauma. Trauma does not discriminate. Traumatic events can include:
An accident or medical trauma
Sexual or physical abuse in adulthood
Sexual, physical abuse or neglect in childhood
Being in a combat situation
A natural disaster
As a result of trauma individuals may suffer from a range of mental health conditions including anxiety, depression, post-traumatic stress disorder (PTSD), complex post-traumatic stress disorder (CPSTD) and dissociative disorders such as dissociative identity disorder (DID: if the trauma was repeated and in early childhood before the age of 6).
The link between mind and body
We know that our mind and body are connected. They can influence each other in many ways. We also know that stress and pain create a cycle, perpetuating one another. There are many ways in which stress worsens pain, including causing tense muscles and increasing inflammation. Trauma and unresolved emotional issues cause stress, so therefore contribute to the pain and stress cycle.
This means that when we experience trauma which takes its toll on us emotionally, it can also have physical effects. This doesn’t make our chronic pain any less valid or mean that it’s ‘all in our head’ as stigma so often dictates. All pain is created by our brains. Chronic pain is just as valid as acute pain or any other physical health condition.
Symptoms of trauma which can influence chronic pain
Patients with a history of trauma 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.
Overly active nervous system
Trauma causes the nervous system to become overreactive, meaning that it is stuck in a state of stress and persistent arousal. When we look at chronic pain, we can see that the same overactivity occurs.
Central sensitization means that your nervous system is stuck on high alert. Like a faulty alarm system, it’s sending out pain messages in reaction to perceived threats, even when no real threat is present. For example, allodynia is a symptom of my fibromyalgia which I really struggle with. It means that things which shouldn’t cause pain (such as me scratching an itch) can cause extreme pain.
So, both chronic pain and trauma cause the nervous system to be overly active, which strongly links both experiences. Research into this link suggests that patients with a history of trauma may be more predisposed to central sensitization.
Re-experiencing means that patients who have experienced trauma may ‘re-live’ aspects of their trauma. This is involuntary and highly distressing. It can involve re-experiencing certain aspects of the trauma including the physical feelings, sights, sounds and smells, or emotions of the trauma, as though they are actually happening again. This can come in the form of flashbacks or nightmares, among other experiences.
When people are re-experiencing their trauma, they are taken back to that heightened emotional state again. Their bodies and minds are actively in that ‘fight or flight’ mode as they try to face the perceived threat. This regular return to such a heightened stress response can cause and worsen chronic pain.
Patients who have experienced trauma often find it difficult to have a restful sleep. This is often due to the re-experiencing we discussed. 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.
Often patients who are experiencing the effects of trauma may start to withdraw and avoid social connections or activities. This may be because they want to avoid anything that could remind them of their trauma or avoid potential triggers (meaning things which could cause a flashback or a severe negative emotional response). This lack of feeling is called emotional numbing.
This social withdrawal is also common in patients with chronic pain and can become detrimental to both physical and mental health. Humans need social interaction to be happy and to stay healthy. Interacting with others helps us to maintain our mood, to enhance cognitive functioning and to gain support from others. When this is lacking, it can contribute to depression, negative perceptions of pain and inactivity.
Those who have experienced trauma may be easily startled, constantly on the lookout for potential threats (also known as hypervigilance). They may be very anxious and find it difficult to relax. These hyperarousal symptoms can cause very tense muscles which can be painful and contribute to chronic pain. This state of hyperarousal also perpetuates the stress and pain cycle.
Pain hypervigilance is a common symptom of chronic pain and can wire the pain response deeper. By being hypervigilant about our pain, we are feeding back to our brain that it should continue producing pain messages. Since those who have experienced trauma are already hypervigilant, they’re more inclined to become hypervigilant about their chronic pain.
Inability to regulate emotions
The same areas of the brain which regulate our emotions, form memories and help us to focus our attention, are also used for processing and regulating pain. So, you can see how chronic pain and emotions can directly influence one another.
The inability to regulate emotions (particularly negative emotions) is commonly seen in those who have experienced trauma. These difficulties can lead to maladaptive (unhelpful) coping behaviours with mental health and physical health. A great deal of research has shown that maladaptive coping behaviours worsen chronic pain and fuels the chronic pain cycle. These maladaptive behaviours can lead to health conditions being left untreated or self-managementbehaviours not being utilized.
Depression and anxiety
Mental illness is common both as a result of trauma and as a symptom of chronic pain. Patients may not practice self-care or proactively manage their pain when they are in a negative mental state. This study on the link between PTSD and chronic pain explains that, “the biopsychosocial model posits that depressive symptoms can exacerbate or lead to increased pain and impaired function”.
This in-depth study on the comorbidity of PTSD and chronic pain states that anxiety is in fact the biggest factor in linking the two. The hyperarousal we discussed earlier and the increased risk of anxiety make chronic pain patients more likely to develop catastrophizing and fear avoidance behaviours, as this study concluded. Catastrophizing means that patients are more likely to think negatively and excessively worry about their pain, therefore contributing to high stress levels. Fear avoidance means that pain patients are avoiding activity for fear of worsening their pain symptoms.
Withdrawal from activity can cause the body to become deconditioned and lose fitness. This makes it more painful when patients try to be active. For example if you are used to walking and you’ve built up a level of fitness, but then become inactive for a long period of time, next time you try to go walking you are likely to feel stiff and out of breath. The same can be said for any activity in life. If the body is not being used actively, it loses fitness.
Damaged neural connections from childhood trauma
When trauma is experienced in childhood, both the mental and physical effects can last way into adulthood. The prolonged ‘fight or flight’ state can be highly detrimental to a child’s developing body and mind. This article from Harvard Medical School explains that, “when this response remains highly activated in a child for an extended period of time without the calming influence of a supportive parent or adult figure, toxic stress occurs and can damage crucial neural connections in the developing brain.”
When you are stuck in a prolonged state of stress, your adrenal system is producing a higher volume of stress hormones than it is designed to. These hormones include cortisol and adrenaline. Just like other areas of your body which become worn out through overuse, your adrenal glands can become exhausted. This can happen with both chronic pain and chronic stress, such as in those with PTSD.
PTSD UK (a charity which works to raise awareness of PTSD) explains that adrenal exhaustion also “raises the level of prolactin (a hormone which helps to regulate pain) and therefore your sensitivity to pain increases.”
Negative perceptions of pain
Those who have been through trauma are more likely to have a negative view of their future and their own abilities. This book on the effects of trauma explains: “Trauma can affect one’s beliefs about the future via loss of hope, limited expectations about life, fear that life will end abruptly or early, or anticipation that normal life events won’t occur.”
Patients who are depressed or anxious are more likely to have negative perceptions of pain, such as feeling they are helpless and can’t do anything to improve their situation. These negative pain beliefs have a significant negative impact on chronic pain management and pain levels.
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 behavioural therapy (CBT)
CBT is a talking therapy which has proven results for both chronic pain and PTSD. CBT can help to introduce more positive thoughts, and in turn more adaptive coping behaviours, to deal with pain and emotional distress. Through CBT, patients can change their way of thinking and feel empowered, ready to take control of their lives. This study concluded that, “Integrated cognitive and behavioural techniques that simultaneously address symptoms of PTSD and chronic pain may help maximize effectiveness.”
Pain management programmes
Pain management programmes or clinics address the patient as a whole, implementing treatment approaches which treat both body and mind. 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 is a great way to learn to reduce stress and regulate your emotions and in turn to reduce your chronic pain symptoms. Guided mindfulness can give you the tools to practice mindfulness in your day to day life. This helps to keep your stress levels low and can help to deal with re-experiencing if you struggle with trauma.
What can you do if you struggle with trauma and chronic pain?
If you struggle with trauma and chronic pain, there are lots of ways you can help yourself:
Talk to someone you trust
Expressing your feelings to someone you trust, whether this is a loved one or even using a helpline, can help you to feel supported and less alone. They may be able to help you in seeking treatment and to find better coping strategies.
There are a wide variety of treatments available for both trauma and chronic pain. The treatments we mentioned are just a few options. Talk to your doctor or specialist and advocate for yourself. You could seek treatment privately. You could access treatment for your chronic pain online through a chronic pain relief app like ours. You can even find psychological therapy options online to help address your trauma. Take your time, do your research, and pick the right option for you.
Do your research
Learning how trauma and chronic pain influence each other, and the science behind pain will help you to get a better understanding of how to manage your symptoms.
Practice adaptive self-management
There are plenty of ways you can learn to actively reduce your stress levels in your day to day life. You can learn to manage your chronic pain and your mental health.
Be kind to yourself
Don’t be too hard on yourself. Learning how to live well despite mental illness and chronic pain is a delicate balancing act. It takes time. You will make mistakes along the way and not everything will be perfect. Praise yourself with every step you take and celebrate your wins, even if they seem small. You can get through this and come out of the other side feeling stronger and more empowered.