The Role of PTSD in Chronic Pain Management
By: Dr. Stephen F. Grinstead, LMFT, ACRPS
Coping with chronic pain is a difficult challenge that requires a lifestyle management approach focused on caring for the body, mind and spirit. This struggle gets even more demanding when the cause of the pain involves a trauma, such as a motor vehicle accident, work-related injury, combat-related injury, assault or complications from a surgical procedure. Sometimes a person who is exposed to a traumatic event will experience an intense fear response to the trauma and develop a psychological syndrome called Post Traumatic Stress Disorder (PTSD).
- With PTSD, a person is exposed to a traumatic event that involves experiencing or witnessing an actual or threat of death or serious injury.
- This person may begin to re-experience the event with reoccurring dreams and/or intrusive thoughts or "flashbacks" that can be very stressful.
- They may avoid thoughts, feelings, activities, people and places that remind him or her of the trauma. They may even avoid talking about the trauma or steer clear of the site of the accident or incident because it is too upsetting.
- They may have symptoms of arousal dysfunction such as having difficulty falling or staying asleep, irritability and anger, difficulty concentrating, an exaggerated response to sudden loud noises or movements, and extreme watchfulness.
Individuals may begin to experience these symptoms immediately after a trauma or even months afterward (called delayed onset). Additionally, while some people who develop these symptoms recover within a few weeks or months, a number of people may continue to experience these symptoms for longer than three months and even years later (Chronic PTSD).
Pain as a result of occupational injuries, motor vehicle accidents, or military combat has led to a growing interest in the interaction between pain and PTSD. As research and clinical practice indicate, they frequently co-occur and can interact in such a way to negatively impact the course of treatment for either disorder.
Some of the theories as to why this relationship occurs relate to personality development, neurobiology or neurophysiology, memory, behavior, and personal coping styles. If someone has a history of any type of trauma, it is essential that healthcare providers have accurate information about those experiences.
The prevalence of PTSD has been estimated to be between 20 to 34% in patients referred for the treatment of pain. The prevalence of pain has been estimated to be between 45 to 87% in patients referred for the treatment of PTSD. Data obtained from VA Boston Psychology Pain Management indicate that 50% of their patients assessed met criteria for PTSD based on PTSD Checklist scores.
Determining if a person with injury-related pain has PTSD is very important so that treatment can begin early in their rehabilitation process. Research shows that patients with co-morbid pain and PTSD experience more intense pain, greater difficulty coping with that pain, more emotional distress, greater disability and higher levels of life interference than pain patients who have no PTSD symptoms. Due to the interaction of these conditions, these patients can also be more complex and challenging to treat. Consequently, efforts to develop more effective treatments for this population are greatly needed.
It is also important to recognize that certain types of chronic pain are more common in individuals who have experienced specific traumas. For example, adult survivors of physical, psychological, or sexual abuse are often more at risk for developing certain types of chronic pain later in life. The most common forms of chronic pain for survivors of these types of trauma involve pain in the pelvis, lower back, face, and bladder; fibromyalgia; interstitial cystitis; and non-remitting whiplash syndromes.
Relationship between chronic pain and PTSD
While chronic pain and PTSD are conditions that may occur together, their relationship to one another is not always obvious and is often overlooked. This is because the health care provider, patient and family may be focusing on the pain disorder. At times, the patient’s level of disability may be attributed solely to pain. Because there is such a close relationship between PTSD and chronic pain, they have been referred to as mutually maintaining conditions. This is because the presence of both PTSD and chronic pain can increase the symptom severity of either condition.
For example, people with chronic pain may avoid activity because they fear the pain—avoiding activity can lead to physical de-conditioning and greater disability and pain over time. Similarly, people with PTSD may avoid reminders of the trauma. This avoidance of activity can lead to the continuation of PTSD symptoms while also contributing to greater physical disability.
People with chronic pain may also focus their attention on their pain while individuals with PTSD may unknowingly focus on things that remind them of the trauma. Consequently, people with both PTSD and chronic pain may have less time and energy to focus on more adaptive ways of coping with both their pain and fear. Furthermore, people with PTSD often experience symptoms of arousal dysfunction and tension, which may decrease their tolerance for handling pain and increase their perception of pain.
In the following paragraphs you will find recommendations for healthcare providers that were developed for the National Center for PTSD by Lorie T. DeCarvalho, Ph.D. You may want to review this and your reactions to this information with your pain management team.
When patients are coping with a chronic pain condition, it is difficult for them to hear from a health care provider that they will need to '”live with it” and “'manage the pain” for the rest of their lives. Being faced with the news of impending health problems, ongoing severe pain, and disability is extremely difficult. These individuals may have lost their physical abilities, and the assurance that they can fully control whatever is going on in their lives. Much like losing a loved one, these individuals will need to grieve their losses. This may take some time and will vary from person to person. Here are some suggestions for assisting these individuals:
- Gather a thorough biopsychosocial history and assess the individual for medical and psychiatric problems. Do a risk assessment for suicidal and homicidal ideation. Also ask about misuse of substances, such as drugs or alcohol, including over-the-counter and prescription drugs or narcotics. Taking appropriate steps to ensure someone is clean and sober and not using medications or other substances to self-medicate is a necessary component of treatment.
- Assess for PTSD symptoms. A quick screening may involve asking the person these questions: In the past month, have you: (1) had nightmares about__ when you didn't want to? (2) tried hard not to think about __ or gone out of your way to avoid situations that reminded you of __? (3) been constantly on guard, watchful, or easily startled? or (4) felt numb or detached from others, activities, or your surroundings?
- Make appropriate referrals for PTSD, depression, other psychiatric disorders, or significant spiritual issues. Likewise, help build up or stabilize their social support network, as this will act as a buffer against the stress they are experiencing.
- Understand that prior to patients being able to come to an acceptance about the permanence of their condition, they will be feeling very much out of control and helpless. Their lives essentially revolve around trying to regain their sense of control, and this can sometimes be difficult, particularly when treatments don't seem to help or the patient's support system is weak. There may be times when they become outwardly angry or depressed. Restoring some sense of control and empowering the patient is a fundamental part of the treatment process.
In recent interview I did with Jerry A. Boriskin, Ph.D. in my “Talking With An Expert” series, he articulates a compelling case for understanding, respecting and mirroring the range, scope and consequence of surviving physical or emotional trauma. He states that PTSD has been part of our lexicon since 1980, but relatively few providers are fluent in terms of expressing what it is and how to mirror the survivors’ emotional reality.
Dr. Boriskin believes that our fixation on evidenced–based approaches captures only a part of the multidimensional changes that require patient and provider to become fluent in a way that simplifies, demystifies and empowers clients to accept, forgive and move forward in a meaningful fashion. Simplification, not reductionism is a key tool of empowerment and activation. When the clinician better understands his or her role as educator, not repair man, he/she can be far more effective in facilitating change for our most complex and damaged clients.
The bottom line is that people living with chronic pain and PTSD can move from surviving to thriving with the right support and tools. It takes a team approach with the patient being the most important member of the team.