PTSD: National Center for PTSD

The Experience of Chronic Pain and PTSD: A Guide for Health Care Providers

Lorie T. DeCarvalho, PhD

What Is Chronic Pain?

According to the International Association for the Study of Pain (IASP), chronic pain involves suffering from pain in a particular area of the body (e.g., in the back or the neck) for at least three to six months (1). Chronic pain may be as severe as, if not more severe than, acute pain but the individual's experience is ''modulated and compounded by the prolonged or recurrent nature of the chronic state, and further complicated by a multitude of economic and psychosocial factors" (2). In stark contrast to acute pain, chronic pain persists beyond the amount of time that is normal for an injury to heal.

Chronic pain can have a variety of sources including disease processes or injuries. Some chronic pain stems from a traumatic event, such as a physical or sexual assault, a motor vehicle accident, or some type of disaster. Under these circumstances the person may experience both chronic pain and Posttraumatic Stress Disorder.

How Common Is Chronic Pain?

Approximately one in three Americans (more than twelve million people) suffer from some kind of recurring pain in their lifetimes (3), and three million of these individuals are seriously disabled from their chronic pain conditions (4). Eighty to ninety percent of Americans experience chronic cervical or lower back problems (2).

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Evaluating Chronic Pain

Medical providers have a difficult time ascertaining the accuracy of patients' pain severity. Care providers generally assess chronic pain by administering physical examinations and having patients perform various tasks, such as exercises that help the provider evaluate the patient's strength, flexibility, and reflexes. At times, patients are asked to rate their pain on a scale from "no pain at all to "completely unbearable". Yet, because every person is different and perceives and experiences pain in different ways, it is difficult for medical providers to determine how much pain an individual is experiencing.

In addition, health care providers usually base their determination of pain severity on their own perceptions of how much pain seems appropriate for a given injury or pain condition (5-6). There is often very little consistency between providers regarding the measurement of their patients' pain. This creates obvious frustration for providers, but this can be even more exasperating for the individual who is suffering from chronic pain. It is common for patients to be disbelieved, or to have the level of their pain or disability minimized. Many times, this frustration causes patients to go from provider to provider in search of answers and relief from their pain. Additionally, this kind of experience often contributes to an increased sense of helplessness and despair, which can subsequently increase tension and pain, as well as emotional distress.

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What Is the Experience of Chronic Pain Like Physically?

There are many forms of chronic pain, and each type of condition results in different experiences of pain and disability. As an example, chronic low back pain (CLBP), the most pervasive or common type of pain, is known to result in severe disability and limitation of movement.

Most patients with chronic pain resort to invasive assessment or treatment procedures, including surgery, to help ameliorate the pain. Individuals with chronic pain are less able to function in daily life than those who do not suffer from chronic pain. Patients with severe chronic pain and limited mobility oftentimes are unable to perform activities of daily living, such as walking, standing, sitting, lifting light objects, doing paperwork, standing in line at a grocery store, going shopping, or working. Many patients with chronic pain cannot work because of their pain or physical limitations.

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What Is the Experience of Chronic Pain Like Psychologically?

Chronic pain and the disability that often comes with it can lead to a cognitive reevaluation and reintegration of one's belief systems, values, emotions, and feelings of self-worth (7). Numerous studies have indicated that many patients who experience chronic pain (up to 100%) tend also to be clinically depressed (8-10). In fact, depression is the most common psychiatric diagnosis in patients with chronic pain (11). The experience of progressive, consistent chronic pain and disability also translates for many individuals into having thoughts of suicide as a means of ending their pain and frustration (12).

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PTSD and Chronic Pain

The prevalence of PTSD is substantially elevated in patients with chronic pain. A current PTSD prevalence of 35% was seen in a sample of chronic pain patients (13), compared to 3.5% in the general population (14). In a study of patients with chronic low back pain, 51% of the patients evidenced significant PTSD symptoms (15). In another study of patients who experienced chronic pain following a motor vehicle accident, researchers found that 50% of the patients developed PTSD (16).

One symptom of PTSD is that the person becomes emotionally or physically upset when reminded of the traumatic event. For people with chronic pain, the pain may actually serve as a reminder of the traumatic event, which will tend to exacerbate the PTSD.

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Past Experiences, Present Pain

It is 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 tend to be more at risk for developing certain types of chronic pain later in their lives. The most common forms of chronic pain for survivors of these kinds of trauma involve: pain in the pelvis, lower back, face, and bladder; fibromyalgia; interstitial cystitis; and nonremitting whiplash syndromes (17).

Some of the theories as to why this relationship occurs relate to personality development, neurobiology or neurophysiology, memory, behavior, and personal coping styles (18-20). In order to increase our understanding of the relationships between certain traumas and specific kinds of chronic pain, it is essential that health care providers ask both male and female patients with chronic pain about their childhood experiences. It is particularly important to gather this information for those patients where the source or basis for their pain conditions is unknown.

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Treating Individuals Who Have Chronic Pain and PTSD

Cognitive-behavioral therapy (CBT) is a psychotherapeutic intervention that helps patients manage chronic pain (21). Other types of treatment that help patients with chronic pain include: stress inoculation training, behavior modification/operant conditioning, self-directed treatments, and adjunctive treatments such as biofeedback and relaxation training (22). There are also manualized treatments that specifically address avoidance behaviors and hypervigilance, because these behaviors tend to reinforce fear reactions.

Research suggests that providing CBT treatments to address PTSD symptoms in patients with chronic pain may lead to improvements in pain-related functioning (23). This has been seen even when the pain was not addressed specifically in the intervention. When treating patients with chronic pain, it is vital that health care providers address patients' symptoms of PTSD and depression. In so doing, they increase the likelihood that patients will have improvements in their levels of pain as well as in their physical and emotional functioning.

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Recommendations for Health Care Providers

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 they have lost 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 screen is the Primary Care PTSD Screen (PC-PTSD) that has been designed for use in primary care and other medical settings. See PTSD Screening and Referral: For Health Care Providers for more information and a copy of the screen.
• Make appropriate referrals for PTSD, depression, other psychiatric disorders, or significant spiritual issues. Likewise, help build up or stabilize the patient's 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. 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.

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References

1. American Medical Association. (2003). Pathophysiology of pain and pain assessment. At www.ama-assn.org/.
2. Rosomoff, H.L., & Rosomoff, R.S. (1991). Comprehensive multidisciplinary pain center approach to the treatment of low back pain. Neurosurgery Clinics of North America, 2 (4), 877-890.
3. Drum, D. (1999). The chronic pain management sourcebook. Los Angeles, CA: Lowell House.
4. Turk, D.C., & Nash, J.M. (1993). Chronic pain: New ways to cope. In D. Goleman and J. Gurin (Eds.), Mind-body medicine: How to use your mind for better health (115-116). Yonkers, NY: Consumer Reports Books.
5. Agre, J.C., Magness, J.L., Hull, S.Z., Wright, K.C., & Baxter, T.L. (1987). Strength testing with portable dynamometer: Reliability for upper and lower extremities. Archives of Physical Medicine and Rehabilitation, 68, 454-458.
6. Waddell, G., & Turk, D. (1992). Clinical assessment of low back pain. In D.C. Turk and Melzack, R. (Eds.), Handbook of pain assessment (pp. 15-36). New York: Guilford Press.
7. Miller, T.W. (Ed.). (1990). Chronic Pain. (Vol.1-2). Connecticut: International Universities Press, Inc.
8. Turk, D.C. (1994). Detecting depression in chronic pain patients: Adequacy of self-reports. Behavior Research and Therapy, 32, 9-16.
9. Lindal, E. (1990). Interaction between constant levels of low back pain and other psychological parameters. Psychological Reports, 67, 1223-1234.
10. Schuster, J.M., & Smith, S.S. (1994). Brief assessment of depression in chronic pain patients. American Journal of Pain Management, 4 (3), 115-117.
11. Fishbain, D.A., Goldberg, M., Meagher, B.R., & Rosomoff, H. (1986). Male and female chronic pain patients categorized by DSM-III psychiatric diagnostic criteria. Pain, 26, 181-197.
12. Fisher, B.J., Haythornthwaite, J.A., & Heinberg, L.J. (2001). Suicidal intent in patients with chronic pain. Pain, 89, 2-3, pp.199-206.
13. Asmundson, G.J., Bonin, M.F., Frombach, I.K., & Norton, G.R. (2000). Evidence of a disposition toward fearfulness and vulnerability to posttraumatic stress in dysfunctional pain patients. Behaviour Research and Therapy, 38, 801-812.
14. Kessler, R.C., Chiu, W.T., Demler, O., Merikangas, K.R., & Walters, E.E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6): 617-627.
15. DeCarvalho, L.T. (2003). Predictors of posttraumatic stress disorder symptom severity level in chronic low back pain patients. Dissertation Abstracts International- B, 64/08, p. 4030.
16. Hickling, E.J., & Blanchard, E.B. (1992). Post-traumatic stress disorder and motor vehicle accidents. Journal of Anxiety Disorders, 6, 285-291.
17. Scaer, R.C. (2001). The body bears the burden: Trauma, dissociation, and disease. New York: Haworth Medical Press.
18. Damasio, A.R. (1994). A passion for reasoning. Descartes' error: Emotion, reason, and the human brain. New York: Avon Books.
19. Grigsby, J., & Hartlaub, G. (1994). Procedural learning and the development and stability of character. Perceptual and Motor Skills, 79, 355-370.
20. Perry, B., Pollard, R., Blakely, T., Baker, W., & Vigilante, D. (1995). Childhood trauma, the neurobiology of adaptation, and "use-dependent" development of the brain: How "states" become "traits." Infant Mental Health Journal, 16 (4), 271-291.
21. Turk, D.C., Meichenbaum, D., & Genest, M. (1983). Pain and behavioral medicine: a cognitive behavioral perspective. New York: Guilford.
22. Brown, K.S., & DeCarvalho, L.T. (2005). Psychotherapeutic approaches in chronic pain management. In M. Boswell & B. Cole (Eds.), Weiner's pain management: A practical guide for clinicians. (7th ed). Boca Raton, FL: CRC Press.
23. Shipherd, J., Beck, J., Hamblen, J., Lackner, J., & Freeman, J. (2003). A preliminary examination of treatment for posttraumatic stress disorder in chronic pain patients: A case study. Journal of Traumatic Stress, 16, 451-457.

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