Trauma

What is trauma?

Trauma is the psychological and bodily response to experiencing an overwhelmingly terrible event. Some examples of events that can lead to trauma are the following:

  • Combat
  • Domestic violence
  • Sexual assault
  • Natural disaster
  • Terrorism
  • Physical or sexual abuse in childhood

These events are not run-of-the-mill bad things that happen in life. Rather, events are typically considered traumatic when they threaten the life or bodily integrity of the individual who experiences them.1 Also, traumatic events tend to overwhelm a normal person’s ability to cope with them.

After experiencing events like the above, people tend to develop certain predictable reactions. Examples are the following:

  • Persistent and unwanted thoughts, memories, or dreams of the event
  • Heightened physiological arousal, such as tension, nervousness, irritability, startling easily, poor concentration, or poor sleep
  • Avoidance of places or things or events that are reminiscent of the traumatic event

All these reactions are related to anxiety. The persistent, unwanted thoughts and memories produce fear and anxiety. The arousal reactions are the physical manifestations of this anxiety. It’s the nervous system in action – tense and nervous. Avoidance is a common coping strategy for things that are anxiety provoking. It’s a way of not getting reminded of the event.

Relationship between trauma and anxiety

Whether due to trauma or other causes, anxiety in general is a state of the nervous system. When anxious, people are literally nervous. They are nervous in their feelings, their body, their thinking and in their behavior. With anxiety, the nervous system is stuck in a state of alarm, as if some scary thing were actually happening.

Psychologists have dubbed this state of alarm the fight-or-flight response. It prepares people to respond to danger by making the body ready to fight or flee from danger. The nervous system gets kicked into high gear, as it were, and it responds with feelings of being alarmed, with physical changes of the body that increase the capacity for action, with an increased cognitive focus on the danger, and avoidance behaviors.

In actual dangerous situations, this fight-or-flight response of the nervous system is a helpful thing. It’s the body’s natural overdrive system and it helps people to survive dangerous situations.

Anxiety is the result of the nervous system going into fight-or-flight in the absence of a real or actual danger. It’s anxiety when the nervous system kicks into fight-or-flight at the mere thought that something dangerous might happen. Such thoughts are called worry – thinking something bad is going to happen and consequently becoming nervous.

The anxiety reactions that occur as a result of trauma are similar. Whether it was an assault, violence or a natural disaster, the original traumatic event was actually dangerous. The person who experienced it had a nervous system that went into fight-or-flight. It was likely helpful at the time. After the event has come and gone, though, the thought of the traumatic event or a memory of it can still kick the nervous system into fight-or-flight as if the event is happening now. It leads to anxiety, increased arousal and avoidance behaviors, as described above.

This reaction is considered a form of anxiety because the event is not actually happening. Instead, the reactions are brought on by the thought or memory of the event.

High rates of trauma in people with chronic pain

As a group, people with chronic pain tend to report much higher rates of having experienced trauma in their past, when compared to people without chronic pain. It is a common and consistent finding in the research.

Upwards of 90% of women with fibromyalgia syndrome report trauma in either their childhood or adulthood and 60% of those with arthritis report such a trauma history.2 With or without back surgery, upwards of 76% of patients with chronic low back pain report having had at least one trauma in their past.3 Sixty-six percent of women with chronic headache report a past history of physical or sexual abuse.4 Among men and women, fifty-eight percent of those with migraines report histories of childhood physical or sexual abuse, or neglect.5 Women with chronic pelvic pain also report high rates of sexual abuse in their past, upwards of 56%.6 

As a point of comparison, rates in the general population for physical abuse in childhood are 22% for males and 19% for females; rates in the general population for self-reported childhood sexual abuse are 14% for males and 32% for females.7 Rates of adult sexual assault in the general population are 22% for women and about 4% for men.8 Domestic violence is upwards of 21% in the general population.9 

As is evident, when compared to the general population, people with chronic pain tend to have at least double the rates of trauma in their past.

The relationship between trauma and chronic pain

What accounts for this high rate of trauma in patients with chronic pain?

To be clear, these statistics do not prove that trauma causes chronic pain in any wide scale sense. Of course, traumas, such as injuries sustained in combat or assaults, could lead to chronic pain, but most of the time the onset of chronic pain is independent of the prior history of trauma. Indeed, many people with chronic pain have no history of trauma in their background. So, trauma doesn’t typically cause chronic pain in a direct way.

Nonetheless, the high rate of trauma in people with chronic pain suggests that it might have some relationship to the development of chronic pain.10

The relationship might be the following: a history of trauma might make a person more prone to develop chronic pain once an injury occurs. Let’s explain.

The nervous system & the transition from acute injury to chronic pain

Assume, for the most part, that painful accidents, injuries or illnesses occur on a random basis. Everyone has an accident or gets injured or gets ill on occasion. The vast majority of the time people get better and the pain goes away. Sometimes, though, they don’t. They transition from an acute injury or illness to chronic pain. Most experts agree that the process that accounts for this transition from acute injury or illness to chronic pain is central sensitization.11, 12

Central sensitization is condition associated with chronic pain in which the nervous system becomes stuck in a state of heightened reactivity. In central sensitization, the sensations of pain can become more intense and things that are not normally painful, like touch or massage, can also become painful. Central sensitization maintains pain even after the initial injury or illness heals.

So, here is the relationship between chronic pain and trauma. Trauma and its resultant anxiety is also a condition of the nervous system being in a persistent state of reactivity. As described above, trauma leads to anxiety, physiological arousal, and avoidance behaviors. These reactions to trauma are all indicators of a persistently aroused or reactive nervous system. As such, when patients with a history of trauma get injured or become ill, their nervous system is already in a state of persistent reactivity.

Might it be the case that such persons are more prone to develop central sensitization and transition from an acute injury or illness to chronic pain?

Many experts think so.13, 14, 15, 16 There is research that supports this hypothesis. Young Casey, et al.,17 showed that past traumatic events (along with depression) predicted continued pain and disability three months after onset of back or neck pain. In a prospective study, Jones, et al.,18 found that childhood adversities significantly raised the risk of developing chronic widespread pain by mid-life. Chronic widespread pain is an indicator of central sensitization. McBeth, et al.,19 found that altered levels of a stress hormone prospectively predicted the development of chronic widespread pain. Scarinci, et al., found that patients with histories of trauma tend to have lower pain thresholds.20 Lowered pain thresholds is another characteristic of central sensitization.

The common denominator between chronic pain and trauma is thus the nervous system. Trauma can make the nervous system persistently reactive. Once an acute painful injury or illness occurs, people with an already reactive nervous system are more prone to develop chronic pain.

Of course, a history of trauma is not necessary to develop chronic pain. Many people without a history of trauma can also develop chronic pain.  There are likely multiple routes to the development of central sensitization. Nonetheless, a history of trauma and its resultant anxiety are likely one route.

Treatment for chronic pain

Chronic pain rehabilitation programs are the only form of chronic pain management that makes it a point to also focus on psychological factors that can complicate chronic pain. Such programs routinely focus on helping patients to acquire the abilities to self-manage pain and return to work. However, they also focus on treating anxiety, depression, sleep problems, and also, importantly, anxiety related to trauma.

References

1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, 4th edition, test revision. Washington DC: American Psychiatric Association.

2. Walker, E. A., Keegan, D., Gardner, G., Sullivan, M., Bernstein, D., & Katon, W. J. (1997). Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: II Sexual, physical, and emotional abuse and neglect. Psychosomatic Medicine, 59, 572-577.

3. Schofferman, J., Anderson, D., Hines, R., Smith, G., & Keane, G. (1993). Childhood psychological trauma and chronic refractory low-back pain. The Clinical Journal of Pain, 9, 260-265.

4. Domino, J. V., & Haber, J. D. (1987). Prior physical and sexual abuse in women with chronic headache: Clinical correlates. The Journal of Head and Face Pain, 27, 310-314.

5. Tietjen, G. E., Brandes, J. L., Peterlin, B. L., et al. (2010). Childhood maltreatment and migraine (part I). Prevalence and adult revictimization: A multicenter headache clinic survey. Headache, 50, 20-31.

6. Walling, M. K., Reiter, R. C., O’Hara, M. W., Milburn, A. K., Lilly, G., & Vincent, S. D. (1994). Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstetrics & Gynecology, 84, 193-199.

7. Briere, J. & Elliott, D. M. (2003). Prevalence and psychological sequelae of self-reported childhood physical and sexual abuse in a general population sample of men and women. Child Abuse & Neglect, 27, 1205-1222.

8. Elliott, D. M., Mok, D. S., & Briere, J. (2004). Adult sexual assault: Prevalence, symptomatology, and sex differences in the general population. Journal of Traumatic Stress, 17, 203-211.

9. Schafer, J., Caetano, R., & Clark, C. L. (1998). Rates of intimate partner violence in the United States. American Journal of Public Health, 88, 1702-1704.

10. Nicol, A. L., Sieberg, C. B., Cauw, D. J., Hassett, A. L., Moser, S. E., & Brummett, C. M. (2016). The association between a history of lifetime traumatic events and pain severity, physicacl function, and affective distress in patient with chronic pain. Pain, 17(12), 1334-138.

11. Apkerian, A. V. (2011). The brain in chronic pain: Clinical implications. Pain Management, 1, 577-586.

13. Arendt-Nielsen, L. & Graven-Nielsen, T. (2003). Central sensitization in fibromyalgia and other musculoskeletal disorders. Current Pain & Headache Reports, 7, 355-361.

14. Macfarlane, A. C. (2007). Stress-related musculoskeletal pain. Best Practice & Research Clinical Rheumatology, 21, 549-565.

15. Basser, D. S. (2012). Chronic pain: A neuroscientific understanding. Medical Hypotheses, 78, 79-85.

16. Heim, C., Ehlert, U., & Hellhammer, D. H. (2000). The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders. Psychoneuroendocrinology, 25, 1-35.

17. Young Casey, C., Greenberg, M. A., Nicassio, P. M., Harpin, R. E., & Hubbard, D. (2008). Transition from acute to chronic pain and disability: A model including cognitive, affective, and trauma factors. Pain, 134, 69-79.

18. Jones, G. T., Power, C., & Macfarlane, G. J. (2009). Adverse events in childhood and chronic widespread pain in adult life: Results from the 1958 British Birth Cohort Study. Pain, 143, 92-96.

19. McBeth, J., Silman, A. J., Gupta, A., Chiu, Y. H., Morriss, R., Dickens, C., King, Y., & Macfarlane, G. J. (2007). Moderation of psychosocial risk factors through dysfunction of the hypothalamic-pituitary-adrenal stress axis in the onset of chronic widespread musculoskeletal pain: Findings of a population-based prospective cohort study. Arthritis & Rheumatism, 56, 360-371.

20. Scarinci, I. C., McDonald-Haile, J., Bradley, L. A., & Richter, J. E. (1994). Altered pain perception and psychosocial features among women with gastrointestinal disorders and history of abuse: A preliminary study. The American Journal of Medicine, 97, 108-118.

Date of publication: April 27, 2012

Date of last modification: August 7, 2017

Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Its mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides Academic quality information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

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