Level of intervention
Potential key issues and intervention methods
Level 1: peripheral nociception
In many trauma-associated pain disorders, an additional somatic nociceptive partial problem exists (e.g., painful muscular tension). The therapeutic goal is to limit the action of this peripheral-nociceptive input through interventions such as muscle-relaxing biofeedback, local heat, heating pads, warming ointment, and warm baths
Sometimes conventional analgesics are employed. Since supportive long-term therapies are often of concern, its usage is restricted due to concern for side effects of drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and opiates. Each analgesic prescription must be critically checked regarding its effectiveness and side effects
On the behavioral level, an important component concerns dosaging of the individual’s physical capacity, e.g., taking regular breaks, physiotherapeutic posture training, and activating movement therapy
Level 2: autonomic imbalance
Stress promotes the development of pain-processing disorders; stress acutely amplifies pain. Reciprocally, pain generates vegetative and emotional stress
Interventions include the correction of sympathovagal imbalance by strengthening the parasympathetic nervous system through practice and regular exercise of a relaxation method (progressive muscle relaxation according to Jacobson, yoga, meditation, autogenic training, biofeedback)
Analysis of the individual biographical stress profile along with the creation of individual orientated stress relief measures
Sleep hygiene measures
Level 3: perceptual processing of pain
Use of central pain-modulating drugs, such as serotonin reuptake inhibitors or tricyclic antidepressants
Body awareness therapy: defocusing on pain training instead of pain scanning, enjoyment and pleasure training, mindfulness exercises, autosuggestion
Distraction strategies: music, media, occupational therapy, excursions, contacts, meaningful everyday tasks
Planning of an individualized home program
Level 4: emotional pain amplification
Anxiety management and disorder-specific cognitive behavioral therapy, antidepressant medication
Conflict resolution therapy to relieve biographic and daily stressors. Important is a distinction between pain-causing distress and pain-maintaining emotional stressors
Awareness regarding the handling of emotions and emotional self-efficacy training
Participation in pleasurable group therapy dealing with drama, music, humor
Personal diary, rituals
Level 5: mental pain amplification
Restructuring of dysfunctional cognitions (“I have an unknown cause of pain,” “I’m going crazy,” “I will end up in a wheelchair,” “I must not move,” “Illness is punishment,” etc.)
Pain group therapy; goal: learn one’s own self-competence and self-efficacy; from “pain victim” to “pain manager”
Restructuring of dysfunctional behavior (e.g., excessive activity due to self-esteem deficit, fear-avoidance behavior)
Involvement in pain information training (=patient education) through presentations, leaflets, movies
Level 6: social consequences
Chronic pain and trauma always have an effect on partnership, family, and friends: involvement and information of the partner and possibly the children. Seek relief solutions that are viable for everyone. Note if the disease has taken on a relationship regulatory influence
Problems with health/social insurances: in many cases patients with pain disorders make frustrating experiences with insurances. Involve professional consultants
Generally: social impacts can become an independent disease-maintaining stressor. Integrating these secondary social effects of the disease is an important part of the multimodal pain therapy
A 54-year-old woman presented chronic pain disorder at our tertiary pain clinic. The patient suffered from whole body pain, especially in the area of the back and the thighs. Her constant pain was increased by stress and anxiety as well as by physical activities, such as standing for some time, walking, or lying down. Additionally, the patient complained about numbness on the right side of the body as well as burning sensations in the area of the foot soles. The pain was associated with disturbed sleep onset and sustained insomnia accompanied by nightmares and fear of the “dark and bad thoughts.” She was easily startled and felt immediately “paralyzed” if she heard certain noises.
A detailed psychosocial exploration revealed the following history: the patient, a professor of history, had been a human rights activist in her native country in the Middle East. Due to her political activities, she was persecuted by the police and jailed. There were several methods used to wear the patient down and to torture confessions from her. The patient saw the origin of the back pain as well the pain in the area of the thighs in her forced fixation in a tire during several days (Fig. 18.1).
Torture of a 54-year-old woman who was politically persecuted. The drawing is based on explanation and a draft by the patient
Diagnostically speaking, the patient fulfilled all the criteria for a posttraumatic stress disorder. The clinical examination showed visible results of the physical torture in the form of 18 stab wound scars in the area of the sacral lumbar spine. The neurological examination additionally revealed a superficial hyperesthesia of the right side of the body. Such nondermatomal somatosensory deficits (NDSDs), typically with hemibody distribution, are known in individuals with high levels of adverse life events in combination with somatic pain events (Egloff et al. 2012). The burning foot sole pain was a result of the lashing (falanga). This form of torture typically leaves a burning and neuropathic-like pain which often increases during the winter months (Prip and Persson 2008). X-rays and MRI of the back and pelvis did not reveal any structural explanations for the pain (e.g., fractures, discopathies). Although there were hardly any visible marks and scars left, the physically abused parts of the body were irreversibly imprinted in her pain perception system (Fig. 18.1).
The patient went through several treatment phases. From the very beginning, it was important for her that the therapist was familiar with trauma-induced bodily pain as well as the psychological sequelae of the traumatization. The pain interview and the examinations were performed very carefully with respectful attention to any signals of stress or dissociation. The formulation of the questions allowed the patient to reveal what and as much as she wanted of her traumatic past. Nevertheless, a coherent story began to develop after a short time.
At the beginning of the treatment, the therapist explained that it is typical that many forms of pain cannot be made visible by MRI or X-rays, noting that, in any case, X-rays never reveal the pain but only marks of physical injuries. The fact that the MRI and X-ray imaging in her case showed no persistent structural lesions was a relief for the patient. The patient’s observation that her type of body pain was of the type that increased in stress situations allowed a change in her pain model: her body developed an “alarm mechanism” with hypersensitivity to any form of threat and stress, including pain. Additionally, these memories were experienced and expressed in her body (hypermnesia). The traumatized organism cannot forget the sufferings. These typical aspects of trauma-associated pain were explained and illustrated to the patient with the help of easily understandable educational pictures (www.hklearning.net/CLIP/Trauma.pdf). These didactic metaphors supported her development of a pain model with which she could identify. She realized that hyperalgesia as well as hypermnesia had developed as essential mechanisms of “protection” for her body.
After having explained the pain sufficiently for the patient, she was also ready for psychotherapeutic sessions focusing on the strengthening of her resources, the treatment of her trauma, as well as the reduction of stress. Her resources luckily included a very strong and intact sense of self-respect that proved to be important and meaningful in her recovery. Her belief in human rights and her ability to express her personal feelings and thoughts facilitated the psychotherapeutic process. Reinforcement of her sense of self-respect as well as her growing understanding of psychophysical nature of her symptoms played an important stabilizing role in her treatment as well as in her personal development and the management of her everyday life. With the help of an additional behavioral therapy, focused mainly on reducing flashback-inducing triggers, the patient succeeded in gaining also more and more control over the other trauma-associated stress symptoms and she overcame the existing “fear-avoidance behavior” step by step. Additionally, treatment for her bodily pain symptoms included a carefully tailored daily (home) program of physical reconditioning and music-supported exercise therapy. With the exception of intermittent use of medication, paracetamol, this patient did not need any long-lasting medical therapy anymore.
As stated above, there is considerable clinical and empirical evidence regarding the comorbidity of chronic pain and trauma-related disorders. Patients with PTSD have higher rates of numerous clinically significant chronic pain conditions. Likewise, patients with chronic pain are often diagnosed with posttraumatic-related stress disorders. Accordingly, patients with comorbid chronic pain and PTSD are more distressed and impaired than those with only one or the other type of disorder. Due to the interaction of these conditions, patients can also be more complex and challenging to treat, especially if there is the need to convey to them that it is likely that they will need to “live with the pain” and “manage it” for the rest of their lives. The assessment of chronic pain in traumatized patients requires consideration of broad etiological factors. It is important to work out with the patient a “model of the pain,” which allows a proper understanding and action perspective.
Interdisciplinary diagnostics and therapy seem to be crucial for therapists and physicians, including psychological therapists and physicians experienced in pain diagnostic and therapy and therefore favor a tailored individualized multimodal and integrative intervention addressing clinically significant pain and posttraumatic stress symptoms. The best way to do so would be to work in interdisciplinary teams in either inpatient, outpatient, or day hospital settings.
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