Trauma and Pain: Linking Emotional and Physical Symptoms

Dust Devils, by MSG Martin J. Cervantez, courtesy of the Army Art Collection, US Army Center of Military History.

Chronic pain is a common complaint in the retired military settings with veterans administration (VA) patients rating significantly worse pain than those in the general public [1]. The higher incidence of pain may be due to the heightened exposure to trauma and psychological stress [2]. The combination of pain and posttraumatic stress disorder (PTSD) creates greater self-reported pain and affective distress when compared to pain in patients without PTSD symptoms [3]. Indeed, childhood abuse has been associated with greater chronic pain in adulthood [4] with emotional neglect predicting lifetime trauma exposure over and above physical or sexual abuse [5]. Abuse is also positively correlated with anxiety, depression , somatic symptoms, and PTSD. Childhood emotional neglect may also predict later emergence of an inability to identify or express emotions (alexithymia) and somatization [6], with alexithymia a known risk factor for psychiatric and psychosomatic disorders.

Theories addressing the relationship of PTSD and pain have been proposed but not well researched. The mutual maintenance model [7] highlights various factors that may occur, including attentional biases with patients attending more to threatening or painful stimuli, pain as a reminder of the trauma events, and avoidance to minimize pain and disturbing thoughts.

The triple vulnerability model for PTSD [8] can also be applied to chronic pain. It asserts that life events and one’s emotional reactions to the events are perceived as unpredictable and uncontrollable, leading to impairment. Additionally, development and attachment theories describe the effects of abuse and neglect on self-efficacy and trust.

It is imperative that both the physical and emotional conditions are addressed simultaneously. One such way is to educate patients on the ways that they maintain and exacerbate one another and to use strategies to minimize both the cognitive and behavioral avoidance that is observed so frequently in both conditions [9]. As patients begin to decrease avoidance and increase their participation in appropriate activities, their level of distress and disability may decrease, leading to an improved quality of life. However, the lack of healthy role models for emoting and the use of poor coping skills, such as the overuse of avoidance, are pivotal in maintaining impairments.

In this case study, the interplay between pain and trauma experiences will be exemplified, as well as the investigative process that is required to understand the connection.

15.1 Biopsychosocial Assessment

Cole is a 22-year-old, married, Caucasian, male corporal with approximately 3 years of continuous active duty in the US Marine Corp. He initially was on limited duty status for his pain and disability after fracturing his thoracic vertebral body (T12) and was eventually started on a Medical Evaluation Board for possible medical separation from the military. He worked in communication as a radio operator until his injury prevented him from performing his work tasks. He was referred to health psychology, a mental health specialty clinic, to aid with pain management and anxiety related to feelings of vulnerability due to his physical limitations.

Pearl

Beginning the assessment with a focus on the pain symptoms and treatment experience portrays the belief that his pain is real. Validation is paramount to rapport building and successful therapy.

Cole was participating in CrossFit training at a public gym and was lifting 165 lbs. of weights when his hands slipped and the dumbbell fell on his right shoulder and neck. He tried to bring the weight above his head again, but he could not feel his extremities and subsequently fell to the floor. At that point, he blacked out for approximately 15 seconds and next recalled being in the hands of a trainer stabilizing his neck. He admitted that he did not want to go to the hospital, not wanting to “frighten my wife…and because of my pride.” While applying ice, he lay on the gym floor for an hour. He then stood and drove home on his own, took a shower, and proceeded to bed. However, he soon felt as if he could not breathe and was gasping for air. He had his wife take him to the emergency department for immediate attention.

He received X-rays and a computed tomography (CT) scan, which confirmed he had fractured his T12 vertebra, and was given a torso brace and pain medications. Surgery was discussed and was not recommended. He received a prognosis that he would begin to feel better after 12 weeks. He was placed on convalescent leave and was required only to phone his command daily for accountability as he was unable to drive.

He initially wore a back brace that spanned from his pelvis to neck, creating difficulties with movements. He progressed to a smaller torso brace and over time used no support. However, his pain continued. He complained of constant throbbing in his mid-back and episodes of shooting pain down his left leg to the mid-shin, mainly felt when moving (such as walking). Sitting or standing for more than a few minutes would increase the pain. He was unable to complete many activities of daily living independently, including bathing and dressing his lower half, as he could not bend over.

His wife would aid him with these tasks; although when she was unavailable, he would struggle unsuccessfully. Due to his discomfort, he could not cook or clean as he could prior to the injury. Eventually, he avoided such tasks. The limitations brought on intense frustration, sometimes leading to anger or sadness and other times leading to anxiety about his future and ability to protect his wife.

He admitted sleeping with a knife next to his bed as he felt vulnerable and less able to protect himself and others without the aid of weapons. He agreed that although he did not fear for intruders prior to his injury, his physical limitations brought up feelings of vulnerability. Further, he felt worthless. Continuing to only have contact with his battalion via phone calls, he gained no sense of accomplishment from work. Rather, he felt he had no skills to offer.

He spent his days at his apartment complex, attempting to walk daily (100 yards) and otherwise staying indoors playing video games, watching movies, or reading. The latter activities caused little pain as his symptoms were lessened when lying flat on his back. These activities became monotonous and no longer offered him distraction. He did not emerge from his home unless required for appointments and socialization ceased. The only consistent contact with others included his wife, who was only home 1 day per week, and a peer from his battalion who he would see inconsistently; sometimes meeting every day and other times not speaking for months.

He presented to sessions with a slow and labored gait, getting up cautiously from his seat in the waiting room.

Pearl

Gaining an understanding of the experience throughout the evolution of pain symptoms and dysfunction creates a holistic view of the person.

During sessions, he sat stiffly in the seat leaning to one side and changing positions throughout in attempts to ease his pain. He often did not show outward expressions of pain; however, with movements he would show subtle signs of discomfort.

Cole often felt down and hopeless about his future as he did not see significant improvements in his physical functioning. He had a sense of feeling disconnected to others and an overall numbness of emotions. He used to be quite social and outgoing but justified to the therapist that he was content with not having friends.

Cole reported an inability to relax due to the constant pain. He often reacted to his depressed and anxious feelings with self-blame and deprecation, feeling he had let himself and others down. He thought he was not fulfilling his role as a husband since it was likely he could not maintain a military career.

While he was hopeless, he denied any suicidal thoughts, plan, or intent, stating he lived for his wife and best friend. He reported significant fatigue, which he attributed to pain interfering with his sleep. He showed insight into the effect of worrisome thoughts on his sleep; however, he stated the concerns were only about his lessened ability to protect his wife at night. There was significant overlap in his symptoms between pain, depression, and anxiety, with fatigue, sleep difficulties, and poor concentration being symptoms of all three conditions.

Cole further mentioned a difficult incident during his first field operation training 3 years prior. He said that he and two peers were awoken with kicks and yelling and made to do manual labor as punishment for something they did not do. Posttrauma symptoms were denied, and thus that diagnosis was initially ruled out.

Pearl

Chronic adjustment disorder can be a diagnostic consideration since the lifestyle changes and effects on military career evolve over time.

He endorsed symptoms consistent with depression and anxiety and was diagnosed with major depressive disorder, moderate, single episode.

15.2 Interventions

15.2.1 Initial Treatments and Responses

With a diagnosis of moderate clinical depression, the overarching treatment goals were to improve Cole’s self-esteem and identity when faced with his current physical limitations. His depressive symptoms were understood to be in response to his changed physical status and limiting pain. He readily noted his frustration with his limitations. He focused on getting better quickly, pushing himself to walk a little further every day. However, this resulted in flares of intense pain that would keep him from reaching his goal the following day, thus bringing on more frustration and hopelessness.

Efforts to improve his daily functioning and pain management were initiated. He was challenged to pace himself to his current ability level, adjusting his expectations for physical tasks. Pacing required acknowledging his limits and honoring them. Practicing self-awareness and listening to the body’s signals were the skills he needed to learn. This process can take time, especially when one’s identity is often tied to physical fitness [10].

Cole was focused on what he was no longer able to do, such as running, lifting weights, and getting out on his own. The new limitations to his physical functioning were explained in terms of grief and loss, with loss including his identity as an active, strong person. This identity was threatened since he was dependent on others for necessities, such as bathing, dressing, and driving. He loathed relying on his military command—not wanting others to see him in his “broken” state.

Taking time to grieve these losses validated his emotional reactions, such as sadness, anger, and jealousy of others’ unchanged physical status. It was reframed that although some aspects of his identity had changed, there were still many parts of his identity that were the same. Defining in clear terms what he believed were important aspects of a husband, son, employee, and friend enabled him to see how he still fulfilled these roles. However, until he more fully accepted the reality of his situation, he could not progress in adjusting his identity to incorporate these changes in a healthy manner.

He often blamed himself for his shortcomings, and he needed constant reminding that he did not choose to have the injury and the subsequent difficulties. Adjusting Cole’s expectations was one way to prevent feelings of worthlessness and failure. He said that he and his wife used to spend time together walking at the mall, and he predicted that his need for frequent breaks to sit down would frustrate his wife. He felt it would not be fun for her, so he stopped going altogether.

Pearl

Including a loved one in the treatment plan offers support and accountability.

His wife was present at a session, and she said she would be happy to take breaks with him if it meant going out again. Further, she was comfortable going to a store without him while he rested. It appeared that his avoidance of past-enjoyed activities was due to concurrent poor communication and self-esteem. Once Cole discussed his concerns with his wife and modifications were problem-solved, he was more likely to follow through with the plan.

He was introduced to the idea of having a limited amount of resources per day now, and once that resource was used up, he would either be “borrowing” from the next day’s resources or faced with the increased level of pain. He learned to make conscious decisions about what activities would be worthy of his precious resources for that day. In this way, he had choices, even if they were not ideal.

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