When Pain and PTSD Meet

How often have you seen a patient with pain? It is a new pain in a series of ‘new’ complaints. It started out relatively manageable and anti-inflammatory medication helped for a short time. As the days after your patient’s car accident progressed, though, she returned continuing to complain of more pain. You referred her for physical therapy and that, too, helped, but didn’t seem to cure her of her pain. Specialists might be tried over time as her pain began to spread. You are starting to think that she is psychosomatic.

In fact, perhaps she is. But not in the way you think. Patients who have seemingly innocuous injuries can find healing from them more difficult if they have a history of prior physical injuries, developmental trauma, prior medical or surgical interventions, anesthesia, emotional or physical or sexual abuse. The autonomic dysregulation resulting from trauma experiences otherwise held at bay can easily erupt with even seemingly ‘simple’ injury or fear. The result: PTSD, chronic pain, occupational problems, headaches, anxiety and depression, fibromyalgia, irritable bowel syndrome. The research supports this—children exposed to abuse or neglect, infants who experience pre- or perinatal trauma, and young children who have a trauma history are at greater risk for developing PTSD and chronic pain later in life after a shock trauma such as a fall, car accident, or emotional upset (Stevens, 2015).

Why? Initially, the autonomic, immediate response to perceived danger, flight or fight, gets disrupted resulting in freeze–deer in the headlights or fainting reflex (heightened and persistent sympathetic charge–anxiety, fear, tension, rigidity, etc., or heightened and persistent parasympathetic charge–depression, low energy, dissociation, etc.). Over time this first domino in a chain of events can affect the autonomic nervous system, endocrine system, fascial and musculoskeletal system, gastrointestinal system, family system, relationships, work ability, and self-esteem. Even executive processes can be affected. (Naviaux, 2014).

Complaints of chronic physical pain can have roots in either end of the continuum between purely physical or purely emotional. The overlap is typical in PTSD as well. Studies suggested correlation between these ends of the continuum and, perhaps, it is why both diagnoses are frustrating to treat. The bi-directional communication between the body and the brain is a significant factor in this challenge.

Somatic Experiencing®, developed by Dr. Peter Levine, is a somatic psychotherapeutic approach which facilitates the redevelopment of a self-regulating autonomic nervous system by addressing the bi-directional communication between body and brain. It includes sensory, affective, behavioral, memory and executive functions and is based on theories of neurophysiology, neuroanatomy, psychology, human development, animal behavior, trauma and normal physiology. It is a very refined and enormously successful exposure therapy that avoids dramatic catharsis and the potential for re-traumatization.

Body awareness is one key component of Somatic Experiencing®. Mammals, including humans have a safety mechanism to avoid the anguish and pain of being traumatized or feel the torture of being killed: we become numb with shock. Humans dissociate from our felt sense or physical sensation through the cascade of biochemical secretions such as endorphins, epinephrine (adrenalin), norepinephrine, and cortisol. When the actions these chemicals are intended to facilitate (flight, fight) fail the tonic immobility of shock sets in. We are meant to come out of this energy conservation state after a short time. If we don’t there will be significant autonomic ramifications that can eventually result in symptoms of PTSD, chronic pain and other problems. During a Somatic Experiencing ® session a client is carefully guided to a level of autonomic excitation in which the potential for the thwarted survival impulses toward action can be felt and completed without the threat present. This allows for a metabolic discharge of the tonic immobility and re-engagement in the present moment.

Affect tolerance, or the ability to feel the feelings and the thwarted movement impulses without becoming overwhelmed or numb, is another main aspect of Somatic Experiencing®. Emotions are varying states of physiology and posture, and they have somatic sensations associated with them. Following a traumatic experience these are often undercoupled or disengaged from one another. When reconnected new cognitions are often developed, with a new understanding of self, of what happened, and a shift in belief to more positive and life affirming.

The most important component of working with trauma that manifests as chronic pain and/or PTSD is that the work be done in manageable titrations (like mixing an acid and a base so there is no explosion) and does not overwhelm or retraumatize. This is the beauty (and art) of Somatic Experiencing ®. To facilitate this delicate balance the therapist must have detailed knowledge of the relationship between the various parts of the autonomic nervous system, comprehend the psychodynamics and neurobiology of relationship, be knowledgeable about human development, and understand anatomy, physiology, and neurophysiology of trauma. Knowing how to support and facilitate autonomic regulation with proper, healthy touch and understanding the anguish of PTSD and chronic pain are also essential for skilled therapists working with this population.

PTSD and chronic pain need to be addressed as aspects of a whole continuum and not as separate diagnoses ‘isolated’ from one another. The constant over association of physical sensations, intrusive images, avoidant behaviors and the constant search for a cure can perpetuate physical pain, emotional anguish, social disengagement (this alone is enough to drive the autonomic dysregulation), poor self-care (including nutrition), re-enactment and destructive beliefs about self.

When pain and PTSD meet, we need to address a patient’s complaints as part of a continuum that includes their body, emotions, spirit, cognition and trauma history. The physiological and behavioral symptoms experienced with PTSD and chronic pain are accompanied by suffering. At a minimum, the suffering can be alleviated and symptoms will be reduced. Complete alleviation, though, is possible with Somatic Experiencing®, proper nutrition, exercise, medication management, and social/emotional support.

References

Levine, Peter (1997). Waking The Tiger: Healing Trauma. North Atlantic Press.

Levine, Peter (2001). In An Unspoken Voice: How The Body Releases Trauma and Restores Goodness. North Atlantic Press.

Naviaux, R. K. (2014). Metabolic features of the cell danger response. Mitochondrion, 16, 7-17. doi:10.1016/j.mito.2013.08.006

Stevens, J. E. (2015, June 3). The adverse childhood experiences study - the largest, most important public health study you never heard of - began in an obesity clinic. Retrieved from https://acestoohigh.com/2012/10/03/the-adverse-childhood-experiences-study-the-largest-most-important-public-health-study-you-never-heard-of-began-in-an-obesity-clinic/