Beyond pain catastrophizing: rationale and recommendations for targeting trauma in the assessment and treatment of chronic pain

KEYWORDS:

• Pain catastrophizing
• trauma
• chronic pain
• stress
• ACEs

1. Background

Cognitive factors, such as maladaptive pain beliefs, are central to the development and management of chronic pain. One of the most important cognitive correlates of chronic pain intensity and pain-related disability is pain catastrophizing (PC), generally defined as the tendency to magnify the threat and interpretation of pain [1–3]. Pain catastrophizing is comprised of three dimensions: rumination, the repetitive focus on symptoms of distress; magnification, an exaggerated perception and anticipation of the threat of pain; and helplessness, a perceived inability to exert control [1]. Reduction in PC is a key mechanism through which gold standard, widely-adopted psychological treatments for chronic pain, such as Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT), are purported to improve pain-related outcomes [4–7]. Although these empirically-supported treatments have a large evidence base, their overall effects on chronic pain are modest. For example, a comprehensive review of psychological therapies for chronic pain found that CBT and ACT have small beneficial effects in reducing pain, disability, and distress in patients with chronic pain [8]. One potential contributor to these modest effects may be that important factors from patients’ histories that interact with and exacerbate PC and pain are often left out of gold standard chronic pain treatments. Such factors include histories of psychological trauma and adverse childhood experiences (ACEs), which are common yet not routinely assessed and treated among patients with chronic pain. In this paper, we argue that effective chronic pain treatments, specifically those targeting the reduction in PC, should also incorporate a thorough assessment and treatment of trauma, recognizing it as a significant and potential underlying factor in PC and chronic pain. We also provide recommendations for integrating trauma-informed care into both medical and mental health practices for more effective and personalized chronic pain management.

Trauma, including ACEs, is a risk factor for the development, exacerbation, and maintenance of chronic pain [9,10]. Adults who report histories of trauma report more pain symptoms than those without such histories, and patients with chronic pain are more likely to report trauma than pain-free individuals [11]. Similarly, trauma and post-traumatic stress disorder (PTSD) are associated with a higher likelihood of chronic pain and more negative pain-related outcomes [12–14]. Trauma may contribute to pain by disrupting physiological, cognitive, emotional, and interpersonal processes [15]. Individuals with pain and trauma experience greater functional impairment, emotional distress, and worse response to treatment compared to patients with only pain or trauma symptoms [12,16,17].

In patients with chronic pain, those who report a greater number of traumatic or adverse experiences report higher PC than individuals who report less or no traumatic experiences [18–21], and several factors may explain this link. Traumatic experiences are associated with heightened threat perception and negative thinking patterns, making survivors of trauma more prone to catastrophic thinking in general. Trauma survivors may develop negative beliefs about themselves, others, and the world, and such beliefs can extend to pain, leading individuals to catastrophize about their pain experiences (e.g. believing that the pain will never improve or that it will lead to dangerous consequences) [21]. Trauma-related symptoms and chronic pain also share emotional characteristics, including fear, anxiety, guilt, anger, and general emotional distress [22]. These shared emotional characteristics can contribute to the cycle of both trauma-related distress and PC. Further, trauma often leads to a state of hyperarousal, characterized by increased physiological and psychological alertness to potential threats, which may lead to a greater awareness and sensitivity to pain signals, and to more severe and distressing pain perceptions [21]. Individuals in this heightened state of arousal may be more likely to catastrophize, magnifying pain’s perceived threat. Trauma can also result in a profound sense of helplessness and loss of control, which may extend to a sense of helplessness regarding one’s ability to cope with or control pain, a key facet of PC. Thus, for patients with comorbid trauma and pain, treating PC without addressing unresolved trauma and related sequelae may perpetuate distress associated with both trauma and pain.

In addition to cognitive factors, trauma and pain appear to be linked by behavioral factors such as avoidance, as posited by the perpetual avoidance model [23], which suggests that avoidance of experiences that may provoke pain or trauma-related symptomatology will tend to amplify the severity and adverse impact of both conditions over time. Pain-related avoidance behaviors, commonly triggered by PC (e.g. the anticipation of pain), lead to avoidance of activities expected to cause discomfort, resulting in activity restriction, increased risk of negative mood, deconditioning, and functional disability. Avoidance of both internal and external trauma-related stimuli (i.e. experiential-avoidance) shares similarities with fear-avoidance in pain. Trauma survivors may develop avoidance behaviors (i.e. avoidance of memories, thoughts, emotions, situations, and activities that trigger fear) to manage the emotional distress associated with their trauma, and these avoidance behaviors can generalize to pain-related situations [21]. Indeed, higher levels of experiential-avoidance are linked to increased pain intensity, pain disability, and psychological distress [21]. Avoidance maintains both trauma-related symptoms and pain because it prevents patients from engaging in experiences than can disconfirm their fears, such as facing and processing difficult trauma-related emotions or engaging in physical activities that may improve pain and functioning.

In summary, chronic pain treatments that aim to reduce PC should also assess for and treat trauma as a potential underlying and important contributor to chronic pain. Trauma-informed care (TIC) is a person-centered approach to patient care that seeks to establish safety, trustworthiness, choice, collaboration, and empowerment by recognizing the prevalence and widespread impact of trauma and ACEs on patients’ lives and health outcomes [24,25]. Medical and mental health professionals should be prepared to account for trauma and ACEs in the assessment and treatment of pain by developing awareness and knowledge of the trauma and pain connection, increasing their utilization of trauma screening tools, and incorporating trauma-informed education and interventions when caring for patients with chronic pain [24,25]. It is important to note that not everyone who experiences trauma will develop chronic pain, and the relationship between trauma and pain can vary greatly from person to person. Nevertheless, there is enough evidence of the trauma-pain connection to warrant routine screening and assessment of trauma when treating patients with chronic pain in both medical and mental health settings, and to warrant trauma-focused adaptation of psychological interventions for chronic pain.

2. Recommendations for practice

Given that reduction in PC is widely acknowledged as a crucial factor in chronic pain treatment, the emphasis in this specific section is on addressing trauma as a potential underlying contributor. Therefore, below we provide a series of clinical recommendations for trauma-informed pain care. It is important to note that the suggested clinical recommendations call for the availability of healthcare providers who are knowledgeable of the trauma-pain connection and who can implement thoughtful clinical decision making and treatment planning for patients with comorbid trauma and pain. We recognize the institutional and organizational constraints for providers and clinics, and the low availability of integrative trauma-pain treatment. Therefore, we strongly advocate for the dissemination of trauma-informed pain services through discipline- appropriate training for both medical and mental health providers. Given the strong need for trauma-focused approaches to chronic pain treatment, the training of healthcare providers grants the opportunity for a systems-level intervention with great potential for impact on patient outcomes, without adding long-term burdens of increased number of visits or demands on clinics to hire more personnel.

A review by Raja et al. [24] provides a synthesis of the literature and an operational framework for general TIC practices in medicine. Applying this TIC framework to medical providers who care for patients with chronic pain includes several key steps, some of which are important and helpful practices when working with all patients, not only those who have been exposed to trauma. Some of these universal TIC principles include using empathetic communication and active listening, demonstrating respect for patients’ experiences, involving patients in treatment decisions, and avoiding invasive procedures without adequate explanation or consent. More specific to the treatment of chronic pain, medical providers are encouraged to seek education and training to develop their knowledge of the trauma-pain connection and the potential effects of trauma on treatment outcomes in this population. Additionally, given that patients with chronic pain often encounter stigma in the healthcare system, it is important to develop medical providers’ skills in sensitively and compassionately discussing the trauma-pain connection with patients. Further, it is recommended that medical providers routinely screen patients with chronic pain for a history of trauma using validated assessment tools or questionnaires. Screenings can inform important clinical decision-making by identifying patients who may benefit from referrals to trauma-specialists and who may benefit from trauma-informed psychological pain interventions as part of their interdisciplinary pain management plan.

In addition to applying the aforementioned general TIC practices, mental health providers who treat patients with chronic pain can become more trauma-informed by also routinely assessing for trauma in this population to identify patients who may benefit from trauma-focused therapy techniques and guide treatment planning. Chronic pain treatments for individuals with trauma histories should begin with psychoeducation on not only how trauma influences thoughts, emotions, behaviors, and interpersonal relationships, but also how ongoing trauma-related distress influences the development, perception, and maintenance of chronic pain. Additionally, providers are encouraged to tailor standard pain interventions to help patients process traumatic experiences along with addressing chronic pain, and to modify treatments to target common mechanisms underlying both trauma and pain [26,27]. For example, CBT for chronic pain commonly includes techniques such as cognitive restructuring, behavioral activation, activity pacing, and skills training which are employed to address pain-related catastrophizing and avoidance behaviors [28]. We suggest implementing, in parallel, similar evidence-based CBT, ACT, and exposure techniques to specifically target trauma-related catastrophizing and avoidance. Specific techniques may include: cognitive restructuring to specifically identify and modify maladaptive beliefs associated with trauma; imaginal, in-vivo, and emotion-focused exposure exercises to specifically address experiential avoidance of trauma-related memories and experiences [26,27] and structured writing assignments to help process trauma and change unhelpful related beliefs [29]. When possible, it is recommended that trauma-focused techniques be implemented concurrently and integratively with pain treatment to reduce time burden on both patients and clinics [30]. A review by Lumley et al. [27] highlights several psychological interventions, such as Emotional Awareness and Expression Therapy [31], that aim to address both trauma and chronic pain simultaneously. Training in such approaches is encouraged for mental health providers who treat patients with chronic pain.

There has been a recent shift in psychotherapy away from ‘protocols for syndromes’ and toward Process-Based Therapy (PBT), defined as ‘the contextually specific use of evidence-based processes linked to evidence-based procedures to help solve the problems and promote the prosperity of particular people.’ [32] Similar to the trend toward personalized pain medicine, focusing on changeable processes through PBS can support the development, testing, and implementation of personalized treatments for chronic pain [33], where patient factors such as trauma history are taken into account in case conceptualization and treatment planning. If, for example, a patient with chronic pain also endorses a history of psychological trauma, and if the clinician identifies through assessment and case conceptualization that trauma is playing a predisposing and maintaining role in the patient’s pain-related symptoms through experiential avoidance (process), then the clinician has the opportunity to select among a set of evidence-based psychotherapy techniques (e.g. exposure) that address the shared processes between trauma and pain, to reverse or alter maladaptive experiential avoidance.

In summary, by modifying psychological treatments such as CBT for chronic pain to be more trauma-focused, or by utilizing interventions and techniques that aim to target both trauma and pain, providers can better address the needs of patients with trauma histories while treating their chronic pain effectively, which can lead to improved outcomes and an enhanced quality of life for individuals with comorbid trauma and chronic pain.

3. Expert opinion

In a personalized approach to pain medicine, providers seek to understand the unique factors contributing to an individual’s pain experience and to develop targeted and customized interventions to improve patient outcomes. Given that trauma is a consistent risk factor for the development and maintenance of chronic pain, the lack of focus on trauma in chronic pain assessment and intervention research, and in clinical practice, is a significant limitation in the field of pain management. Future research should focus on further elucidating the underlying mechanisms that link trauma to chronic pain to inform targeted and personalized interventions. Rigorous evaluation of the efficacy of existing and novel interventions for comorbid trauma and chronic pain is also needed, including the evaluation of which patients benefit most from integrative trauma-pain treatments. Additionally, and importantly, the development and implementation of integrative trauma-pain treatments should be informed by the lived experiences of individuals with comorbid trauma and chronic pain.

Implementing trauma-informed care for chronic pain in clinics faces significant challenges rooted in the need for a fundamental shift in healthcare culture and practices. Key barriers include a lack of awareness and training among healthcare providers, time constraints, and practices of ‘one-size-fits-all’ pain management that may impede comprehensive trauma-informed approaches. Additionally, measuring and evaluating the impact of trauma-informed care poses challenges, necessitating the establishment of clear metrics. Overcoming these challenges requires concerted efforts at multiple levels, which may include comprehensive and discipline-appropriate training programs for pain-focused healthcare providers, incorporation of trauma-informed care principles into ongoing professional development and continuing education programs, and the development of supportive organizational policies and practices (e.g. resource allocation, leadership commitment, interdisciplinary collaboration) to create healthcare environments that prioritize the nuanced needs of individuals with chronic pain.

Declaration of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

The authors are supported by the National Institute of Neurological Disorders and Stroke via grant [K24NS126570]; National Institute of Arthritis and Musculoskeletal and Skin Diseases grant [K23AR077088].