Chronic Pain and Trauma: A Psychiatric Perspective

Many of my patients with chronic pain are women who are depressed and whohave experienced a tragedy of some sort in their past. Often, their pain seemed tostart after an accident that occurred years earlier. Physical examination andlaboratory studies do not yield tangible findings in most cases.Does chronic pain in such patients have a psychological component? And, ifso, what are the implications for management?--Percy Kepfer, MD
  &nbspFort Pierce, Fla
Chronic pain that lasts more than 6 months isassociated with a high rate of depression--around 90%.¹ Unremitting pain and the inabilityto resolve it can lead to a sense of helplessness.It can also produce hopelessness, whichstems from the perception that caregivers are unable toprovide help.Past trauma and chronic pain. In some patients, ahistory of trauma may play a significant role in the causationand perpetuation of pain. For example, a man seeshis friend die of a chest injury during a car accident. Althoughthe man who witnessed the accident sustains nophysical injury, he complains of chest pain. GI and cardiologyevaluations reveal no cause. He is referred to a psychiatrist,who initiates antidepressant therapy and briefpsychotherapy. As the psychotherapy helps the patientgradually feel less guilty about surviving the accident,the pain decreases.Post-traumatic pain is probably most commonly seenin women who have been sexually abused or raped. In astudy of 2 groups of women who underwent laparoscopyto investigate pelvic pain or infertility, the women withpelvic pain were much more likely to have a history ofsexual abuse.² Such pain may represent a "flashbulb"memory (one that is seared into the patient's mind as ifa flashbulb had illuminated the scene) of the traumaticevent.Treatments for post-traumatic pain. Effective treatmentsare available for pain associated with traumaticevents. Antidepressants, particularly selective serotoninreuptake inhibitors such as sertraline or citalopram, canhelp reduce the comorbid depression commonly seen inpatients with post-traumatic pain.Psychotherapy can also be helpful. The most effectivepsychotherapy for patients who have experienced atraumatic event is cognitive behavioral therapy (CBT).CBT helps patients see their trauma from a more adaptiveviewpoint. For example, a woman who was sexually molestedas a child believes she was somehow responsiblefor the attacks; therapy can enable her to reassign blamemore appropriately to the perpetrator.For patients who lack insight into the psychologicalorigins of their problem, CBT can still be effective. CBT isbased on the idea that beliefs and thoughts drive emotions.If a person believes that his pain will continue toescalate, his suffering will be worse than it would be if hethought there was potential relief in the future. Similarly,if a patient believes that his pain is totally incapacitating,he will restrict functioning. However, if you ask such apatient to test his belief by trying to perform some routinefunctions, and then give him positive reinforcement, hemay be helped to change the ideas he holds about hispain.Pain results from both biomedical injury and psychosocialforces. Even when nothing can be done biomedically,psychological interventions can still be helpful.--Stuart J. Eisendrath, MD
  &nbspProfessor of Clinical Psychiatry
  &nbspUniversity of California at San Francisco

References:

REFERENCES:1.

Eisendrath SJ. Psychiatric aspects of chronic pain.

Neurology.

1995;45:S26-S34.

2.

Walker E, Katon W, Harrop-Griffiths J, et al. Relationship of chronic pelvicpain to psychiatric diagnoses and childhood sexual abuse.

Am J Psychiatry.

1988;145:75-80.