It is increasingly recognized that childhood trauma and PTSD affect not only the quality of life of many individuals but also their physical health. Research has increasingly demonstrated that trauma can lead to neurobiological dysregulation, altering the functioning of catecholamines, the hypothalamic-pituitary-adrenocorticoid axis, endogenous opioids, thyroid and immune function, and neurotransmitter systems. It is not surprising, therefore, that exposure to traumatic stress is associated with increased health complaints, health-services utilization, morbidity, and mortality.
Trauma and Chronic Pain
The prevalence of trauma is substantially elevated in patients with chronic pain. A current PTSD prevalence of 35% was seen in a sample of chronic pain patients,28 compared to 3.5% in the general population.29 In a study of patients with chronic low back pain, 51% of the patients evidenced significant PTSD symptoms.31 Daniel Claw and others have found a strong association between trauma, childhood sexual abuse in particular, and central sensitization (CS) syndromes.30 Emotional pain can amplify physical pain perception, and pain itself can actually serve as a reminder of the traumatic event, and thus put the patient at risk for dose escalation.
Screening and Referral Overview
- PTSD symptom screening is an important addition to routine preventive health screening in primary healthcare settings because:
- Patients are unlikely to report trauma history or symptoms unless directly asked.
- Trauma exposure is associated with many problems—emotional and physical—that affect health.
- Patients with long-lasting PTSD are unlikely to achieve significant improvement in symptoms without behavioral health treatment.
- Gather a thorough bio-psycho-social history and assess the individual for medical and psychiatric problems. Do a risk assessment for suicidal and homicidal ideation. Also ask about substance abuse.
- Assess for PTSD symptoms. There are a number of screening tests that have been designed for use in primary care and other medical settings. See PTSD Screening and Referral: For Health Care Providers for more information.
- Make appropriate referrals for PTSD, depression, other psychiatric disorders, or significant spiritual issues. Likewise, help build up or stabilize the patient’s social support network, as this will act as a buffer against the stress they are experiencing.
Trauma-Informed Treatment
- Research suggests that providing CBT treatments to address PTSD symptoms in patients with chronic pain may lead to improvements in pain-related functioning.32
- Other useful treatment methods include behavioral regulation methods (imagined or actual exposure to feared activities or circumstances) and physiological strategies (relaxation-response training; movement therapy) that overlap substantially with many aspects of cognitive behavioral therapy used in the treatment of chronic pain.
- Multimodal pain programs, which are trauma informed, also provide a good referral resource for those suffering from PTSD and persistent pain.
What Can Healthcare Providers Do
Healthcare providers can increase the chances of improved health outcomes for their patients by following these steps:
- Identify behavioral health professionals in the healthcare system or community who work with patients who have PTSD
- Screen for trauma
- Discuss the results openly with your patient
- Provide a referral when appropriate
- Provide educational materials
- Follow up with the patient
Further information can be found on: U.S. Department of Veterans Affairs website
Tools
See Primary Care PTSD Screen (PC-PTSD) in Appendix D.
