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How should I work with PTSD alongside chronic pain?

The experience of pain can interact with PTSD in several ways. Some clients experience pain relating to physical injuries caused by the same trauma that led to their PTSD. For others, there is no identifiable physical cause for their pain and it remains ‘medically unexplained’ but nevertheless arose after trauma. Others present with chronic pain relating to pre-existing, known conditions such as arthritis, which may have little functional relationship to PTSD but make both conditions harder to deal with, and can act as a barrier to accessing treatment. Lastly, there is evidence that people with PTSD may experience physical symptoms more acutely. For example, anxiety can increase pain sensitivity and lower pain tolerance meaning that, in all cases, the problems interact and can form mutual maintenance cycles.

Exploring these associations and understanding them alongside our clients can be a helpful process in normalising the problems, as well as identifying areas to focus an intervention. To do this, we need a thorough assessment of when different symptoms started, how they have progressed, perceptions and beliefs about them, coping strategies used, and how the symptoms impact on our clients. We can use diaries to track symptoms, both physical and psychological, to see how they interact with each other, as well as with coping behaviours, trauma reminders, activity levels and so on. We can also draw on information from medical professionals and any tests or treatments our clients have had. This information will inform our formulations and highlight potential treatment targets.

A collaborative and exploratory stance is also important as many of our clients with pain difficulties have already had unhelpful healthcare experiences and may feel their pain has been dismissed, misunderstood, inadequately treated or perceived as “all in your head”. It is particularly important then to be validating, compassionate and curious, taking these problems seriously, being sensitive to use of language, and working together with our clients to better understand the problem.

We also need to be flexible in how we deliver therapy to make it as accessible as possible to our clients. Depending on their needs, this could include remote sessions if they will struggle to travel to appointments (video is preferable to phone if possible), pacing sessions such as offering shorter appointments or including breaks, discussing the best time of day for sessions, being flexible with cancellations where possible, making sure our therapy rooms are accessible and comfortable and so on. Between-session tasks like reclaiming your life activities and behavioural experiments will need to achievable. But don’t make assumptions about what is needed – these adaptations are all discussed and agreed based on individual preferences and requirements.

Depending on an individual’s formulation and treatment goals, there are different ways to approach treatment. One option is to focus primarily on PTSD, delivering our usual trauma-focused psychological treatments, while adapting only minimally as required to help someone get through treatment. If PTSD is, at least in part, worsening or causing pain symptoms, this should lead them to improve as a natural consequence. However, if pain is so severe that it interferes with therapy, or is the client’s primary treatment goal, it might require more direct attention – either by accessing specialist pain treatment prior to, or concurrently with PTSD work, or by integrating the treatments. Integrated treatment does not, in our view, mean abandoning the models and techniques that we know are effective in treating PTSD. Instead, we try to formulate both problems and understand overlapping processes. Then we use techniques from both our PTSD treatments and evidence-based pain treatments to address the key maintenance processes. For example, avoidance, hypervigilance, attentional bias, and threat appraisals are key to understanding both PTSD and chronic pain (e.g. Beck, & Clapp, 2011).

PTSD symptoms can also be experienced in very physical ways. Where a client experienced pain (or other physical sensations) peri-traumatically, it makes sense that these are re-experienced when trauma memories are triggered. This is why we talk about traumas being ‘re-experienced’ rather than ‘remembered’ in PTSD; they are powerful physical, sensory, emotional as well as cognitive memories. When we track physical symptoms like pain after trauma, we may discover that some of the pain triggers are reminders of the memory. If so, reconceptualising these as re-experiencing symptoms allows us to test a hypothesis – if we can better process the trauma memories through treatment, it may mean that some of these symptoms resolve or lessen. Conversely, pain may itself be a reminder of the trauma and trigger strong memories and emotions. In fact, these two processes can interact, leading to a ‘folding over’ where physical pain in the present and memories of past pain fuel each other. As with other triggers, we can help clients recognise and understand this process, and then use trigger discrimination to separate the past and the present. We’ll write a future FAQ on how best to update very physically painful memories.

Practice points

· PTSD and pain can interact via various pathways.

· A thorough assessment is needed, including collecting symptom and trigger data, to understand and conceptualise the link.

· Treatment delivery may need to be individually adapted to make it accessible and comfortable.

· Depending on the formulation and treatment goals, approaches may be ‘tethered’ to a PTSD model, delivered sequentially, concurrently, or via an integrated approach.

· Integrated treatments for comorbid problems stay close to evidence-based models by targeting processes common to both problems.

· PTSD symptoms can be expressed in physical ways, including through pain and, conversely, pain can be a trigger to PTSD symptoms.

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