Chronic pain may make trauma more difficult to treat, a study reveals

Post-traumatic stress disorder, or PTSD, affects many people who are exposed to real conditions, such as torsion. Recent research suggests that chronic pain may make trauma more difficult to treat.

Trauma-based treatment is effective for many patients with PTSD, allowing them to talk through the trauma they have experienced.. “

Iselin Solerød Dibaj, Psychologist, Oslo University Hospital

However, not everyone benefits equally from this type of treatment.

“Unfortunately sufferers of both chronic pain and PTSD unfortunately benefit less from conventional treatment,” Dibaj says.

The Red Cross estimates that between 10 000 and 35 000 people with refugee backgrounds who came to Norway have been tortured, highlighting the great need for effective treatment in this country as well.

“Torture is one of the worst forms of abuse a person can ever suffer. Physical and mental pain is introduced with the intention of breaking down a person or obtaining information,” says Håkon Stenmark, an expert in psychiatry. clinical psychiatry at RVTS Midt, a regional resource center for violence, traumatic stress and suicide prevention in central Norway.

“Mental health therapists are finding it difficult to provide effective help to people who have suffered a stroke. They are pushing to increase their experience and find more effective ways,” says Stenmark.

Now Dibaj and Stenmark, along with Professor Leif Edward Ottesen Kennair and Joar Øveraas Halvorsen, a specialist in clinical psychology and PhD at the Regional Trauma Treatment Unit at St Olavs Hospital, have published an article in the journal Torture about treatment of this patient group.

Professor Kennair, from the Norwegian University of Science and Technology, has been the leader and driving force behind the research project that could lead to better treatment of victims pain.

“Exposure therapy” involves absorbing patients ’memories and trying to talk through the trauma.

“But trauma-focused treatment for torture victims has been criticized in a number of clinical and academic settings for being overly concerned about the trauma and ignoring context, such as social, political factors. and historical, “Dibaj said.

Dibaj says they understand this criticism, at the same time not wanting to write a trauma treatment for this group that has documented efficacy in other patient groups.

Other groups exposed to trauma in recent years have shown evidence that both chronic pain and PTSD contribute to the consolidation of the other condition. One disorder can trigger the other, ensuring that neither disappears.

“So people with both complications have worse treatment outcomes with both the trauma condition and the chronic pain than if they had only one disorder,” Kennair says.

Having both problems also presents a number of additional challenges that physicians do not specifically and purposefully address in trauma treatment or pain management.

“So we question whether these factors are partly to blame for the trauma treatment not being as effective for the victims of the pain,” Kennair says.

Effective trauma treatment is largely about experiencing mastery and learning new ways to deal with painful memories.

“But if the patient feels uncontrollable pain, without the tools to deal with it, there is a risk that he will not have this experience. The patient may then let go. or unwillingness to explore the memories, “Dibaj said.

Similarly, pain management by the physiotherapist rarely works directly with trauma memories. Therefore, this treatment can fall into the same trap – the patient would not be allowed to perform the rehabilitation exercises in case they experience the trauma.

“We criticize the current ‘gold standard trauma therapies’ for not working deliberately and especially with important maintenance devices for patients with both pain and PTSD , “said Dibaj.

But these patients may achieve better results if the therapists worked with the pain and trauma at the same time.

“In other words, psychologists and physiotherapists should cooperate more in the treatment of these patients,” Dibaj says.

“We must also remember that the pain is such a unique and special experience that we cannot just conclude that the pain problems in these patients are the same as we see in other patients with the same problem, “said Dibaj.

Norway has ratified the UN Convention against Torture. He says that people who have been tortured have the right to be rehabilitated. In a report from earlier this year, the Red Cross found that the services offered to torture victims in Norway were mixed and highly dependent on people.

“At the same time, it is incumbent on those of us who work in the health care services to offer evidence-based treatment and equitable health services,” Halvorsen said.

This means that patients with PTSD must offer the type of treatment that currently sees the best documented effect. This guide applies regardless of history. The treatment must be adjusted to each individual patient.

“International guidelines for the rehabilitation of torture victims recommend an interdisciplinary, specialized follow-up of these patients. However, studies show that even patients who receive such pain. of multifaceted treatment has very few side effects. We just need to know more about how we can help this group, “says Dibaj.

“We have been showing that Norway does not have dedicated rehabilitation services for victims of torture for a long time. But since we still don’t know much about what identifies effective rehabilitation for this group, the funding and implementation of clinical studies must be an essential part of a specific rehabilitation program, ”Halvorsen says.

But why do some people suffer from PTSD?

“From an evolutionary perspective, we can understand the function of both pain and anxiety. These are warning systems that indicate to us that something may be a danger to us. These symptoms are causing us the condition This can be flexible in the short term, so that we steer clear of potential harm, “says Dibaj.

With PTSD and / or chronic pain, our alert system is proactive and fires a series of false alarms about danger.

Avoidance usually diminishes when the high risk is over, but with PTSD and / or chronic pain, our alert system is proactive and fires a series of false warnings about danger.

“If we treat these alarms as a real threat and avoid the triggers of the alarm, there is a risk that the alarm system will become more sensitive,” Dibaj says.

“Research shows that post-traumatic experiences or thoughts – that is, thoughts that arise after experiencing trauma – can play an important role in developing and prolonging post-traumatic stress. Examples of this type of post-traumatic psychology may be, ‘The world is a dangerous place’ or ‘I am a broken man,’ ‘says Halvorsen.

Both PTSD and chronic pain are characterized by several such false alarms. The affected person may have obstacles, for example, where something dangerous from the past is seen as dangerous now. Victims can also experience symptoms of pain without attaching them to something that is wrong with their body.

“Torture is designed to create this kind of distress and, especially recently, to create pain that will not lead to visible separations,” Dibaj says.

Many pain sufferers find that completely normal movements energize their alert system. This naturally leads to less physical activity and also makes many people afraid to move. This condition is called kinesiophobia, when normal activities can lead to severe pain and a recurrence of the trauma.

“When patients develop a fear of completely normal movements, it is difficult to do physiotherapy or other things that may improve – and that is why we believe that kinesiophobia contributes to the consolidation of the ailments. But this is something we rarely focus on in normal trauma. treatment. So physicians need to broaden their understanding of these connections, “he says. Stenmark.