A Trauma Perspective on Chronic Pain
Written for Pain Australia in 2024
When Jane [1] contacted me, she was desperate. Her pain was so intense and unremitting, she was wondering if life was worth living. A friend of hers, who knew about my work as a trauma and chronic pain therapist, told her she should see if I could help. Jane had been diagnosed with psoriatic arthritis - PSA. One ankle had been fused, the other was about to be. Jane’s work required almost constant standing, meaning she had to push through her pain every day to keep earning a living.
Jane also had a history of physical and mental abuse, starting at an early age with her father, then her boyfriends. She had been in a serious car accident in her early adult years. She’d had a gastric bypass and was a recovering alcoholic. The PSA started around the time she quit drinking and had moved into her ankles. She felt lonely and isolated, was exhausted and anxious all the time and had never been able to truly stand up for herself. Her DASS21 [2] scores were in the extremely severe range for both depression and stress.
Fortunately, Jane was very open to working on her trauma, to see if it would help her pain. I carefully explained how pain can be used by the body to try and keep it safe; and Jane’s body had decided the world was not a safe place for her. So it found a way to immobilise her, shut her down, keep her away from the danger that was her life. Jane’s drinking and overeating were dysfunctional ways she had developed of trying to manage and regulate her emotions, avoiding facing the pain of abuse and rejection. When she quit drinking, but didn’t deal with her underlying trauma, the body developed a different way to keep her shut down.
After therapy, Jane’s unconscious core belief “my body is my enemy”, reversed back to one of healthy respect and compassion for her body. Her DASS21 scores went back to normal. Jane is not troubled by pain now, just a little ankle discomfort after work, and because she changed some other fundamental beliefs about herself that were not true, her experience of life changed too. She is happy now and has found her voice for the first time. No longer a disempowered ‘victim’ of her past, she is now excited about her future.
So how does this happen? How are chronic pain and trauma related? What is actually going on in the mind and the body?
Millions of people struggle with chronic pain; chronic pain is now the leading cause of disability, affecting 20 - 30% of the global population, yet treating professionals still don’t know why pain persists long after an injury has healed, lingering for no apparent reason. Untreated or undertreated pain is an ongoing epidemic. Yet we do know that a high percentage of all chronic pain patients also struggle with some form of traumatic stress. These are the ones I focus on.
Pain clinics have been supporting clients through education, medication management, self-pacing, lifestyle, and cognitive behavioural therapy for many years. The first pain clinics emerged in the late 1960s and early 1970s. During this time, there was growing recognition of the need for specialized medical care and management of chronic pain conditions. The establishment of pain clinics aimed to address the complex nature of chronic pain and provide comprehensive treatment approaches. We are starting to see now a stronger focus now on helping clients develop healthier neural pathways which means a deeper exploration of the role that emotions play on those neural pathways. It requires the client to become more emotionally aware and stress resilient. This article does not seek to provide commentary on all chronic pain conditions, it focuses specifically on the stress response and the way that past trauma affects the neural pathways, causing chronic pain.
Studies worldwide have shown a particularly strong relationship between traumatic events in childhood and later development of chronic pain. Adults who have experienced ACE (adverse childhood events) have two to three times more risk of developing chronic pain.
The link between trauma and chronic pain is complex. The link lies in understanding the ‘reset’ mechanism of the neural pathways and the consequences of constant low level immune activation on the body, but more on that later.
First, what is ‘trauma’? Trauma is the Greek word for wound, and it is used to refer to physical and emotional wounds. Psychotherapists typically use language such as ‘the wounded child’, ‘the wounded soul’, ‘the wounded part’.
Emotional trauma refers to a range of experiences that are perceived as life-threatening or overwhelming, including physical or sexual abuse, accidents, combat exposure, natural disasters, and other forms of violence or extreme stress.
During World War 2 a Harvard anaesthesiologist noted soldiers with serious injuries were being carried off the battlefield alert, awake, not in shock and often refusing morphine, whereas in his civilian practise patients with far less severe injuries were in agony. This led to the laboratory exploration of how psychological factors, like the difference between being relieved to be leaving the battlefield and away from danger, versus going into surgery and into danger, could radically affect the experience of pain. One only has to look at the effect of a placebo to know how powerful the mind can be in this respect. Our brains have evolved to alert us to emotional distress through the same pathways that tune us into physical injury, and both types of pain can feel equally intense. We all know the physical effects of emotional upset: tension in our head and neck, headache, nausea, or abdominal discomfort. Our brains use a process known as ‘predictive coding’ [3] to decide which situations will activate the neural networks to create pain, and conditioned expectations from past painful memories play a central role after experiencing a trauma. Parts of you continue to view new situations in your life through the distorted trauma-based lens, interpreting subsequent events as ‘dangerous’ even if they are unrelated to the initial event. They become frozen in the time of trauma and consequently the body believes it is still in danger.
People who experience developmental trauma, often referred to as ‘disrupted attachment’ trauma, are just as likely to hold trauma in their body as those who have suffered traumatic stress. Individuals with early trauma, experience symptoms on a continuum of less to greater dysfunction depending on the degree of disruption and the coping strategies they have been able to develop. Disrupted attachment trauma is difficult and confusing not only for those who have experienced it, but also for those who treat it. In response to care givers who fail to offer ‘secure’ attachment to their children, those children can experience their environment as threatening and dangerous and their options are to either cling to others or to withdraw into themselves. Children who grow up in unsafe homes become hypersensitive to the emotions, body language and voices of their caregivers, because often their life depends upon it. This early trauma compromises their sense of safety, their sense of self and agency, their ‘right’ to exist and be in the world, and their capacity to form healthy relationships.
There are other types of events that can cause long term trauma in a child's life, which occur before they are born. Children who are carried in the womb of a mother who does not want them, who is traumatised depressed or anxious, or who abuses alcohol or drugs during pregnancy, they all experience attachment trauma. Shock Trauma [4], another form of trauma, can occur where there are difficulties in childbirth, attempted abortions, separation from the mother without sufficient physical contact, being born into significant poverty or being exposed to the intergenerational trauma suffered by the parents. The prisons are full of people with all these sorts of background. They are, sadly, very rarely asked “what happened to you?” to explain their behaviour.
At the recent Australian Pain Society Conference [5] which I attended, one of the keynote speakers, Dr Melanie Noel presented her findings about the importance of using the ACE questionnaire when dealing with children who had chronic pain. She also stated that even the way their caregivers talk about, and make sense of pain, either theirs or their child's, can influence that child's experience of pain.
I was heartened to hear Dr Noel say that anyone working in the pain field should have training in a trauma informed approach. In fact, the evidence between ACE and chronic pain has been around for about 20 years.
Many clients have no idea that their bodies have been predisposed to chronic pain, anxiety, and depression because of these early childhood experiences. Trauma held implicitly in the body and in the brain, resulting in a systemic dysregulation, is as confusing for people who exhibit symptoms of trauma they cannot remember, as it is for the clinicians who want to help them. When trauma occurs early in the development of the neocortex and before the hippocampus comes online, many individuals show symptoms of developmental post-traumatic stress without any conscious memory of traumatic events. The lifelong impact of early trauma is generally underestimated by medical and psychological professionals.
It was only in 1988 that the American Medical Association first recognised that infants feel pain. Before that, surgeries were routinely performed on neonates using a medication that kept these young patients from moving but did not deaden their pain. Children exposed to this kind of experience felt panic and pain while frozen and helpless. That experience alone would have a lifelong impact on the way they experienced pain.
It is known among trauma professionals that the way we keep ourselves safe and avoid danger, comes from our past experiences and our beliefs about what we must do to keep ourselves safe. This happens subconsciously and the subconscious has an incredibly powerful influence on our physical body.
But back to the ‘reset’ notion. Trauma is what stays in the body after a stressful event. The reason it is still ‘in’ the body is because there has been no safe ‘resolution.’ When facing danger, the fight and flight response kicks in and shuts down the neo-cortex. If running away from an attacker, you do not need complex thinking. You need strength and speed. If our natural reactions to threats are not completed and released from the body (because the victim has been unable to fight, flee, or seek help) the accumulation of ongoing bracing and defensive reactions related to fight, flight, and freeze can generate continued pain, resulting in a pain trap. The body acts as though the event is still happening because it believes it is. The nightmare of those who have PTSD and unresolved trauma is that their bodies keep finding ways to remind them it is not safe, and those reminders just keep perpetuating, like video loops in the mind that won’t stop. If the natural reactions are completed and calm returns to the body, the memory of the stressful event moves from the fear centre of the brain, the amygdala, into the hippocampus, the memory centre where it becomes a past event, “it’s over, and I’m safe”.
What studies have shown is that people who experience trauma are more likely to develop chronic pain conditions. So, treating someone’s chronic pain without investigating the relationship between potential past adverse events and trauma is like prescribing anxiety medication without investigating the source of the anxiety. The signs are evident to the therapist in the allostatic load on the nervous system and often (but not always) the pattern of muscle pain from continued unconscious bracing. A hyper aroused system that is constantly on alert for danger is not difficult to identify, when you know how to look.
In 2017, the International Association for the Study of Pain, the leading body of pain researchers, defined a third type of pain – NOCIPLASTIC pain. This was to distinguish it from Neuropathic pain (irritation or damage to nerves) and Nociceptive pain (signalling from tissue/muscle/bone injury but healthy nerves). Nociplastic pain is thought to arise when the body’s own pain-processing network gets rewired to overreact to incoming stimuli. It changes the nerve signalling so it cannot distinguish between mild and painful sensations. It can also occur when the chemicals manufactured by the endocrine system are less readily manufactured.
Trauma alters the way the brain processes pain signals, leading to a heightened sensitivity to pain. Trauma may disrupt the body's stress response systems, leading to chronic inflammation and pain.
‘Nociplastic’ pain probably best explains the type of pain trauma therapists work with. So now we know that chronic pain can have little to do with damaged tissues, it's actually maintained by complex mind body interactions. We've begun to learn for example that histories of childhood sexual or physical abuse are significant risk factors for chronic back pain and that job dissatisfaction is a much stronger predictor of back pain than having a job that requires heavy lifting, constant sitting, or other physical strains. Pain that's widespread or spreads overtime in a pattern that isn't typical for known diseases- like a whole arm or leg, or one side of the body- is also likely to be psychologically induced. Anyone with a mind-body disease like anxiety or depression has a greater probability that their pain is psychophysiological in origin. The therapist needs to look for clues to help see where their mind might be playing a role in their distress, such as pain that comes and goes, shifts location, or gets triggered by activities or stimuli. Helping clients understand they don't have something dangerous, incurable, or necessarily disabling is an important first step in treatment. And in just the same way, it is very important to help clients with past trauma to understand that they are not responsible for what happened to them, but they are responsible for their recovery.
However, while we know there is a link between trauma and chronic pain, the definitive scientific research connecting the two is scant and the cause of chronic pain remains complex and not yet fully understood.
To really understand how pain affects the body, and how chronic pain might develop, it is useful to look at the human body from a systems perspective. I developed an appreciation and deep understanding of ‘systems thinking’ during 10 years in the early 2000’s that I spent studying and teaching sustainability and came across teachers like the late Donnella Meadows (Environmental Scientist) who were able to explain the complexity of systems thinking in ways that even I could understand. Meadows talked about “leverage points.” These are places within a complex system (a corporation, an economy, a living body, a city, an ecosystem) where a small shift in one thing can produce big changes in everything. When it comes to sustainability, the leverage point with the most potential (but the hardest) for changing the system is our ‘paradigm’ around ‘growth’ (what is it we are trying to grow?) and our dependence on the ecological systems that sustain us. In other words, a total rethink from the top down, about how we create a sustainable future for the human race.
So, when I came across some pain research that attempted to look at the body’s response to pain from a Systems Perspective, it got my attention. The article I refer to was published in the Journal of Pain in 2008.[6]
I will attempt to quote, summarise and simplify this article here, because I believe it does a great job of explaining why a hyper-aroused and hypervigilant autonomic nervous system can predispose someone to the development of chronic pain.
The article postulates that some chronic pain conditions are the product of ‘supersystem’ dysregulation. The supersystem refers to the nervous, endocrine and immune system responses to wounding and pain within this framework. To quote, they “postulate that the nervous-endocrine- immune ensemble constitutes a single overarching system, or supersystem, that responds as a whole to tissue trauma and contributes to the multidimensional subjective experience of pain. Individuals vary and are vulnerable to dysregulation and dysfunction in particular organ systems due to the unique interactions of genetic, epigenetic and environmental factors, as well as the past experiences that characterize each person.”
Their hypotheses - “That supersystem dysregulation contributes significantly to chronic pain and related multi-symptom disorders. Finally, we discuss factors that make the individual patient uniquely susceptible to developing a particular pattern of chronic pain.”
Systems thinking is based on the assumption that “all adaptive systems have three essential features. The first is irritability: the system is dynamic and responds to perturbations such as tissue injury by moving away from equilibrium to meet the challenge and returning toward equilibrium afterwards. Second, connections and interactions exist among the components of a system; this is its connectivity. Through connectivity patterns form and self-regulating feedback occurs. Consequently, the connectivity of a system is more important than the system components themselves. Third, adaptive systems have plasticity.”
“In many chronic cases, the local tissue environment appears to repair itself, but sensory processes remain abnormal, creating chronic pain. One hypothesis for this type of chronic pain is failure of the central nervous system processes to ‘reset’ sensitizing adjustments implemented during injury when peripheral tissue complete wound healing. This underscores a second key point: The impact of a wound extends beyond its local tissue environment to its interactions with higher order systems. Incomplete wound healing may involve altered relationships between local tissue and higher order systems.”
Fever, sickness and depression are all responses of the immune system to force the body to limit social interactions and activity, rest and recover when unwell. Because the immune system has autonomic innovation it also responds to heal tissue damage or inflammation.“Evidence has been mounting that common chronic conditions including Alzheimer's, cancer, arthritis, asthma, gout, psoriasis, anaemia, Parkinson’s disease, multiple sclerosis, diabetes, and depression among them are indeed triggered by low grade long-term inflammation. But it took that large scale human clinical trial to dispel any lingering doubt: the immune system's inflammatory response is killing people by degrees so if trauma work can assist calm the chronic inflammation, then the implications are very significant.” [7]
To a trauma therapist this notion that the central nervous system must ‘reset’ is a familiar one and the absolute key to effective therapy.
Trauma, both physical and emotional, affects the allostatic load on the body. Emotional trauma has the same effect because the body continues to believe that it is in danger. The nervous endocrine and immune systems all have their own way of dealing with perceived threat, but of course they are a supersystem and so are all interdependent, relying on healthy feedback loops for their information to return the body to homeostasis. If those feedback loops (I am safe, I am not safe) are hijacked at a nervous system level, then the endocrine and immune systems will respond accordingly.
A body’s normal response to danger? The cortex senses the danger. The limbic system (amygdala, hypothalamus, and hippocampus) is then fired up. The amygdala registers fear and the hypothalamus responds by dumping cortisol in the system, flooding the nervous system with chemicals which shut down unnecessary parts (like digestion, higher order thinking) so that fight and flight can occur. The hippocampus is also shut down. The sympathetic nervous system gears up ready for fight or flight. Once the danger is over, the system returns to calm, the parasympathetic system takes back control, the memory is re-stored in the hippocampus and cortisol production reduces to healthy levels.
But if the danger is not over (unable to flight, flee, or seek help, in other words helpless) then the central nervous system changes in response to the prolonged noxious stimulation of the stress chemicals, (the main one being cortisol) and prolonged exposure to cortisol can cause tissue damage. Sympathetic arousal also disrupts blood flow through the autonomic and endocrine mechanisms. In addition, the psychosocial system surrounding the patient can be a potential source of stressors that demand allostatic response above and beyond that elicited by injury. In the presence of psychosocial stressors, wound-induced acute stress responses can fail to resolve properly, leading to chronic disorders.
What happens is the system becomes disorganised and can't self-regulate in a healthy way leading to chronic disorganisation at many levels.
A single trauma of sufficient magnitude can produce a stress response that does not resolve properly. In the same way: 1) unremitting or chronic stressors; 2) inability to adjust to a stressor of modest duration and demand; and 3) not hearing the “all clear” in which the stress response persists after the stressor has disappeared, are all examples of how the body stays in the stressed state and does not allow for the recovery phase. Stress is immunosuppressive.
Ongoing stress can therefore also result in:
· Prolonged dysregulation causing irreversible organ pathology, and this in turn can generate noxious signalling, as in rheumatoid arthritis and other auto-immune disorders. Dysregulation may manifest in at least four ways in chronic pain patients. These manifestations are not mutually exclusive.
· Allodynia is a familiar example of positive feedback in chronic pain, as is panic attack in emotional regulation.
· Dysregulation could occur if a system alters its set point in response to a stressor and then fails to readjust to the normal level after the stress has passed. This explanatory model nicely describes the hypervigilance and hyper-reactivity of post-traumatic stress disorder (PTSD)8. Traumatic life events can permanently alter the set point of an individual’s feedback-dependent HPA axis26, 43.
· Major surgery is also a stressor.
· High cardiac variability, or vagal tone, may be an indirect marker of an individual’s ability to respond effectively to a stressor and recover efficiently from it.
· Sleep deprivation is a stressor. Sleep deprived subjects have increased cortisol levels. Sleep deprivation, correlates strongly with increased hunger.
So, this explains how some chronic pain conditions and related multi-symptom disorders stem from supersystem dysregulation. Trauma causes system dysregulation.
So back to the systems thinking analogy. When faced with the excruciating and unfathomably common problem of chronic pain, what is a good leverage point for the therapist? It's not a quick nor easy task, but I would suggest the health professional look back, take a trauma history and an ACE history and look for clues about the state of the autonomic nervous system. This approach may seem unusual and not always welcomed by the client, so it takes a little explaining, and in some cases a lot of education is required, otherwise you are at risk of the client accusing you of telling them that their pain is ‘all in their head’ or that they are the cause of their pain (and in some cases, as Dr Melanie Noel would attest, the cause of their children’s chronic pain).
A recent study from UCSF[8] provides the first direct evidence that acute and chronic pain do in fact have different neural representations within the same person’s brain. Participants of the study, all with chronic pain, had electrodes placed into their limbic brain (Anterior Cingulate Cortex (ACC) and Orbitofrontal Cortex (OFC)), and they recorded their pain levels over several months. Researchers then compared the recorded pain levels to the electrical readings and noticed that each sufferer had their own distinct neural signature. The ACC and OFC of course have direct connectivity to the Amygdala.
Health professionals who work with chronic pain are gradually understanding these relationships and are taking a trauma-informed approach. One example is a group called SIRPA (Stress Illness Recovery Practitioners’ Association) founded in 2010 in the UK by physiotherapist Georgie Oldfield. SIRPA has Physiotherapists and Osteopaths who now do additional training in either Somatic Experiencing [9] or Embodied Processing [10] with encouragement to go on to more training as required. In USA, physiotherapist Scott Musgrave developed something called the Reflexercise [11] which (put simply) is another chronic pain (hands on) approach, that aims to reset nervous system dysregulation.
Recent advances in neuroscience have highlighted memory reconsolidation as a key mechanism for lasting change in trauma and chronic pain recovery. This process allows deeply ingrained emotional memories to be reactivated and updated, enabling transformational shifts rather than temporary symptom relief. Approaches such as TRTP (The Richards Trauma Process), Internal Family Systems (IFS), EMDR (Eye movement desensitisation and reprocessing) and Spellbreaking (Brian Ridgway) work directly with emotional memory and meaning, aligning with the reconsolidation model. These integrative therapies are showing promise in achieving profound and lasting outcomes, offering new hope for those affected by trauma and persistent pain.
When taking a trauma informed approach to chronic pain, the client has to be 100% willing to explore their trauma, and the therapist can only offer the carrot; the stick will never ever work. It is deeply personal work but also deeply rewarding, when you can help someone with their pain and their trauma.
In this article, I have explored the intricate relationship between chronic pain and unresolved trauma, illustrated through the compelling case study of my client named Jane. Drawing from both clinical experience and emerging research, I have highlighted how traumatic life events—particularly adverse childhood experiences—can dysregulate the body’s nervous, endocrine, and immune “supersystem,” leading to chronic pain conditions such as nociplastic pain. The article explains how trauma alters pain perception and healing by disrupting the body's feedback loops and stress-response systems, causing the nervous system to remain in a heightened state of alert. I advocate for trauma-informed care, emphasizing the role of emotional memory, stress resilience, and neural pathway retraining in pain recovery. Given the pioneering findings of neuroscience, systems biology, and therapies like TRTP and IFS, this piece calls for a paradigm shift in chronic pain treatment—one that acknowledges the body’s history and emotional reality as central to healing.
[1] Name changed
[2] The DASS21 is a quantitative measure of distress along the 3 axis of depression, anxiety, and stress. It is not a categorical measure of clinical diagnoses. Emotional syndromes like depression and anxiety are intrinsically dimensional - they vary along a continuum of severity (independent of the specific diagnosis). A scale such as the DASS can lead to a useful assessment of disturbance.
[3] In neuroscience, predictive coding (also known as predictive processing) is a theory of brain function which postulates that the brain is constantly generating and updating a "mental model" of the environment. According to the theory, such a mental model is used to predict input signals from the senses that are then compared with the actual input signals from those senses.
[4] Can also be called betrayal trauma or neglect trauma depending on which book you read
[5] APS 2023 Annual Scientific Meeting, National Convention Centre Canberra 2-5 April 2023
[6] Pain and Stress in a Systems Perspective: Reciprocal Neural, Endocrine and Immune Interactions.J Pain. 2008 February ; 9(2): 122–145. C. Richard Chapman, Ph.D.#, Robert P. Tuckett, Ph.D.*, and Chan Woo Song, M.D., Ph.D.†
[7] Shaw, J. (2019, May-June) Raw and red hot: Could inflammation be the cause of myriad chronic conditions? Harvard Magazine. www.harvardmagazine.com/2019/05/inflammation-disease-diet.
[8]https://www.ucsf.edu/news/2023/05/425386/has-science-cracked-code-chronic-pain May 2022
[9] Somatic Experiencing is a pioneering body awareness approach to healing trauma. It focuses on experiencing the ‘felt sense’ in the present moment to relieve the physical, emotional and physiological effects of post traumatic stress disorder and other stress and trauma-related health problems. Somatic Experiencing was founded and developed by Dr. Peter Levine
[10] A bottom up approach to healing trauma and nervous system dysregulation.
[11]https://www.wellnessandperformance.com/clickbank/index.html
