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Pain is the most common health problem reported by individuals with posttraumatic stress disorder (PTSD), underscoring the need for integrative pain-trauma interventions. Current standard of care does not target pain and trauma simultaneously, and patients are not usually offered pain psychology treatment until they exhaust biomedical interventions. We propose a shift in standard of care for patients with chronic pain that involves early assessment of trauma symptoms and triage to a targeted pain-trauma intervention. The first step towards this goal is to explore trauma symptoms and treatment preferences of patients with chronic pain. We conducted a quality assessment and improvement project at Cleveland Clinic by distributing a survey to patients with chronic pain (N= 702). Trauma histories were prevalent (46.0%) and 32% endorsed elevated trauma symptoms (PCL-5 score 25–80). Of individuals with elevated trauma symptoms, 19.5% did not endorse a DSM-5-defined traumatic event, which highlights the importance of assessing traumatic stress in patients regardless of a PTSD diagnosis. Patients with elevated trauma symptoms reported high levels of pain intensity (M= 6.5, SD= 2.0) and interference (M= 6.2, SD= 2.1), which were significantly higher than patients with lower trauma symptoms (PCL-5<24). Patients reported that they believed their pain (51.9%) and trauma (74.9%) are undertreated, and expressed interest in therapy that targets pain and trauma concurrently (61.5%). Results highlight a patient-centered need and interest in comprehensive pain management that goes beyond current standard of care and intentionally addresses the challenging pain-trauma comorbidity.

Psychological trauma and abuse are robust risk factors for the development and exacerbation of chronic pain. Trauma can influence the way individuals interact with the healthcare system, and patients with comorbid pain and trauma may be particularly disadvantaged in establishing trust and therapeutic alliance in psychological treatments for pain. Patients with fibromyalgia (ages 18-65 years) completed baseline questionnaires assessing for history of verbal abuse, physical threat, and physical abuse, and were randomized to an eight-week Cognitive Behavioral Therapy (CBT;n=58) or Pain Psychoeducation (n=33) intervention. Correlational analyses examined the relationship between patients’ history of abuse and patient- and therapist-reported relational empathy (9-item Consultation and Relational Empathy (CARE) Measure) following CBT or Psychoeducation. Results revealed that in the CBT group, history of physical abuse was significantly inversely associated with patient-reported relational empathy (r=-.28,p=.03). Specifically, on an item-level of the CARE measure, history of physical abuse was significantly inversely associated with patient ratings of the therapist “making them feel at ease” (r=-.29,p=.03), “letting them tell their story” (r=-.36,p<.01), “really listening to what they were saying” (r=-.33,p=.01), and “helping them to take control to improve their health” (r=-.27,p=.03). None of the abuse variables were associated with therapist-reported relational empathy in the CBT group, nor with patient- or therapist-reported relational empathy in the Psychoeducation group. Findings highlight the potential impact of trauma on the therapeutic relationship in CBT for pain. Future studies to identify providers’ familiarity with and application of trauma-informed pain care are needed.

Widely-used therapeutic approaches, such as cognitive behavioral therapy and mindfulness-based therapies, can improve pain and functioning in people with chronic back pain, but the magnitude and duration of their effects are limited. Based on advances in pain neuroscience, our team developed a novel 12-week program (psychophysiologic symptom relief therapy or PSRT) to substantially reduce or eliminate pain. This study examined whether PSRT helped more patients achieve substantial (i.e., 30%, 50%, and 75%) reductions in back pain-related disability compared to mindfulness-based stress reduction (MBSR) and usual care (UC), and if the beneficial effects of PSRT were explained by greater reductions in pain-related anxiety following treatment. Data from a three-armed randomized controlled trial were used (N=35 adults with chronic back pain). Change scores (baseline to 6-months post-enrollment) were computed for back pain disability (RDQ) and pain-related anxiety (PASS-20). Fisher's exact tests and mediation analyses were conducted. Compared to MBSR and UC, PSRT helped more patients achieve substantial (75%) reductions in back pain disability (ps<.04). Change in pain anxiety mediated the relationship between treatment group and change in back pain disability from baseline to 6 months (PSRT vs. MBSR: 95%CI[-5.74, -.32]; PSRT vs. UC: 95%CI[.43, 7.66]). PSRT appears to help more patients achieve clinically meaningful improvements than an established treatment (MBSR) and usual care. Findings indicate that reduced pain anxiety may be a mechanism by which PSRT confers long-term benefits on disability. This work importantly aims to move the field toward more precise and effective treatment for chronic back pain.