When the International Association for the Study of Pain (IASP) arrived at a definition of pain that included the “emotional experience,” as well as the “unpleasant sensory experience associated with actual or potential tissue damage,”¹ it was acknowledging the impact of pain on our human capacity for sentience and reflection and, by extension, suffering. By the time pain has become chronic in an individual’s life, it has almost certainly achieved the status of a major source of stress. More than merely an unpleasant sensory stimulus, chronic pain can come to affect the whole individual by becoming, itself, the source of a broad range of psychosocial stressors. The following case report illustrates the extent to which this is possible.

Case 1 A 42-year-old married man was referred to a pain management center, 8 months after sustaining a work-related, crush-type injury to his hand. His pain, which had been diagnosed as complex regional pain syndrome, type 1 (CRPS-1), had remained intractable to conservative measures and surgical intervention. According to the patient, several trials of medications had left him with uncomfortable mental status changes, and a reparative surgery and several procedures had exacerbated his pain considerably. He reported his distress as “worse than ever” and indicated that he was unable to work or pursue any of his previous recreational outlets. Although his primary care physician and surgeon supported his claim to disability, his worker’s compensation carrier’s representatives insisted that he should be able to return to light duty at his previous job. As a result, the patient had entered a lengthy and frustrating process of litigation, which had proved exhausting and overwhelming. As his anxiety escalated concerning his loss of income, mounting legal fees, and inability to resume work and provide for his family, he became increasingly withdrawn, irritable, and depressed. His marriage and relationships with his children and friends suffered, and by the time he arrived at the pain management center, he reported feeling angry, helpless, hopeless, and suicidal.

Cases such as this are familiar to everyone who specializes in the treatment of patients with chronic pain. The challenge, where successful medical resolution is concerned, is to maintain the focus on the whole of the individual’s experience, both sensory and affective, because the development and course of chronic pain represents a progressive series of complex interactions among the biologic, psychological, and social dimensions of an individual’s life. Purely physiologic explanations cannot account for its impact.² Nor can an exclusive reliance on the interventions that spring from such a limited understanding ordinarily bring the enduring relief and solace sought by many patients with chronic pain.³

The quality, intensity, and duration of pain are influenced by a myriad of psychological and social factors, which—although they may have arisen in the context of pain—are by no means less influential or consequential than the unpleasant sensory experience arising from actual or potential tissue damage.⁴ Such factors may, indeed, play a critical role in the etiology, severity, exacerbation, and maintenance of pain, suffering, and disability.⁵ The experience of chronic pain ultimately comes to be the product of conflict between a sensory stimulus and the entire individual. It will always require some level of adaptation and adjustment, but it can, in many cases, interfere with one’s work and livelihood, recreational pursuits, relationships with family and friends, and even sexual intimacy. Through the introduction of more enduring affective changes, it can also influence one’s self-esteem and the ways in which one views oneself as a man or woman, husband or wife, father or mother, friend, member of society, and spiritual being.

With so much at stake for patients with chronic pain, it is not surprising that psychological evaluation is a required or highly recommended feature of comprehensive evaluation in many pain management centers.⁶ For many patients, some form of psychological intervention is also recommended as part of the comprehensive treatment plan. Such interventions are usually prescribed to run concurrently with medical treatment and other therapies and may include one or more of many available modes of individual or group psychotherapy. When offered as part of a multidisciplinary package, psychotherapeutic approaches to managing chronic pain have demonstrated their efficacy repeatedly, and there is considerable evidence to suggest that the more effectively such interventions are integrated into a comprehensive or team approach, the greater are the chances of improvement for health and quality of life.⁷

With the IASP reporting an incidence of chronic pain in the United States of 70 million and with more than 50 million being partially or totally disabled for periods ranging from a few days to a few months, a concerted multidisciplinary effort becomes even more critical to the effective marshaling of available medical resources.⁸ Especially for patients whose chronic pain has remained initially intractable to medical and surgical interventions, a careful plan of treatment coordinated by a team of providers can ultimately result in greatly reducing the costs of health care, as well as raising the quality of that care—improving patients’ response to treatment, level of functioning, and satisfaction—and enhancing the morale of all the providers concerned.⁹ Psychotherapeutic management, in this context, necessarily involves not only a multidisciplinary approach but also an interdisciplinary effort in which the interventions of each member of the team—physicians, nurses, physical therapists, medical and complementary specialists, and mental health providers—can be seen as having a synergistic therapeutic impact on the patient and must be directed toward having a complementary effect on the interventions of all other members of the team.

PSYCHOLOGICAL FACTORS IN CHRONIC PAIN

It is, by now, a generally accepted, if not always carefully considered, tenet that stress is influential in the development, expression, and tractability of chronic pain.¹⁰ Because stress is also influential in the development and expression of somatization and other psychological symptoms, associations among chronic pain, stress, and psychiatric disorder are frequently observed and well documented in the literature of both pain and psychiatry.¹¹ Attempting to parse or separate these influences prematurely for the sake of treatment is frequently tantamount to disregarding the often volatile interactions among these factors and the cyclically reinforcing relationship between chronic pain and stress.

When such a unilateral approach is taken, it often represents the attempt of physicians adhering to too strict a medical model to establish the extent to which a patient’s problem may be mental as opposed to physical. As a result, both the physician and patient may be left wondering why a clearly prescribed nerve block or medication has not achieved the expected relief. It may also lead to the premature and potentially harmful conclusion by the physician and the patient’s health insurance carrier that nothing further can be done medically or surgically to assuage the patient’s pain and that the problem is no longer a medical one but strictly a psychological one, now unrelated to a precipitating injury or historical tissue damage. What is being overlooked is the individual patient’s stress reactivity and the enduring influence of the pain–stress cycle on the development and maintenance of chronic pain.

Stress Reactivity and the Pain–Stress Cycle

The term stress reactive is suggestive of a continuum of the degree to which any individual reacts to external or internal stressors, including the stressors of pain and its psychosocial sequelae. We are all on this continuum, but highly stress-reactive individuals are likely to develop a broader spectrum of more severe psychological and social concomitants or consequences, as well as to experience their pain with greater affective involvement and suffering. Less stress-reactive individuals may still experience the need to accommodate to their pain, psychologically, socially, and occupationally, but their adjustment to living with chronic pain is typically more successful, and their adaptation to their limitations is more enduring.

The term pain–stress cycle is indicative of the unfolding neuropsychosocial matrix in which (1) pain tends to amplify the impact of stress while (2) stress magnifies the subjective experience of suffering associated with pain. The former occurs when a patient’s experience of pain facilitates the development of new and secondary psychosocial stressors, as in Case 1, but it may also be evident in the patient’s tendency to rely on or resort to maladaptive coping strategies, such as self-medication; social withdrawal; and the development of generalized, reactive pain behaviors. The latter refers more specifically to the contributions of heightened autonomic arousal and musculoskeletal tension in the maintenance and intensity of the experience of pain.

We have only an inchoate appreciation of how these mechanisms work and interact, but advances in our understanding of the neurophysiology and molecular biology of our perception and experience of pain strongly suggest that the influence of psychosocial factors and emotions is translated neurophysiologically into the realm of perception and behavior.¹² Stress, regardless of its origin, can result in physiologic deterioration and the exacerbated experience of pain through a variety of mechanisms. Neurosignature patterns can be modulated or altered destructively by stress of psychological origin, no less than by sensory input. Because any stressor, whether external or internal, physical or psychological, can affect stress-regulation systems adversely, the resulting lesions or tissue damage can influence the neurosignature patterns that originate and maintain chronic pain.¹³

Seen from this perspective, the distinction between stresses of psychological versus physical origin tends to assume less importance, and a multidisciplinary or comprehensive approach to treatment becomes paramount. All models of chronic pain acknowledge the neuropsychosocial relationship and interaction between stress and pain; however, it is yet a further step to begin to understand and appreciate how this works in the life of a particular patient or how to incorporate this approach into a successful plan of treatment. In a multidisciplinary approach to treating chronic pain, therefore, making an assessment of the degree to which any patient is stress reactive and addressing the nature of his or her unique expression of the pain–stress cycle become primary objectives of intervention in pain management.

There is a tendency to regard this as the special province or purview of the psychologist, psychiatrist, clinical social worker, mental health counselor, or psychiatric nurse practitioner, but in a team approach, all interventions may be seen as having a psychotherapeutic action. The reassurances of the physician or nurse that a patient’s pain is being taken seriously; the verbal reinforcement to the patient by all providers that progress in pain relief and management can be achieved; and even the comforting touch of physicians, nurses, and physical therapists during examinations, procedures, or exercises may all possess a powerful psychotherapeutic dimension. What is shared in team meetings and clinical rounds can also prove critical to all providers in assessing a patient’s progress and determining the extent to which he or she remains stress reactive, as well as how the pain–stress cycle continues to unfold in the context of his or her family, social relationships, work, and livelihood.

Influence of Psychopathology

As the ongoing evaluation and treatment of chronic pain proceeds, one area in which psychologists, psychiatrists, and clinical social workers can be especially valuable lies in determining the extent to which psychopathology is present and influential. As psychological intervention begins, the first important consideration—one that will likely have implications for both prognosis and treatment—concerns the juxtaposition of psychological factors affecting the patient’s pain experience, especially with regard to the order, magnitude, and relative duration of influence. In some cases, psychopathology occurs as a complicating feature in the diagnosis and treatment of chronic pain and existed before the development of the pain syndrome. In these instances, some delineation of the premorbid or existing psychopathology becomes critical to understanding the role and meaning of pain from the patient’s perspective. In other cases, psychopathology is reactive to and arises within the context of the patient’s experience of pain, and special care may be needed to introduce the idea of and address the disorder without the patient’s feeling that the focus has been removed from his or her pain.

Chronic pain is far more prevalent among psychiatrically disordered individuals than in the general population, and there is considerable evidence that alterations in the experience of pain occur in conjunction with some psychiatric disorders, including mood disorders, anxiety disorders, and psychotic disorders.^5,14 Prevalence rates for depression among individuals with chronic pain in clinic-based samples vary in the literature from 30% to 54%,¹⁵ with significant depressive symptoms ranging from 60% to as high as 100% in some samples.¹⁶ The question of which came first—the depression or the pain—remains controversial as an issue but is often made more complicated and even confusing when considered in the context of an individual case.¹⁷ Clinical evaluation can certainly reveal depressive symptomatology to be a premorbid or disposing influence in the development of chronic pain, as well as a comorbid one. That depression might be a consequence of chronic pain is acknowledged by many patients, but that pain might constitute the somatized expression of premorbid but unacknowledged depression or intrapsychic conflict typically meets with resistance from some patients and their families, who may find a psychiatric diagnosis both less accessible and less acceptable than a medical one.

Case 2 A 52-year-old married woman with a previous lumbar laminectomy and a well-documented history of mild and episodic but well-managed low back pain developed an exacerbation shortly after the last of her three children left home to enter college. Her pain did not resolve as easily as it had in the past, and 2 months later, she presented to a pain management center, tearful, agitated, and in obvious distress, having exhausted her primary care physician’s ordinarily effective armamentarium of conservative treatments. Her husband reported that she had become increasingly withdrawn from her friends and previously busy schedule and now stayed mostly in bed, watching television or sleeping. With a diagnostic workup and clinical examination devoid of any findings except a few mild trigger points, the patient’s pain physicians prescribed an antidepressant, which they were careful to explain is also considered a “pain medication,” and referred her to a structured group psychotherapy program, emphasizing the importance of learning techniques for greater musculoskeletal relaxation. One month later, the patient presented for follow up, excitedly discussing her cognitive-behavioral assignments for stress management from her group and chatting with the nurses about the success of her children, with whom she had developed a frequent e-mail correspondence. She complained of occasional, mild residual pain but was not allowing this to impede the gradual resumption of her daily schedule.

In this case, the patient had little insight into the development of her reactive depression or its relationship to her worsening pain. Considering her history of surgery and episodic low back pain, it is difficult to ascribe her distress solely to somatization, but instances of pure somatization are usually difficult to document convincingly. As in most cases, this woman’s exacerbation of pain appears to stem from both physiologic and psychological factors, and especially when discussing her experience with the patient herself, it is important not to become distracted by questions of primacy. When there is a clear, established history of a premorbid psychiatric disorder, it becomes critical to understand how such psychological factors may have contributed to the development of chronic pain and how they shape the patient’s experience of chronic pain. When there is little to suggest premorbid psychiatric influences, however, it is far more important to maintain a clinical focus on the relationship between psychological and physical factors as a whole, as well as their ongoing interaction.

For this reason, a model reflecting the influence of stress reactivity and the pain–stress cycle is probably more versatile and more efficacious in such cases because it promotes a view of health that takes into account the interaction of psychological and physical factors without the need or presumptive burden of trying to establish causal direction—an enterprise that, despite our best efforts and intentions, might easily result in harm to the patient. With such a model, psychological factors can be viewed as both amplifying pain and inhibiting successful adjustment to it, but chronic pain itself can be viewed as a potent psychological stressor in its own right and one that can easily give rise to other psychosocial stressors.¹⁸

The disposing premorbidity, for example, of personality disorders, depression, and posttraumatic stress in the development of chronic pain is often accepted uncritically in the clinical arena. That they are found in significantly greater proportion comorbidly is indisputable.^19,20 Yet when viewed according to a diathesis-stress model, even personality-disordered and posttraumatic stress–disordered behaviors may emerge for the first time and coalesce around chronic pain.²¹ So the question becomes less a chicken-or-egg issue of, “Which came first, the chronic pain or the psychiatric disorder?” but rather, “What approach is more helpful to the patient in understanding and assisting in the resolution, both psychologically and physically, of his or her pain?”

Somatization, according to this model, can be seen as an immature psychological defense capable either of giving rise to pain in the apparent absence of organic pathology or of complicating and magnifying pain in the established presence of organic pathology. As a defense, it simply represents the symbolic displacement of intrapsychic conflict onto the somatic sphere in an unconscious attempt to avoid distressing affects associated with psychosocial stress. All stress-reactive individuals tend to somatize, when under sustained or escalating stress, and because we are all on a stress-reactive continuum, we all tend to express affects through our bodies to some degree. Highly stress-reactive patients may have well-documented histories of somatization and physical complaints at many sites, but any tendency toward somatization can magnify a patient’s suffering well beyond what is expectable, given the nature and extent of actual tissue damage.

Alexithymia—a subclinical inability to identify and describe one’s emotions—can be a predisposing, complicating, and exacerbating feature of somatization²² because patients who are unable to articulate their emotions and affective states in words may have few outlets, other than bodily expression, for their intrapsychic pain and discomfort. For those who have come to regard the experience of psychological distress or displays of affect as signs of weakness or occasions for shame, displacing intrapsychic conflict onto the body may also allow them to feel that they have more legitimate claims to others’ attention and the fulfillment of their needs—a phenomenon or symptom also known as secondary gain. Such constructs as alexithymia and secondary gain, in turn, raise the question of whether the phenomenologic focus of the interaction between pain and stress is more appropriately placed on psychiatric disorder or on temperament, personality traits, coping attributes, and even environmental factors such as availability of support.²³ Again, shifting the clinical focus too quickly to that of psychiatric disorder can discourage the patient further or even lead to the termination of treatment.

The dangers of prematurely settling on a psychiatric diagnosis were addressed with the promulgation of the category of somatic symptom and related disorders of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), the common feature of which is the prominence of somatic symptoms associated with significant distress and impairment.²⁴ In the previous nomenclature of the DSM-IV, the emphasis of the somatoform disorders was on their medically unexplained nature. All too frequently, such diagnoses heralded the closing of the door to continued medical attention and intervention. According to the new criteria, somatic symptom disorders can occur concurrently with diagnosed medical disorders, acknowledging our limitations on declaring pain and other somatic symptoms to be medically unexplained.²⁴ So, too, the coincidence of mood, anxiety, and personality disorders should not be considered a medical end point but rather should highlight the need for multidisciplinary approaches to the treatment of chronic pain. Psychiatric diagnosis in chronic pain is valuable only insofar as it develops a deeper and richer understanding of the patient and promotes multidisciplinary options for treatment, including that of psychotherapeutic intervention.

PREPARING FOR PSYCHOTHERAPEUTIC INTERVENTION

Not all patients with chronic pain exhibit significant psychopathology, of course, or experience the complicating influences of the range of psychological factors that can affect the course of physical symptoms. Many individuals adjust well to the limitations imposed by their pain and continue to work productively and to enjoy satisfying relationships and rewarding personal interests. Most of them have no histories of premorbid psychopathology, and by virtue of resilient temperaments, adaptive personality traits, and successful coping skills, they manage to avoid the comorbid development of psychological distress and psychiatric symptoms that can become associated with chronic pain.

Those who are less fortunate, however, include among them the most memorable and challenging patients in any primary care practice or pain management center. Their suffering is often dramatic and, even when their numbers are few, their drain on resources is considerable when calculated in terms of time, money, and the morale of staff. Their families, other physicians, employers, and even health insurance carriers frequently become demanding agents in their behalf even as their pain remains puzzling and intractable to an ever-lengthening list of interventions, and their escalating sense of urgency continually reminds us of our limitations as health care providers. When all else appears to have failed and all available resources have been tapped, it is a small step toward collusion with the patient’s own escalating sense of urgency to make one more referral to yet another specialist or to raise the level of pain medication, one more time; to consider one more improbable intervention; or, as is often the case, to simply close the door, abandoning the patient to begin the process all over again.

It is under such circumstances that psychologists and psychiatrists frequently find patients with chronic pain at their doors. Having been told that there is nothing further that can be done, that there is no hope of further surgical or medical palliation, patients can be left to begin the process of psychologically adjusting to their pain and its sequelae in the most angry, anxious, and despairing of states. For these individuals, pain may already have become an organizing principle, and the enterprise of psychotherapeutic management is no longer only that of addressing transiently reactive mood or anxiety or difficulties with adjustment but that of attempting to alter a way of life or effecting change at the level of personality and identity. Chronic pain of this nature continues to call for a multidisciplinary approach, often just at a time when patients are most discouraged by or disillusioned with their medical care, and it is often a long road back to successful pain management, made far more arduous for having been consigned to being undertaken in pieces.

When psychological factors are influential in the development or maintenance of chronic pain, the greatest progress is likely to be achieved most expediently when there is not only interdisciplinary cooperation but also an integrated, comprehensive plan of treatment in which all providers work together with the same goals in sight. Undertaking medical and psychotherapeutic approaches to chronic pain separately—or worse, sequentially—greatly reduces the chances of making global progress in patients’ adjustment to their pain, and increasing the chances that interventions from different disciplines may compete or contradict one another, leaving patients feeling confused and helpless. It can also leave physicians and psychotherapists feeling alone and unassisted in their attempts to help their patients and more likely, as a result, to communicate their own anxiety and sense of helplessness about the slowness or lack of progress back to the patient.

The patient’s developing stability and success with managing chronic pain may well depend on an abiding trust that his or her physicians are doing everything possible to offer appropriate relief and comfort through medical means, and his or her psychotherapist is doing everything possible to assist with the adjustment to what the patient sees as the emotional impact and consequences of pain. This does not mean that there is a strict division of labor, however, and patients often turn to their physicians and nurses for emotional support and ask their psychotherapists for reassurance about medical decisions. Patients with chronic pain often ask their providers, without respect to discipline, for validation—the reassurance that their physicians, nurses, physical therapists, and psychotherapists have heard their concerns and understand their experience. Many have gone from provider to provider, encountering repeated disappointments in their search for answers, and their often challenging and sometimes provocative presentations may reflect the defensiveness, hypersensitivity, and hypervigilance of the scars, both physical and psychological, they have sustained in their search for relief and solace.

Establishing a good working alliance is, therefore, critical for all members of a multidisciplinary team. Patients’ compliance with directives and interventions and their cooperation with a plan of treatment often depend on their perception that all members of the team are working together on their behalf. When patients lose trust in their providers or sense that providers are not fully engaged in the process of helping them in their search for answers and relief, the alliance deteriorates, sometimes irredeemably. Patients’ complaints of feeling rushed, dismissed, or devalued may result, not surprisingly, in an increase in pain behaviors and dependency, as well as tendencies toward the expression of retaliatory impulses. In a multidisciplinary approach to treatment, the responsibility for maintaining the integrity of the alliance is shared among all providers, with the result that the patient’s urgency is experienced by all as less demanding or overwhelming.

When the psychologist, psychiatrist, clinical social worker, mental health counselor, or psychiatric nurse practitioner enters the scene, patients frequently need the reassurance of the rest of the team that their pain has not suddenly been relegated to the uncertain status of being purely psychological in origin or “all in the head.” Especially in the initial psychological interview, it is reassuring to patients to be able to focus on what they know best—namely, the emotional impact of pain on their lives—and not to feel as if their beliefs and psychological defenses are being challenged or threatened. When the patient feels secure that his or her story has been heard and fully appreciated, the direction of the psychotherapist’s inquiry can turn toward a consideration of the psychological and behavioral antecedents, correlates, and sequelae of pain—all of the factors influencing the pain–stress cycle. When the patient is willing to acknowledge and discuss the possibility that stress may contribute to his or her subjective experience of pain, the way is prepared for psychotherapeutic intervention.

Nevertheless, it is critical not to presume too much or too quickly here. A final, essential question to consider in preparing for psychotherapeutic intervention concerns the range of variables in individual temperament and personality that make psychological adjustment possible: Is the patient disposed toward making the changes necessary to facilitate more adaptive coping? Because patients vary widely in their receptiveness to making the behavioral changes that lead to more successful adjustment, their readiness for change^20,25 may require continual monitoring and nurturing in psychotherapy (see Chapters 14, 15, 18, and 22). Suggesting to a patient, for example, who is waiting for his or her physician to “fix the problem” that relaxation exercises might assist in the management of pain is unlikely to result in anything but frustration. Accurately assessing and nurturing the patient’s readiness for change, therefore, becomes one of the principal prerequisites for the successful psychotherapeutic management of chronic pain.

The psychotherapeutic treatment of chronic pain accompanying other psychiatric disorders may have more than one goal, including the relief of pain itself, the decrease of disability and illness-related or “pain behaviors,” the restoration of activity and the increase in functional quality of life, as well as the decrease in reliance on opioid and other analgesic or anxiolytic medications.²⁶ Individual psychotherapy may prove to be of great benefit in achieving these goals, but it must be noted from the outset that structured group programs, whether inpatient or outpatient, have been studied more widely and demonstrated to be of greater efficacy in their application to chronic pain populations.²⁷

The hallmark of such programs has been the successful integration of multidisciplinary approaches into a unified interdisciplinary perspective, with greater coordination of services and frequent communication among all providers. Progress in individual psychotherapy, by itself, is frequently hamstrung by a less unified, more piecemeal approach to the patient’s concerns, which may change from session to session. As a result, more structured forms of individual treatment, such as cognitive-behavioral therapy (CBT), have been developed specifically for pain patients. But individual treatment, whether combined with structured group psychotherapy or undertaken on its own, tends to work best when its approach is eclectic and includes a number of components,²⁰ each of which may appeal to a different or succeeding stage in the patient’s receptivity or readiness for change.²⁵

Keeping in mind that psychotherapeutic management is the concern of the entire treatment team, any intervention may, broadly speaking, have a psychotherapeutic impact on the patient. The beginning of formal psychotherapeutic intervention, however, is usually marked by a clinical interview and anamnesis administered by a mental health professional. Psychological testing may also be included as a means of evaluating the current level of functioning; symptoms of psychopathology; presence of psychosocial risk factors affecting prognosis; and other cultural, educational, and attitudinal indicators warranting consideration in the planning of treatment. Psychopharmacologic evaluation may be included at this stage as well, but many pain physicians are conversant with the use of psychotropics in pain management, and referral to a specialist is often considered redundant unless the initial interventions have proven unsuccessful. After a picture of the patient’s presenting baseline of coping and functioning emerges, ongoing and longitudinal assessments provide a measure of psychotherapeutic progress, as well as indications for appropriate changes in the treatment plan.

PSYCHODYNAMIC PSYCHOTHERAPY

Psychodynamic or insight-oriented and supportive psychotherapies are not usually considered treatments of choice for patients with chronic pain, precisely because their approach is less structured and more patient directed, but they may be the logical starting point for patients whose pain and disability are sustained or exacerbated by intrapsychic conflict or unconscious motives, such as trauma or secondary gain.^28,29 The high correlation between the history of physical or sexual abuse and the subsequent development of chronic pain is well documented in the literatures of psychiatry and pain.^30–32 In patients who have suffered abuse as children or as adults or who have experienced or witnessed situations in which either death or serious injury was real or threatened, chronic pain may come to represent a means of psychologically symbolizing and organizing an unbearable traumatic event or series of events. Nor is the situation of childhood or adult abuse the only form of trauma associated with chronic pain and disability. The development of comorbid posttraumatic stress disorder is also prevalent in work-related injuries and motor vehicle accidents.^33,34

Whether premorbid or comorbid, posttraumatic stress disorder remains a powerful confounding factor in many cases of chronic pain, and for patients with such a background, a frequently necessary step in the development of their readiness for change is the experience of making a conscious connection between their trauma and their pain. In cases in which premorbid psychopathology has contributed to the development of chronic pain and disability, an understanding of the relationship between the patient’s history and the development of his or her symptoms may prove essential in assisting him or her toward a more active role in treatment.

Case 3 A 28-year-old, recently married woman was referred to a pain management center with a 6-month history of chronic abdominal and pelvic pain of uncertain etiology. She reported having a history of episodically severe “stomach aches and cramps” as a child but felt that these had long since been resolved. Although similar to these early episodes, her current pain had become more intense and urgent, even to the point where walking was sometimes difficult, literally necessitating her husband’s support to get down the stairs in their home. Her anxiety had also escalated, interfering with the couple’s sexual intimacy, despite her husband’s obvious concern and willingness to assist her in whatever ways she asked. The patient agreed to enter psychotherapy but denied the impact of any stress in her life, beyond that of her pain. During the course of treatment, she disclosed to her psychotherapist that she had endured sexual abuse from her father as a child but, again, placed no significance on its enduring influence. When asked how and when the abuse stopped, she indicated that her father typically became more solicitous of her and less likely to molest her when she became ill. Over time, she made the connection that her pain had begun in the weeks immediately after her wedding, when the couple’s sexual intimacy had greatly increased in frequency. Wondering whether there might be a relationship between her pain and her feelings and attitudes about sex, she eventually came to the realization that her developing sexual relationship with her husband was, through no fault of her own or her husband’s, recapitulating her childhood trauma. After she recognized that this recapitulation might have contributed to the onset of her pain, she became motivated to address the complete range of issues both influencing and influenced by her pain. Several months later, after the addition of couples therapy and a cognitive-behavioral component to her individual treatment, her pain was largely resolved, and she and her husband were reporting the mutually satisfying reintroduction of sexual intimacy to their relationship.