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Join us as we delve into the often-overlooked connection between trauma and chronic pain. Our guest, Cindy Perlin, a social worker, sheds light on how unresolved trauma contributes to chronic pain and why this crucial link is frequently ignored by health care providers. We’ll explore the findings of the Kaiser Permanente ACE study, common misconceptions, and the effectiveness of traditional pain treatments. Cindy will also discuss innovative therapies like energy psychology and neurofeedback, and share strategies for individuals to manage trauma-related pain.

Cindy Perlin is a social worker.

She discusses the KevinMD article, “From suffering to healing: the role of trauma in chronic pain.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Cindy Perlin. She’s a social worker, and today’s KevinMD article is “From suffering to healing: the role of trauma in chronic pain.” Cindy, welcome back to the show.

Cindy Perlin: Thank you.

Kevin Pho: So Cindy’s been on in the past. Go to KevinMD.com/podcast to search for her name, hear her story and our prior episode. But today let’s jump right into your most recent article, “From suffering to healing: the role of trauma in chronic pain.” What’s this one about?

Cindy Perlin: Well, it’s about how unresolved trauma can affect you lifelong and cause all kinds of chronic illnesses, including chronic pain. Also, what to do about it, because you can’t change the past, but you can change what’s going on in your mind and body so that you don’t have to be in pain or sick anymore.

Kevin Pho: All right. So give us some case studies or examples of that concept.

Cindy Perlin: So one of the most recent examples I ran into is Dr. Tracy Patterson, who runs a clinic for people with complex regional pain syndrome. And she suffered from that herself for many years, and she literally went all over the world looking for a solution. She was down in Latin America, she was all over the US, she was in Europe. She tried everything you could name in terms of looking for treatment.

And it wasn’t until after many years that she discovered that her trauma was at the root of her pain, and she addressed it with pain reprocessing therapy, and she’s been in remission for 11 years and now runs a clinic teaching other people how to do that. And her story and her clinic are listed on my website, the Pain Treatment Directory.

Kevin Pho: So you talked about a study from Kaiser Permanente, the ACE study, the adverse childhood experiences study, which outlines some of your concepts. So talk to us more about that study, for those who aren’t familiar with it.

Cindy Perlin: OK. So that study was done in 1998, and Kaiser Permanente has really been in the forefront of this kind of research. So they did a study asking their subscribers about childhood trauma. They looked at things like physical, sexual, and emotional abuse, domestic violence, mentally ill parent, parent in prison, things like that.

And they found that the more types of childhood trauma someone had, the more likely they were to be ill in adulthood. And it was really a groundbreaking study that not many providers pay much attention to, unfortunately.

Kevin Pho: And can you speculate why that connection between unresolved trauma and chronic pain, why is that overlooked by clinicians?

Cindy Perlin: Well, I think most clinicians are not trained in that way. Way back when, mainstream medicine decided that there was a split between the mind and the body, they weren’t that connected. They left the mind to the church and the body to the medical profession.

And there’s such a strong connection. I mean, somebody said, I can’t remember who, anybody who thinks the mind isn’t connected to the body, how do they explain how we walk? Because you have to have an intention and then your body responds.

And so there’s all different kinds of ways that the mind affects the body, and one of the most critical ones is the fight or flight response, where if you’re stressed, your physiology changes. Everything about your body changes, your muscle tension, your heart rate, your blood flow, your immune response, your digestive response. And when you have trauma in your past, what happens if it’s unresolved is you continue to stay at some level of fight or flight chronically, and that’s not a healthy state.

Kevin Pho: Are there any specific types of chronic pain that are more connected to trauma?

Cindy Perlin: Well, you could say that if somebody has an acute injury that it’s not related to trauma, but even then, in terms of how much pain a person experiences from an injury, how quickly or whether they recover, also has to do with their arousal level, which is related to trauma in the past.

Kevin Pho: So how can health care clinicians better screen for trauma as a potential contributor to a patient’s chronic pain?

Cindy Perlin: Well, I think they need to ask questions. They need to ask about their history, their emotional history, what kind of childhood they’ve had, what kind of trauma they’ve had. And then they have to either have the skills, or know who to refer to with the skills, to deal with that. And a big problem, as we all know, is that most primary care providers spend very little time with patients and often don’t have the time to screen for that.

Kevin Pho: So what are some signs in the exam room, or during the interview in the primary care setting, that would potentially alert me to ask those questions, or refer that patient to someone who could delve deeper into that connection?

Cindy Perlin: Well, I don’t know that there are always signs, but one of the things that Kaiser Permanente discovered way back in the 50s is that the fatter the person’s medical file, the more likely they were to be in emotional distress.

So particularly if you’re seeing somebody who has all kinds of medical conditions, every system is involved, they’ve got heart issues, they’ve got pain issues, they’ve got diabetes, they’ve just got a myriad of different illnesses, that’s one clear sign that there’s something systemically that could be wrong. And I don’t like to say it’s always psychological, because it’s not. It could be a toxic exposure, it could be a nutritional deficiency, poor self-care in general. But generally speaking, if people have all kinds of comorbid conditions, it’s very likely that they’re in psychological distress.

Or if they’re very young and they’ve got conditions that don’t usually happen to people, I mean, my own history is, I had chronic disabling back pain when I was 25, and I kept hearing, you’re too young for this. So if there’s an onset at a very young age, I mean, I once saw a child in my practice who was nine and she had ulcerative colitis, so that can be a sign. But really, people can look pretty good and seem pretty calm, and they’re very good at suppressing what’s going on emotionally with them. It eventually comes out.

Kevin Pho: So if we have a patient where we feel that there’s a psychological etiology that contributes to their chronic pain, in general what are some of the treatment approaches to address that?

Cindy Perlin: So usually people think psychotherapists, and that sounds like a reasonable thing, but Dr. Bessel van der Kolk wrote a book called The Body Keeps the Score about how talk therapy doesn’t resolve trauma. It often can make people worse, because when people talk about it they get triggered.

So there are specific techniques that get at trauma kind of at the nonverbal level. So one of them that I use a lot is energy psychology, where you’re asking the person to recall a distressing event and then you have them tap or hold different acupuncture points on the body that relate to different emotions. And it seems so simple, but it’s almost miraculous what can happen, where someone’s been traumatized by an event for 50 years and in 15 minutes it’s gone and it no longer bothers them.

There’s also something called EMDR, eye movement desensitization and reprocessing, that a lot of therapists are using with trauma.

And then another technique that I use is neurofeedback, which works with brain functioning, because if you have trauma your brain is chronically over aroused. And what you do with neurofeedback is you measure the electrical activity of the brain and then you reward the brain’s change towards something that’s calmer and more functional.

So the way that I do it in my practice is, if there are specific events that stand out I use energy psychology, and if they’ve got really chronic problems I also use neurofeedback to calm the brain. There’s a phenomenon called central sensitization in pain, where the brain just keeps sending the pain signals even though the tissues have healed, and that can happen particularly in traumatized people. So just doing a brain training protocol where you’re calming the brain down can be very helpful.

Kevin Pho: So take us into your office and give us a story, it could be real or hypothetical, where you successfully addressed a patient’s trauma and it helped move the needle in improving their chronic pain.

Cindy Perlin: Yeah, so this isn’t an example of childhood trauma, but this is someone who I saw 20 years after 9/11, and she was in one of the World Trade Center towers when it was attacked. She was on an upper floor, she had just had a botched knee surgery, and somehow she made it out of the building and was sitting at a bench outside the building trying to rest.

And a truck came by, and people were jumping in to get a ride out of the area, and she jumped in. And in the rear view mirror she could see, right after she left, that the building came down right where she was sitting. So she narrowly escaped death twice that day.

And she came to me for general anxiety and wellness. And one day she came in and she said, on the radio driving here I heard something that triggered my 9/11 trauma. So we worked on it with energy psychology, and at the end she felt a lot calmer.

And then she called me afterwards and she said, I’ve had back pain for 20 years since that event, and it’s gone. And it stayed gone. I stayed in touch with her for a couple years afterwards and her pain just stayed gone. She no longer had back pain from that incident.

Kevin Pho: How often is that success story told? Do you feel that most people with chronic pain have a psychological component to it?

Cindy Perlin: Well, I hesitate to say most, because there’s so many reasons for chronic pain. As I said earlier, it could be a muscle imbalance, which I didn’t mention earlier, it can be inflammation from a bad diet, it can be a toxic exposure, nutritional deficiency. But oftentimes chronic pain is very complicated, there’s more than one thing involved.

And with something like energy psychology, if it’s something like a one-time event I was just talking about, or with EMDR, you can very quickly resolve things. If someone has a history of childhood trauma where the trauma was almost daily, emotional insults or physical assaults, then it’s much more complicated and it takes much longer.

And I just want to say something about a concept I ran into not that long ago, called small-t trauma. So when we think of trauma, we think of the big stuff. We think of something that’s life-threatening in the moment, like the 9/11 story, or sexual assault or something like that. But small-t trauma is belittling insults, more emotional trauma, where a parent is overly critical, or doesn’t do things to help you feel safe, who’s nonaccepting, emotionally unavailable.

That’s the kind of trauma that is kind of under the radar a lot of times. That was kind of more my trauma in terms of my pain. So that’s a lot harder to unearth, and for people to even realize that that’s what was going on, because if you grow up with that, you’re so used to it, you just think that was normal. So that kind of trauma could take a while to undo.

Kevin Pho: We’re talking to Cindy Perlin. She’s a social worker. Today’s KevinMD article is “From suffering to healing: the role of trauma in chronic pain.” Cindy, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Cindy Perlin: Well, I think it’s very important to look at the mind-body connection and to address it. And even if you don’t have a lot of trauma in your background, just learning to relax and keep your physiology in that relaxed state can be very helpful for avoiding and healing any kind of illness.

Kevin Pho: Cindy, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Cindy Perlin: Thank you for having me.