Research consistently demonstrates high comorbidity rates between Post-traumatic Stress Disorder (PTSD) and chronic pain, with prevalence estimates reaching up to 10% in civilian populations and as high as 50% among veterans (Kind & Otis, 2019). These conditions share overlapping neurobiological, cognitive, and behavioral mechanisms, reinforcing each other in ways that complicate treatment. The purpose of this article is to 1) provide a brief overview of the shared mechanisms between PTSD and chronic pain and 2) highlight common clinical challenges while offering recommendations for improving therapeutic outcomes.
Shared Mechanisms of PTSD and Chronic Pain
Neurobiological Mechanisms
PTSD-related hyperarousal leads to heightened nervous system reactivity, which can lower the pain threshold and amplify pain perception (Sherin & Nemeroff, 2011). PTSD and chronic pain are also both associated with dysregulation of the hypothalamic-pituitary-adrenal gland (HPA) axis, the bodily system responsible for regulating cortisol release, and contributes to issues with pain sensitivity (Hannibal & Bishop, 2014). Further, chronic pain involves central sensitization, a process in which the nervous system amplifies pain signals even when patients are exposed to non-painful stimuli, and is associated with PTSD (National Center for PTSD, 2024). Both PTSD and chronic pain can additionally change the brain structure, which may include processes such as hippocampal atrophy and amygdala hyperactivity that reduce the brain’s ability to regulate stress and responses to pain (Choi et al., 2022).
Psychological and Behavioral Mechanisms
Pain catastrophizing refers to the tendency to magnify the threat of pain, feel hopeless in response to it, and ruminate on pain experiences (Petrini & Arendt-Nielson, 2020). This cognitive pattern is also observed in individuals with PTSD, who may experience exaggerated negative appraisals of bodily sensations due to heightened threat sensitivity (McDermott et al., 2024). Indeed, research has identified that pain catastrophizing mediates the relationship between PTSD symptoms and the experience of chronic pain (Gilliam et al., 2019).
Additionally, both PTSD and chronic pain contribute to avoidance behaviors and result in worsening symptoms. The Fear-Avoidance Model of Chronic Pain (Zale & Ditre, 2015) posits that pain-related fear promotes behaviors that cause individuals to disengage in movement or physical activity. While this may be adaptive in the context of acute pain, long-term avoidance of these behaviors in those with chronic pain may potentially lead to greater overall levels of disability (Zale & Ditre, 2015). Similarly, among individuals with PTSD, avoidance of trauma-related cues such as people, places, sensory stimuli, as well as memories and thoughts, is characteristic of the condition (APA, 2022). Emotional Processing Theory (Rauch & Foa, 2006) posits that traumatized individuals must engage in exposure-based psychotherapy to modify the memory structure surrounding the traumatic event, which in turn reduces anxiety and fear over time. In the treatment of both chronic pain and PTSD, approaching anxiety-provoking stimuli is needed to confront avoidance of thoughts, emotions, and physical sensations, reduce fear-based avoidance behaviors, and foster adaptive coping strategies that promote resilience and functional recovery.
Social Mechanisms
Chronic pain and PTSD comorbidity may disproportionately affect individuals with marginalized identities. Research using a large national VA database (Hadlansmyth et al., 2024) found that veterans who identified as women, Black/African American, Hispanic or Latina, and residing in urban environments were significantly more likely to experience PTSD-chronic pain comorbidity. Further, social determinants of health, such as socioeconomic status, access to healthcare, systemic discrimination, and community support all play a critical role in shaping both conditions. Individuals with lower income or unstable housing may face barriers to timely medical and psychological care, leading to exacerbated symptoms over time (Webb et al., 2022). Patients with racial and ethnic minority statuses often report limited access to pain management services and are more likely to have their pain symptoms dismissed or undertreated due to implicit biases in healthcare (Meints et al., 2019).
Additionally, social support and isolation influence treatment symptom severity and treatment completion in both PTSD and chronic pain. Both conditions are associated with social withdrawal, which can perpetuate feelings of hopelessness and distress (Bannon et al., 2022; Fox et al., 2021). Conversely, strong social support networks can tremendously buffer the negative effects of trauma and chronic pain, empowering the individual to cope adaptively (Cusack et al., 2024).
Challenges and Recommendations in Treating Comorbid PTSD and Chronic Pain
Avoidance and Treatment Engagement
Avoidance is a core feature of PTSD and can extend to medical and therapeutic interventions. Patients may even fear discussing trauma-related experiences and view some treatment options as a trigger for worsening symptoms. Similarly, chronic pain can lead to avoidance of physical activity, contributing to increased impairment and distress over time.
Strategies for managing avoidance behavior may include returning to motivational interviewing strategies prior to continuing with an intervention for either PTSD or chronic pain (Alperstein & Sharpe, 2016; National Center for PTSD, 2017). This approach allows the clinician to use validating statements to build rapport and connect the goals of the intervention to the patient’s individual goals. Using open-ended questions, affirmations, reflective statements, and summaries may communicate to the patient that clinicians acknowledge the impact their PTSD and chronic pain has had on their life, bolstering the patient’s motivation to come from an intrinsic place. Similarly, utilization of the Cultural Formulation Interview (CFI) during the assessment and shared decision making process can facilitate an understanding of the patient’s experiences of their chronic pain and PTSD from a specific cultural lens (Aggarwal et al., 2022). Concurrently, the clinician can promote small, manageable steps towards treatment adherence. Once motivation is enhanced, the clinician may implement a gradual exposure-based approach to help desensitize patients to both trauma-related stress and activity-related pain, ideally using an interdisciplinary approach (Bosco et al., 2013).
Heightened Sensory and Physiological Arousal
Chronic pain and PTSD both involve nervous system dysregulation, leading to difficulties with relaxation and sensitivities to certain movements, positions, touch, or other physical sensations. These sensitivities may leave patients skeptical to certain treatment recommendations that are meant to increase physical activity and engage in exposure-based actions that activate fear responses.
To counteract this barrier, gradual exposure to movement, mindfulness-based relaxation techniques, and paced breathing exercises can help retrain the nervous system to tolerate and adapt to physical sensations more effectively. Given that both PTSD and chronic pain involve heightened threat sensitivity, interventions may first focus on establishing a sense of safety in the body before introducing a manualized treatment. Introducing concepts and skills related to mindfulness and somatic experiencing can be effective in disrupting the cycle of hyperarousal and pain catastrophizing (Anderson et al., 2017; Boyd et al., 2018). These interventions help build nonjudgmental acceptance of physical sensations and self-regulation strategies to help patients recognize that pain and trauma-related distress are not necessarily signs of current danger. Practices such as progressive muscle relaxation, diaphragmatic breathing, or grounding exercises can dampen autonomic dysregulation by activating the parasympathetic nervous system, which reduces both arousal and pain intensity (Toussaint et al., 2021). Clinicians may model these skills with their patients by guiding them through a practice during session. Recording this with the patient’s phone or other device can also give them a tool to use when feeling activated by pain or PTSD symptoms in the future.
Further, educating the patient on how painful sensations and PTSD symptoms are connected can help establish a framework for how treatment is being approached. To start, clinicians may use the analogy of an alarm system. When someone experiences a trauma, their nervous system stays on high alert, like a smoke detector that goes off even when there is no fire. Chronic pain can be thought of as the body’s alarm system in the “stuck on” position, even when there is no injury or danger. The more the alarm goes off, the more sensitive it becomes, making both pain and trauma reminders feel more intense over time. Treatment in psychotherapy can be used to help “change the wiring” of the alarm system, so it is more accurate when identifying a threat. By framing symptoms in this way, patients may begin to understand that their pain and PTSD symptoms are not “all in their head”, but rather a real consequence of nervous system dysregulation. Providing education on catastrophizing is also key for this comorbidity, and providers may emphasize how this cognitive style impacts the experience of pain, emotional functioning, attention, and memory (Bosco et al., 2013).
Conclusion
The interplay between PTSD and chronic pain presents unique challenges that require a comprehensive, multimodal approach. By understanding their shared neurobiological, psychological, and social mechanisms, clinicians can use tailored interventions that promote engagement, reduce avoidance, and enhance overall effectiveness. Integrating gradual exposure-based therapies, motivational interviewing strategies, and nervous system regulation techniques may help improve quality of life for individuals facing this complex comorbidity.
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