What is the role of adversity, personality, depression, and post-traumatic stress in nociplastic pain?
People who have experienced trauma or adversity in childhood are more likely to develop persistent pain as adults. This includes: physical, sexual, or verbal abuse; physical or emotional neglect; mental illness or addiction in a parent; imprisonment of a family member; witnessing abuse of mother, sibling, or father; arguments or tension in the family; losing a parent to separation, divorce, or death; community violence, racist abuse, identity based discrimination and oppression; poverty; bullying at school; lack of affection or communication in your family; early medical trauma; family secrets. These experiences shape our perception of the world as a safe or threatening place, and heighten the activation of survival energy; as discussed above, our brain creates pain when there is more credible evidence of danger than of safety, and repeated experiences of danger will make us more vigilant. All of this, however, says nothing about your ability to recover. In addition to experiences of adversity, you also have a unique set of talents and skills that we can harness in support of resilience and healing.
Depression and post-traumatic stress
Many people struggling with depression experience physical symptoms. If you have been diagnosed with depression or you are experiencing sleep disruption, fatigue, challenges with coping, loss of interest or pleasure in usual activities, changes in appetite, difficulty with decision making or suicidal thoughts or plans that are not secondary to a medical diagnosis such as cancer or neurodegenerative disorder, there is a high likelihood that your pain and other physical symptoms have a nociplastic component and can improve or completely resolve with a mindbody approach. In fact, we can consider depression as a condition that can be treated through bodymind (re)learning, harnessing bioplasticity and neuroplasticity.
Post traumatic stress often presents with a physical symptom too. Sometimes the physical symptoms will happen shortly after significant trauma, but for some people they will develop years after the traumatic event as a result of a more recent triggering event. If you have experienced developmental trauma or live with complex post traumatic stress, you may also be experiencing physical symptoms associated with it. Once again, this has to do with neural pathways of danger and fear.
Personality “traits”
The term “personality traits” refers to relatively stable characteristics inferred from a pattern of behaviors, attitudes, feelings, and habits. Some of these patterns are common in people with nociplastic pain and other psychophysiologic or functional symptoms, including: perfectionism, an overactive inner critic, conscientiousness, goodism, people-pleasing, conflict avoidance, anxiousness, constant worrying, and fearful thoughts. All of these traits put the brain on high alert, making it more likely to create pain.
There are some important considerations here:
Many people can have these personality traits or features but don’t develop chronic pain, and many people who develop chronic pain don’t have these personality traits. And sometimes it’s a chicken and egg kind of situation, where we have a population of people who have been experiencing pain for a long time, and we find that they display a set of traits, and some of them may have predated the pain, and some may have developed as a result of coping with persistent pain. There is strong evidence that state factors (such as chronic pain) may influence or distort trait measurement, so we can’t assume that personality measurement after chronic pain onset reflects a stable pre-pain personality.
When we think or talk about “personality traits” it might feel as something fixed or permanent that can’t change, and we also might have a judgmental stance of “bad” traits. It’s important to think about this differently, and recognize that we have all developed habitual responses and patterns of thinking, feeling, relating and being with to best cope with the challenges we’ve faced in life. So something I’ve found useful in doing this work is getting curious about how those habitual patterns have developed, how they’ve helped to take care of me, with a sense of compassion, and even a sense of awe. And then ask how can I expand my repertoire and cultivate other ways of thinking, feeling, relating to myself and others, being with that best support me at this time and that help me grow in flexibility.
If you find yourself relating to some of these personality patternss, and wishing to address them, know that there are many mindbody practices and tools that can help you build capacity for distress tolerance, emotion regulation skills, flexibility, and resiliency.
Keep this in mind as you read the following.
Personality traits may influence development and adjustment to ongoing pain. According to Naylor et al., the most distinguishing personality features of chronic pain sufferers may be:
High harm avoidance, a tendency to be fearful, pessimistic, catastrophizing, sensitive to criticism, and requiring high levels of re-assurance. It makes us more likely to develop conditioned fear/threat responses and require more reassurance and encouragement. People with high harm avoidance can be emotionally reactive and vulnerable to interpreting ordinary situations as threatening and minor frustrations as hopelessly difficult.
Low self-directedness, which often manifests as difficulty with defining and setting meaningful goals, low motivation, and problems with adaptive coping.
Evidence for this personality profile is found across a wide variety of chronic pain conditions including fibromyalgia, headache and migraine, temporomandibular disorder, trigeminal neuropathy, musculo-skeletal disorders and heterogeneous pain groups. High harm avoidance is also found in those suffering anxiety and depression. In line with the fear avoidance model, these negative appraisals may then lead to pain-related fear which results in avoidance of feared movement and activities. Consequently, this avoidance then results in disuse, disability and depression, further exacerbating the pain experience and maintaining a vicious cycle of fear and avoidance, which is often characteristic of chronic pain sufferers.
The existing literature on chronic pain populations also describes a higher prevalence of “personality disorders” than in non-pain samples. Of note, we know that what is diagnosed as “personality disorder” is most often the result of developmental trauma - so developmental trauma mediates some personality traits that have developed as effective coping mechanisms and that can later on contribute to persistent pain. There’s also a link between insecure attachment and the development of chronic pain or greater disability.
People with these traits may respond or adjust differently to pain, and as a result may be more likely to suffer more and exacerbate the pain experience. One example is attending to their pain and bodily symptoms in a way that leads to hypervigilance and amplification of symptoms, which are suggested cognitive-affective components in the development of chronic pain.
Other habits and patterns that can contribute to persistent pain are giving control to another person or some external factor or intervention, and allowing pain to adversely affect other areas of life. This is of great importance to treatment, because we know effective recovery is about experiencing a greater sense of agency, being in charge of our own healing, and reclaiming real estate, so to speak, from pain. You reclaim your life and then pain goes down, not the other way around. You are healing yourself - no external intervention or provider is healing you. If you seek help and/or engage in some kind of treatment or other, it is my hope that you can remember that you have the resources and ability to heal in your bodymind - the person working with you has a supportive role.
If you’d like my support on your path towards healing and recovery, contact me. If you’d like to learn more about what keeps the cycle pain going, and how to interrupt it, check out the next blog entry.