By Pat Anson, Editor
An article in a peer-reviewed medical journal that promotes a “new way of thinking” about chronic pain – and its possible ties to childhood trauma -- is stirring some controversy in the fibromyalgia community.
In the article, published in The Journal of Family Practice, co-authors Bennet Davis, MD, and Todd Vanderah, PhD, say there may be “psychological reasons” for chronic pain that is not caused by tissue injuries or damage to the nervous system – what they call a “third type of pain.”
“We hypothesize that this pain may be the consequence of changes in nervous system function that arise from developmental trauma, other traumatic experiences in a patient’s life, or mental health disorders. It is this third type of pain that may offer us insights into conditions such as fibromyalgia,” they wrote
Davis and Vanderah say the third type of pain can be recognized when a patient makes an “emotionally charged presentation” that they are in severe pain when there is no physical evidence of tissue injury or pathology.
Where then does the pain come from? Davis and Vanderah say childhood accidents, trauma and abuse are so emotionally upsetting that they can lead to long-term changes in the central nervous system that amplify pain.
“We believe that these changes lead to a bias toward hyperactivation of emotional pain circuits, which leads to the emotionally laden pain behaviors that often seem out of proportion to tissue pathology,” they said.
“Perhaps this will explain what is happening with some of our patients who complain of pain ‘all over’ and who are often classified as having fibromyalgia.”
Fibromyalgia is a poorly understood disorder that is characterized by deep tissue pain, fatigue, depression, mood swings and insomnia. The exact cause of fibromyalgia is unknown.
Article Called "Dangerous"
Are Davis and Vanderah onto something? Or is their theory simply a new variation of the “it’s all in your head” explanation that many patients get from doctors?
“This article is dangerous,” says Jan Chambers, President of the National Fibromyalgia and Chronic Pain Association. “The slippery slope created by this article for a quick shove-off of patients with fibromyalgia generally to a psychiatrist or psychologist for talk therapy is very concerning.
“Singling out childhood psychological trauma without rigorous research as a ‘third type of pain’ and potential cause of fibromyalgia is dangerous because this could become an easy reason for medical doctors to further dismiss pain patients with challenging treatments from their care or withhold needed medical treatments or prescriptions. Additionally, other medical conditions could go undiagnosed with their symptoms attributed to being a psychological aspect of childhood trauma.”
Chambers says research has found that about 70 percent of people with fibromyalgia have neck pain – and many also have a history of whiplash-type injuries – indicating there is a physical explanation for fibromyalgia.
“When people receive appropriate care and spinal rehabilitation for their cervical spine, their fibromyalgia symptoms significantly reduce,” Chambers said in an email to PNN. “Several prominent fibromyalgia researchers have known this for years but have not convinced medical doctors to recruit chiropractors to help alleviate the suffering of their patients with fibromyalgia who have significant neck or low back pain.”
Another patient advocate disputes the notion that chronic pain is linked to childhood trauma and abuse.
“We would be hard pressed to find anyone who hasn't experienced psychological trauma at some point in their life,” says Celeste Cooper, a retired nurse and fibromyalgia sufferer.
“So, are we to assume they will all have multiple sclerosis, nerve impingement, Ehler's Danlos, CRPS, fibromyalgia, myofascial pain syndrome, Crohn's disease, chronic fatigue, cancer, etc.? Childhood trauma is a horse of a different color and should be left to those who specialize in this type of care. I cannot connect the dots on that one. Mental illness should be addressed by a trained psychiatrist and psychologist, not someone treating adult chronic pain.”
Davis is a pain management specialist at the Integrative Pain Center of Arizona in Tucson, while Vanderah is a Professor of Pharmacology at the University of Arizona.
Davis said he developed his theory about the connection between childhood trauma and fibromyalgia after listening to thousands of patients’ stories. He believes there is a connection between emotional and physical pain that every doctor needs to understand.
“The nervous system is the connector between tissues and mind/consciousness, and every health provider needs to understand the nervous system to do their job, especially primary care providers,” Davis wrote in an email to PNN. “The artificial separation of mind and body represents a paradigm that has led the American health care system to multiple dead ends (including a dead end in understanding fibromyalgia), to misdiagnoses, to unnecessary surgeries and tests, to accusing patients that ‘it’s in your head’ when it most definitely is not, and has contributed to nearly bankrupting our health care system.”
How would Davis and Vanderah evaluate and treat fibromyalgia? If a physical cause of the pain cannot be found, they recommend doctors look for signs of “psychologically traumatic experiences” in patients, and assess them for anxiety and depression.
Recommended treatments include counseling, cognitive behavioral therapy, hypnotherapy, post-traumatic stress disorder therapies and anti-depressant medications such as Cymbalta (duloxetine) and Effexor (venlafaxine). Interestingly, they do not recommend any type of pain medication – either opioids or over-the-counter pain relievers.
“Above all, when you are caring for someone who has pain without clear tissue pathology or who has recognized intensified emotional pain processing, reassure the person that the pain experience is not in his or her head, but rather in his or her nervous system,” they said. “Such discussions go a long way toward helping patients understand their experience, as well as feel validated. And that can lead to improved compliance with therapy going forward.”
The Journal of Family Practice is delivered to nearly 100,000 family physicians, general practitioners and osteopaths in primary care.