Recent research published in the journal Psychological Trauma: Theory, Research, Practice, and Policy found that a majority of Arizona primary care physicians do not screen patients with chronic pain for psychological trauma though they were aware that it is often a risk factor for chronic pain. At the same time, physicians also acknowledged that treating psychological trauma is often necessary to address chronic pain. The survey was conducted by researchers at the University of Arizona Comprehensive Center for Pain and Addiction in collaboration with pain medicine clinicians.
Katherine Herder, biostatistics doctoral candidate in the Mel and Enid Zuckerman College of Public Health.
Photo courtesy of Katherine Herder, Mel and Enid Zuckerman College of Public Health
“Psychological trauma is recorded in the central nervous system, and it can activate a pain response even without a disease process or physical damage. Psychological trauma needs to be addressed, or it can be difficult to treat chronic pain,” said senior author Jennifer De La Rosa, the center’s director of strategy. “The survey showed that while most primary care physicians are aware of the connection between psychological trauma and chronic pain, they don’t screen patients for it consistently, if at all.”
First author Katherine Herder, a biostatistics doctoral candidate in the Mel and Enid Zuckerman College of Public Health, spearheaded the development of the survey questionnaire. The survey showed that only 24% of the 71 primary care physicians who responded said they consistently screened for psychological trauma, though 93% said they were aware of the connection between psychological trauma and chronic pain. Physicians cited structural barriers – including lack of time, limited support staff and uncertainty about how best to address patients’ behavioral health needs – as reasons they did not screen their patients.
Most respondents said they screened patients more regularly for depression, anxiety and other conditions.
“Clinicians need to be aware of ways to objectively assess trauma,” De La Rosa said. “They also need to be comfortable discussing it and intervening, especially when making referrals to behavioral health specialists. We found a lack of standardized interventions that are systematized and part of a clinical workflow.”
Study co-author Dr. Bennet Davis, a pain management physician and director of the Sierra Tucson Pain Recovery Program, pointed to several possible reasons that primary care physicians might not screen patients for trauma.
“One issue is that there are national guidelines for screening for depression and anxiety, but similar guidelines don’t exist for trauma,” Davis said. “Primary care physicians told us they didn’t necessarily know how to screen and what to look for. Much of the screening for trauma is focused on domestic abuse.
“Another reason is that screening for depression and anxiety is reimbursable, while trauma screening is not,” Davis said, adding that other structural barriers to screening and treatment include understaffing, limited behavioral health resources and poor communication.
“People tend to equate trauma with mental health and its psychological effects, but there is a physical aspect to trauma, too,” Davis said. “Past trauma can cause pain to be felt in the present, even without tissue damage. It’s known as nociplastic pain.”
Davis said behavioral health-based interventions are often an essential and effective part of treating chronic pain.
“Many individuals visit a primary care physician with chronic pain but may not have received behavioral health care because it feels like a physical problem,” Davis said, noting long COVID, fibromyalgia and other conditions that would not typically lead people to seek behavioral health treatment. “The underappreciation of chronic pain has led to misdiagnosing it as solely a physical issue and to inappropriate treatment.”
Nociplastic pain and related psychological trauma – along with associated physical reactions – can contribute to heart attacks, strokes and cancers.
“We need to better understand the barriers,” Davis said. “We want to create pathways between primary care and behavioral health care and make it easier to follow up if a patient screens positive for trauma.”
Some physicians surveyed reported they were unsure whether patients wanted to discuss their trauma.
“They didn’t know if the conversation could be harmful and weren’t sure they could address patients’ needs,” said De La Rosa, who was surprised by the difference in comfort levels among providers when screening for anxiety and depression versus trauma. “More often, those confident discussing anxiety and depression were less confident about trauma.
“We’d like to normalize the conversation about psychological trauma in the context of chronic pain,” De La Rosa said.