PTSD, Developmental Trauma and Chronic Pain
Traumatic experiences and chronic pain can be connected, but the relationship is neither simple nor inevitable. A history of trauma does not prove why someone has pain, and it does not make the pain less real. Many people who experience trauma do not develop post-traumatic stress disorder, while many people living with chronic pain do not have PTSD or a known history of developmental trauma.
When chronic pain and PTSD occur together, however, each condition can make the other more difficult to manage. Disturbed sleep, heightened threat responses, avoidance, loss of confidence in movement and distressing healthcare experiences may all contribute. Recognising these interactions can help clinicians provide care that is safer, more individualised and better coordinated.[1–5]
WHAT DO THESE TERMS MEAN?
Trauma and PTSD
A potentially traumatic event is an experience involving actual or threatened death, serious injury, sexual violence or another overwhelming threat. Examples include assault, abuse, serious accidents, combat, disasters and some medical events.
Distress after such an event is common, but most trauma-exposed people do not develop PTSD. PTSD is diagnosed when characteristic symptoms persist, cause significant distress and interfere with daily life. These symptoms include:
unwanted memories, nightmares or flashbacks;
avoidance of reminders of the event;
a continuing sense of danger, hypervigilance or an exaggerated startle response; and
associated changes in mood, thinking, sleep and function.
Exposure to trauma and having PTSD are therefore not the same thing.[5,6]
Developmental trauma and adverse childhood experiences
Developmental trauma is a broad descriptive term for harmful or overwhelming experiences occurring during childhood and adolescence, particularly when adversity is repeated, interpersonal or associated with a lack of safety and reliable care. It is not, by itself, a single formal diagnosis.
The term adverse childhood experiences, or ACEs, is commonly used in research and public health. ACEs may include abuse, neglect, exposure to violence, parental mental illness, substance-related problems or other serious household adversity.
An ACE count is not a diagnosis and does not explain an individual person’s pain. It does not capture when an event occurred, its severity, protective relationships, cultural context or the meaning it had for that person. It is best understood as a population-level marker of exposure rather than a personal pain test.[1,3]
Complex PTSD
Complex PTSD, or CPTSD, is recognised in the World Health Organization’s ICD-11 classification. It includes the central symptoms of PTSD together with more persistent difficulties involving:
regulation of emotions;
a deeply negative or diminished sense of self; and
forming or maintaining relationships.
CPTSD is commonly associated with prolonged or repeated trauma, but prolonged trauma does not automatically lead to CPTSD. Diagnosis requires an appropriate clinical assessment. Research specifically examining CPTSD and chronic pain remains limited.[3,6]
WHAT DOES THE RESEARCH SHOW?
Research supports an association between childhood adversity and chronic pain in adulthood, but it does not show that trauma is the sole or inevitable cause of pain.
A 2023 systematic review included 85 observational studies involving more than 826,000 adults. Exposure to at least one direct childhood adversity—such as abuse or neglect—was associated with approximately 45% higher adjusted odds of reporting chronic pain in adulthood. The association increased with cumulative exposure: people reporting four or more ACEs had approximately twice the odds of reporting chronic pain as those reporting none.[1]
These are relative differences between groups, not predictions for an individual. The underlying studies were observational and often relied on retrospective self-report. They cannot determine that adversity directly caused a person’s later pain, and factors such as genetics, injury, social disadvantage, access to healthcare, mental health and adult life events may also contribute.
PTSD also occurs more often in some chronic pain populations. A meta-analysis of 21 studies found an overall pooled PTSD prevalence of 9.7% among people with chronic pain, rising to 11.7% in clinical populations and 20.5% in studies of chronic widespread pain. Estimates ranged from 0% to 57%, largely because the studies differed greatly in pain conditions, populations and diagnostic methods. The upper end of that range should not be presented as the usual prevalence in pain clinics.[2]
The evidence concerning developmental trauma, CPTSD and chronic pain is less developed. A 2024 systematic review identified only 13 relevant studies, and just four explicitly examined the relationship between trauma factors and pain symptoms in people with chronic pain. Findings involving CPTSD and experiences described as “pain flashbacks” came from a small number of selected samples and should be regarded as preliminary rather than generally established.[3]
HOW CAN PTSD AND PAIN INTERACT?
There is no single pathway that explains every person’s experience. Several processes may operate together.
A shared event
The same event may produce both physical injury and psychological trauma. A motor vehicle collision, workplace accident, assault or serious medical event may lead to persistent pain while also becoming the focus of intrusive memories, fear and avoidance.
In this situation, pain can become a reminder of the event. A flare of pain, a particular movement, travelling in a car, attending hospital or even feeling a loss of control over the body may activate a trauma response.[4]
Heightened attention to danger
PTSD can involve an ongoing sense of threat. A person may closely monitor physical sensations, the environment and possible signs of danger. Pain-related sensations may therefore attract attention quickly and feel especially alarming.
This does not mean the sensations are imaginary. Attention, expectation and perceived threat influence how all pain is experienced, including pain associated with identifiable tissue or nerve injury.[4]
Avoidance and loss of confidence
Avoiding painful movement or trauma reminders can be protective in the short term. When avoidance becomes prolonged, however, it may reduce activity, physical conditioning, independence and confidence.
Someone may become caught between two understandable fears: that movement will cause injury or intolerable pain, and that particular places, sensations or activities will trigger traumatic memories. This may contribute to isolation and reduced participation in work, family and valued activities.[4]
Sleep, mood and stress
Nightmares, hyperarousal and pain can all disturb sleep. Poor sleep may then reduce emotional resilience, increase fatigue and make pain more difficult to manage the following day.
Depression, anxiety, grief, anger, substance use and social or financial stress may also influence both conditions. These factors should be assessed without assuming that any one of them fully explains the pain.
TRAUMA CAN AFFECT THE EXPERIENCE OF HEALTHCARE
For some people, aspects of healthcare can feel unsafe or trigger a trauma response. Possible triggers include unexpected touch, undressing for an examination, enclosed spaces, needles, sedation, being positioned in a way that restricts movement, uncertainty about what will happen next, or feeling unable to stop a procedure.
Responses may include intense anxiety, freezing, dissociation, irritability, difficulty remembering information, cancelling appointments or avoiding healthcare altogether. These reactions are not necessarily deliberate or a sign that the person is being uncooperative.
Trauma-informed care is an approach to how healthcare is provided. It aims to promote safety, trust, choice, collaboration and respect for autonomy. Practical measures may include:
explaining what will happen before an examination or procedure;
asking permission before touching or repositioning the patient;
offering reasonable choices where clinically possible;
agreeing on a signal to pause;
allowing additional time for questions;
checking understanding after discussing complex information;
minimising unnecessary repetition of a trauma history; and
involving a support person when appropriate and desired.
A patient does not need to disclose the details of past trauma to request these accommodations. Trauma-informed care is also not the same as trauma-focused psychotherapy: it creates a safer context for healthcare but does not, by itself, treat PTSD.[8]
A person may find it helpful to tell a clinician:
“Some parts of medical care are difficult for me because of past experiences. Please explain each step, ask before touching me and let me pause if I need to.”
ASSESSMENT WITHOUT ASSUMPTIONS OR BLAME
Pain should still receive an appropriate medical assessment. A trauma history should not become a shortcut explanation that replaces consideration of musculoskeletal, neurological, inflammatory, visceral or other contributors.
When PTSD may be relevant, assessment can consider:
intrusive memories, nightmares, avoidance and hyperarousal;
whether pain or healthcare situations act as trauma reminders;
sleep, mood, substance use and current safety;
the effect of symptoms on movement, relationships, work and self-care;
previous treatment experiences and possible triggers; and
the person’s priorities and preferences for care.
Questions about trauma should be asked sensitively, with an explanation of why the information may be relevant. The patient should generally have control over how much detail they disclose. Screening questionnaires can help identify symptoms requiring further assessment, but they do not establish a diagnosis by themselves.
The purpose is not to decide whether pain is “physical or psychological.” It is to understand the different contributors to suffering and disability so that care can be planned more effectively.
COORDINATED TREATMENT
There is no single treatment protocol suitable for every person with chronic pain and PTSD. Depending on symptom severity, safety, readiness, access and personal preference, treatment may be:
sequential, addressing the most urgent or disruptive condition first;
parallel, with pain and trauma treatment occurring at the same time through different clinicians; or
integrated, with clinicians coordinating treatment around a shared formulation and goals.[4]
Pain management
Pain care may include education, physiotherapy or exercise-based rehabilitation, pacing, occupational therapy, sleep interventions, psychological pain-management strategies and appropriately selected medical or interventional treatment.
Rehabilitation may need to begin gradually, with attention to both physical tolerance and trauma-related responses. A pain flare or trauma response during treatment does not necessarily mean that the activity is harmful, but it may indicate a need to adjust the pace, provide more preparation or reconsider the plan.
Psychological treatment for pain is not based on the belief that the pain is imagined. Its role may include reducing pain-related fear, improving coping, restoring activity and helping the person pursue meaningful goals despite ongoing symptoms.
Treatment for PTSD
Australian guidelines recommend established trauma-focused psychological treatments for adults with PTSD. These include trauma-focused cognitive behavioural therapy, prolonged exposure, cognitive therapy, cognitive processing therapy and eye movement desensitisation and reprocessing, or EMDR.[6]
These treatments should be delivered by appropriately trained clinicians and adapted to the person’s circumstances. Trauma-focused treatment does not mean forcing someone to recount traumatic experiences without preparation, consent or adequate support.
A 2026 systematic review of 30 randomised trials found low-quality evidence that trauma-focused treatment may produce a moderate average improvement in PTSD symptoms and a small average reduction in pain intensity. Most included studies had methodological weaknesses, and results varied substantially. Trauma treatment should therefore be offered for appropriate PTSD indications—not promoted as a reliable cure for chronic pain.[7]
Complex PTSD
People with CPTSD may require additional attention to emotional regulation, trust, self-concept, relationships and the pace of treatment. However, evidence supporting one specific CPTSD-and-pain programme remains insufficient. Treatment should be individualised rather than based on claims that a particular approach has been proven to resolve both conditions.[3,6]
Medication
Medication may have a role in treating particular pain conditions, PTSD symptoms, depression, anxiety or sleep disturbance. A medicine that is effective for one problem should not automatically be described as treating the other.
Choice of medication should take account of the individual diagnosis, the type of pain, other medical conditions, potential adverse effects, interactions, substance-use risk and the person’s preferences. Current PTSD guidance, for example, does not support presenting duloxetine as an established general treatment for PTSD, while prazosin is considered in some guidelines specifically for PTSD-associated nightmares rather than as a treatment for daytime pain.[9]
WHAT CAN IMPROVEMENT LOOK LIKE?
Meaningful improvement does not always require complete elimination of pain or trauma memories. Depending on the person, progress may include:
fewer nightmares, flashbacks or episodes of intense alarm;
improved sleep;
greater confidence with movement;
less disruption from pain;
more predictable participation in work, relationships and daily activities;
reduced reliance on avoidance or unhelpful coping strategies; and
a stronger sense of safety, choice and control.
Progress may be gradual and uneven. A symptom flare does not necessarily mean that treatment has failed. Outcomes vary, particularly when there are multiple injuries, ongoing adversity, compensation or legal stress, limited social support, or other physical and mental health conditions.
KEY MESSAGES
Trauma exposure, PTSD and chronic pain are associated, but none automatically causes the others.
A trauma history does not make pain imaginary or less deserving of medical assessment.
Population-level ACE findings cannot determine the cause or prognosis of an individual person’s pain.
Trauma-informed care emphasises safety, consent, choice and collaboration; it does not require detailed disclosure of trauma.
Trauma-focused therapy treats PTSD, while pain rehabilitation addresses pain-related function. They may be delivered sequentially, in parallel or in a coordinated programme.
Evidence for treatments that reliably improve both PTSD and chronic pain remains limited, so outcomes should not be guaranteed.
Treatment goals should be individualised and may include better function, sleep, participation and quality of life as well as symptom reduction.
WHEN TO SEEK HELP
Professional assessment may be helpful when pain, nightmares, intrusive memories, avoidance, hypervigilance or sleep disturbance persist and interfere with daily life. Urgent help should be sought if there is immediate danger, suicidal thinking, inability to remain safe or unsafe use of alcohol, medication or other substances.
In Australia, call 000 in an emergency. Lifeline provides confidential 24-hour crisis support on 13 11 14.
This article provides general educational information and is not a substitute for individual medical or mental health advice. Assessment and treatment should be tailored by appropriately qualified health professionals. The potential benefits, limitations and risks of treatment vary between individuals.
Last Medically Reviewed: 28/08/2026
REFERENCES
Bussières A, Hancock MJ, Elklit A, Ferreira ML, Ferreira PH, Stone LS, et al. Adverse childhood experience is associated with an increased risk of reporting chronic pain in adulthood: a systematic review and meta-analysis. European Journal of Psychotraumatology. 2023;14(2):2284025. doi: 10.1080/20008066.2023.2284025.
Siqveland J, Hussain A, Lindstrøm JC, Ruud T, Hauff E. Prevalence of posttraumatic stress disorder in persons with chronic pain: a meta-analysis. Frontiers in Psychiatry. 2017;8:164. doi: 10.3389/fpsyt.2017.00164.
Karimov-Zwienenberg M, Symphor W, Peraud W, Décamps G. Childhood trauma, PTSD/CPTSD and chronic pain: a systematic review. PLOS ONE. 2024;19(8):e0309332. doi: 10.1371/journal.pone.0309332.
National Center for PTSD. Chronic Pain and PTSD. United States Department of Veterans Affairs.
World Health Organization. Post-traumatic stress disorder. WHO Fact Sheet. Updated 27 May 2024.
Phoenix Australia—Centre for Posttraumatic Mental Health. Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, Posttraumatic Stress Disorder and Complex PTSD. NHMRC-approved 2020; updated recommendations approved December 2021.
O’Donnell ML, Arjmand HA, Lumley MA, Seal K, Mani R, Sterling M, et al. Systematic review and meta-analyses of nonpharmacological interventions for co-occurring chronic pain and posttraumatic stress disorder. Pain. 2026;167(4):756–766. doi: 10.1097/j.pain.0000000000003880.
Phoenix Australia—Centre for Posttraumatic Mental Health. Trauma-Informed Practice Tools.
National Center for PTSD. Clinician’s Guide to Medications for PTSD: Recommendations from the 2023 VA/DoD Clinical Practice Guideline. United States Department of Veterans Affairs.
