Confronting trauma alleviates chronic pain: study

Newly developed psychotherapy that works by confronting past trauma and stress-related emotions that can exacerbate pain symptoms could help reduce chronic pain significantly among older adults, suggests a new study.

The study, by UCLA Health and the US Veterans Affairs Office, compared the newer therapy, known as emotional awareness and expression therapy, or EAET, to traditional cognitive behavioural therapy, or CBT, in treating chronic pain as well as mental health symptoms such as depression, anxiety and post-traumatic stress disorder symptoms among older veterans.

Researchers recruited 126 veterans — predominantly men — aged 60 to 95 with at least three months of musculoskeletal pain. More than two-thirds of participants had a psychiatric diagnosis, with about one-third having post-traumatic stress disorder.

This was the first full-scale clinical trial of EAET among older adults, older men and veterans, with past studies being largely made up of younger, female participants, said lead author Brandon Yarns, an assistant professor at UCLA Health’s Department of Psychiatry and Biobehavioral Sciences and psychiatrist at the Veteran’s Affairs Greater Los Angeles.

Pain reduction — CBT vs EAET

The study, published in JAMA Network Open, found that 63% of veterans who underwent EAET reported at least a 30% reduction in pain after treatment compared to only 17% of veterans who underwent cognitive behavioural therapy.

Around 41% of EAET participants had sustained pain reduction six months after treatment compared to 14% of CBT patients. Additionally, EAET patients reported greater benefits for addressing anxiety, depression, PTSD and life satisfaction.

“Most people with chronic pain don't consider psychotherapy at all. They’re thinking along the lines of medications, injections, sometimes surgery or bodily treatments like physical therapy,” Yarns said.

“Psychotherapy is an evidence-based treatment for chronic pain. What this study adds is that the type of psychotherapy matters.”

Cognitive behavioural therapy has long been the ‘gold standard’ for psychotherapeutic treatment of chronic pain among veterans, Yarns said. However, studies so far have shown CBT produces modest benefits for relieving pain. For chronic pain, patients undergo a treatment package with some similar exercises to those used to treat depression or anxiety such as guided imagery, muscle relaxation, cognitive restructuring and activity pacing. The end goal is for patients to improve their ability to tolerate their pain, Yarns said.

Stress and pain perception

“The goal in CBT is not necessarily to cure pain but to learn to cope and live well despite chronic pain,” Yarns said.

By comparison, EAET has one primary intervention: experiencing, expressing and releasing emotions. Developed in the 2010s, the therapy aims to show patients that the brain’s perception of pain is strongly influenced by stress-related emotions. Patients are asked to focus on a stressful interaction, from anything as mundane as being cut off by a driver to severe traumas such as sexual assault.

Yarns said the purpose is to have patients experience these emotions both in mind and in body. The patients then work to confront these emotions, express their reactions and ultimately to let go.

“If there is a hurt or stressor people have a series of normal, natural emotional reactions. There might be anger, guilt and sadness. Because these feelings are painful, people often avoid them, but EAET helps people face difficult feelings with honesty and self-compassion,” Yarns said.

“In therapy, they can release anger, pain and guilt that they’ve been carrying and are left with self-compassion in the end.”

Yarns said he is now studying whether similar positive results could be replicated using virtual group sessions, which will compare EAET, CBT and also include a mindfulness therapy cohort. Additionally, Yarns said that neuroimaging studies will be pursued to understand the brain changes among participants in EAET versus CBT therapies.

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