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Fall 2026

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Co-Occurring PTSD and Chronic Pain: From Shared Mechanisms to Integrated Treatment Approaches

Mariel Emrich; Laura E. Laumann; Katherine L. Applegate, PhD; Rose Constantino, PhD, BSN, MN, JD - Violence and Trauma SIG

Posttraumatic stress disorder (PTSD) and chronic pain frequently co-occur, with populations such as veterans,1,2 physical injury survivors,3 and those with widespread pain4,5 at particularly elevated risk. PTSD is characterized by symptoms such as intrusions, avoidance, negative alterations in cognitions and mood, and hyperarousal following a Criterion A traumatic event (i.e., threatened death, serious injury, or sexual violence).6 Chronic pain is a complex biopsychosocial condition defined as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” that has lasted at least three months.7 While PTSD and chronic pain each independently pose difficulties for patients and their healthcare systems, the comorbidity of these conditions constitutes an even more substantial public health challenge. PTSD and chronic pain tend to exacerbate one another, resulting in greater symptom severity, disability, opioid use, and suicidality in individuals with the comorbidity compared to those with only one condition.8–10 PTSD and chronic pain may develop simultaneously following a traumatic injury or have separate onsets, with one condition increasing vulnerability to the development or maintenance of the other.11

Theoretical Underpinnings 

Importantly, PTSD and chronic pain are often maintained by similar underlying mechanisms. Both involve heightened sense of threat, increased nervous system activation, and avoidance of activities, situations, or emotions that feel distressing or unsafe.12 Multiple theoretical models have been proposed to explain the relationship between PTSD and chronic pain. Among the most common is the fear avoidance model which posits that individuals avoid feared trauma- and pain- related stimuli, leading to increased fear and impeded recovery.12 Other theoretical models include the mutual maintenance and shared vulnerability models. While the mutual maintenance model suggests that shared factors (e.g., attentional biases, anxiety sensitivity, and heightened threat perception) perpetuate one another to maintain both PTSD and chronic pain,13 the shared vulnerability model posits that shared factors (e.g., genetics ,biological vulnerabilities) increase risk of developing both conditions.13 

Treatment Approaches 

Despite this well-documented overlap of PTSD and chronic pain, these conditions are typically treated separately. Gold-standard psychological treatments exist for both PTSD (e.g., Prolonged Exposure [PE]14; Cognitive Processing Therapy [CPT]15) and chronic pain (e.g., Cognitive Behavioral Therapy for Chronic Pain [CBT-CP]16 and Acceptance and Commitment Therapy [ACT]17). Although these treatments are generally effective for their intended conditions, most were developed to target PTSD or chronic pain individually rather than their co-occurrence, and symptoms of the co-occurring condition may interfere with treatment engagement or outcome.8,18,19 Patients with comorbid PTSD and chronic pain therefore tend to receive sequential or parallel care across multiple providers and settings, which may increase treatment burden and fail to fully address underlying shared mechanisms.20–22 Some newer wave pain treatments increasingly recognize the role of stress and trauma in the context of pain. For instance, Emotional Awareness and Expression Therapy (EAET) integrates pain neuroscience with recognition and expression of avoided emotions.23 Although EAET incorporates a trauma framework, it is mainly a treatment for primary chronic pain rather than a treatment designed for the comorbidity of PTSD and chronic pain. Patients with co-occurring PTSD and chronic pain express interest in integrated treatment approaches,21 yet to date, there is not a well-established treatment manual for this common comorbidity.

There have only been a few integrated treatments tested (e.g., combined CPT and CBT-CP24,25 and ongoing trial of integrated treatment of PE and CBT-CP (NCT07225049)). PTSD and chronic pain treatments may be particularly amenable to integration as they share many similar elements such as psychoeducation, gradual exposures to avoided behaviors and emotions, cognitive restructuring, relaxation exercises, and behavioral activation.26 Integrated treatment approaches may be particularly well-suited to address the mind-body connection, including how persistent physical symptoms and injuries shape patients’ relationships with their bodies and can serve as ongoing trauma reminders.27  These emerging treatments are highly promising but require more rigorous testing in large-scale randomized controlled trials. Continued investigation into integrated treatment models for comorbid PTSD and chronic pain has the potential to improve patient outcomes, reduce appointment burden, and more comprehensively treat mental and physical health conditions.

References:

  1. Fishbain DA, Pulikal A, Lewis JE, Gao J. Chronic pain types differ in their reported prevalence of post-traumatic stress disorder (PTSD) and there is consistent evidence that chronic pain is associated with PTSD: an evidence-based structured systematic review. Pain Med. 2017;18(4):711-735. doi:10.1093/pm/pnw065
  2. Hadlandsmyth K, Zhuang C, Driscoll MA, Lund BC. Comorbid chronic pain and post- traumatic stress disorder: current rates and psychiatric comorbidities among U.S. military veterans. Mil Med. 2024;189(11-12):2303-2306. doi:10.1093/milmed/usae313
  3. Jenewein J, Moergeli H, Wittmann L, Büchi S, Kraemer B, Schnyder U. Development of chronic pain following severe accidental injury. Results of a 3-year follow-up study. J Psychosom Res. 2009;66(2):119-126. doi:10.1016/j.jpsychores.2008.07.011
  4. Fishbein JN, Malaktaris A, Afari N, Herbert MS. Multifocal pain prevalence and associations with psychiatric symptoms and emergency healthcare use among post-9/11 veterans. J Pain. 2024;25(4, Supplement):61. doi:10.1016/j.jpain.2024.01.281
  5. Siqveland J, Hussain A, Lindstrøm JC, Ruud T, Hauff E. Prevalence of posttraumatic stress disorder in persons with chronic pain: a meta-analysis. Front Psychiatry. 2017;8:164. doi:10.3389/fpsyt.2017.00164
  6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
  7. Raja SN, Carr DB, Cohen M, et al. The Revised IASP definition of pain: concepts, challenges, and compromises. Pain. 2020;161(9):1976-1982. doi:10.1097/j.pain.0000000000001939
  8. Benedict TM, Keenan PG, Nitz AJ, Moeller-Bertram T. Post-traumatic stress disorder symptoms contribute to worse pain and health outcomes in veterans with PTSD compared to those without: a systematic review with meta-analysis. Mil Med. 2020;185(9-10):e1481-e1491. doi:10.1093/milmed/usaa052
  9. Otis JD, Keane TM, Kerns RD. An examination of the relationship between chronic pain and post-traumatic stress disorder. J Rehabil Res Dev. 2003;40(5-6):397-406. doi:10.1682/jrrd.2003.09.0397
  10. Finley EP, Bollinger M, Noël PH, et al. A national cohort study of the association between the polytrauma clinical triad and suicide-related behavior among US Veterans who served in Iraq and Afghanistan. Am J Public Health. 2015;105(2):380-387. doi:10.2105/AJPH.2014.301957 
  11. Kind S, Otis JD. The interaction between chronic pain and PTSD. Curr Pain Headache Rep. 2019;23(12):91. doi:10.1007/s11916-019-0828-3
  12. Bosco MA, Gallinati JL, Clark ME. Conceptualizing and treating comorbid chronic pain and PTSD. Pain Res Treat. 2013;2013:174728. doi:10.1155/2013/174728
  13. Asmundson GJ, Coons MJ, Taylor S, Katz J. PTSD and the experience of pain: research and clinical implications of shared vulnerability and mutual maintenance models. Can J Psychiatry. 2002;47(10):930-937. doi:10.1177/070674370204701004
  14. Foa EB, Hembree EA, Rothbaum BO. Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Therapist Guide. 2nd ed. Oxford University Press; 2019.
  15. Resick PA, Monson CM, Chard KM. Cognitive Processing Therapy for PTSD: A Comprehensive Manual. Guilford Press; 2016.
  16. Murphy JL, McKellar JD, Raffa SD, Clark ME, Kerns RD, Karlin BE. Cognitive Behavioral Therapy for Chronic Pain Among Veterans: Therapist Manual. US Department of Veterans Affairs; 2014.
  17. McCracken LM, Vowles KE. Acceptance and commitment therapy and mindfulness for chronic pain: model, process, and progress. Am Psychol. 2014;69(2):178-187. doi:10.1037/a0035623
  18. Wells SY, Morland LA, Hurst S, et al. Veterans’ reasons for dropping out of prolonged exposure therapy across three delivery modalities: A qualitative examination. Psychol Serv. 2022;20(3):483-495. doi:10.1037/ser0000714
  19. Wald J, Taylor S, Fedoroff IC. The challenge of treating PTSD in the context of chronic pain. In: Taylor S, ed. Advances in Treatment of Posttraumatic Stress Disorder: Cognitive-Behavioral Perspectives. Springer: 2004:197-222.
  20. Åkerblom S, Perrin S, Fischer MR, McCracken LM. Prolonged exposure for pain and comorbid PTSD: a single-case experimental study of a treatment supplement to multiprofessional pain rehabilitation. Scand J Pain. 2022;22(2):305-316. doi:10.1515/sjpain-2021-0100
  21. Pratt AA, Van Tiem J, Lund BC, et al. Comorbid chronic pain and posttraumatic stress disorder among veterans: approaches to care. Mil Med. 2025;190(9-10):e2058-e2064. doi:10.1093/milmed/usaf118
  22. Murphy JL, Discoll MA, Odom AS, Hadlandsmyth K. Posttraumatic stress disorder and chronic pain. PTSD Res Q. 2022;33(2):1-10.
  23. Lumley MA, Schubiner H. Emotional awareness and expression therapy for chronic pain: rationale, principles and techniques, evidence, and critical review. Curr Rheumatol Rep. 2019;21(7):30. doi:10.1007/s11926-019-0829-6
  24. Otis JD, Keane TM, Kerns RD, Monson C, Scioli E. The development of an integrated treatment for veterans with comorbid chronic pain and posttraumatic stress disorder. Pain Med. 2009;10(7):1300-1311. doi:10.1111/j.1526-4637.2009.00715.x
  25. Otis JD, Comer JS, Keane TM, Checko (Scioli) E, Pincus DB. Intensive treatment of chronic pain and PTSD: the PATRIOT Program. Behav Sci. 2024;14(11):1103. doi:10.3390/bs14111103
  26. Hellman N, Haft SM, Woodbury A, Sherrill AM, Rauch SAM. The pain of PTSD: integrating persistent or chronic pain within emotional processing theory of posttraumatic stress disorder. Eur J Psychotraumatology. 16(1):2479923. doi:10.1080/20008066.2025.2479923
  27. Avieli H. “A constant reminder”: how intimate partner violence survivors with long-term injuries perceive their bodies. J Interpers Violence. 2026:08862605261473532. doi:10.1177/08862605261473532