The Neurological Connection Between PTSD and Chronic Pain

4-16-25

By Dr. Howard Friedman, MD | Veteran | U.S. Army Medical Corps | Internal Medicine | HHOM LLC

"Exploring how PTSD rewires the nervous system—and why chronic pain and trauma are deeply connected. Understanding the link is the first step toward healing."

A wound unseen can echo loud,

In flash and fire, beneath the shroud.

The body tenses, breath held tight,

Long after day gives way to night.

But name the pain, and pathways shift—

Where truth is spoken, there lies the lift.

---Dr. Howard Friedman MD

Post-traumatic Stress Disorder (PTSD) is a psychiatric condition that can develop in individuals who have experienced or witnessed a traumatic event—or, in some cases, a prolonged series of distressing experiences. Importantly, not all individuals who experience trauma go on to develop PTSD. Many may endure symptoms that mirror PTSD—such as heightened anxiety, insomnia, or emotional detachment—without meeting the full diagnostic criteria. For PTSD to be formally diagnosed, the symptoms must persist for more than a month and must cause significant distress or impair a person’s ability to function in daily life. While symptoms often emerge within three months of the traumatic event, they can sometimes remain dormant for longer, only surfacing years later. PTSD frequently co-occurs with other mental health conditions, including depression, substance use disorders, anxiety, and memory or concentration difficulties.

PTSD symptoms fall into four major categories. The first is intrusion, which includes unwanted and involuntary thoughts, distressing dreams, vivid flashbacks, and emotionally triggering memories of the trauma. The second category is avoidance, where individuals actively avoid people, places, conversations, or activities that remind them of the trauma. The third involves negative changes in cognition and mood, such as distorted thoughts about oneself or others, feelings of detachment, or persistent emotional numbness. The fourth is alterations in arousal and reactivity, which may include hypervigilance, exaggerated startle response, irritability, and difficulty concentrating or sleeping.

This last category—arousal and reactivity—is particularly significant when discussing the neurological underpinnings of PTSD. PTSD can be understood as a condition in which the brain’s alarm system becomes hypersensitive and fails to reset. At the center of this malfunction is the amygdala, a structure deep in the brain that plays a critical role in processing emotions, especially fear and threat perception. In PTSD, the amygdala becomes hyperactive, remaining on high alert long after the danger has passed. Normally, this response would be modulated by other brain structures, particularly the prefrontal cortex and the hippocampus. The prefrontal cortex is responsible for higher-level functions such as decision-making, planning, and emotional regulation, while the hippocampus is involved in memory formation and contextualizing events.

In PTSD, this neural circuitry is disrupted. The prefrontal cortex loses its ability to effectively regulate the amygdala, and the hippocampus struggles to differentiate between past trauma and present reality. This results in the brain misfiring its alarm signals, causing individuals to relive traumatic memories as if they are happening in real time. These disruptions can lead not only to emotional distress but also to physical manifestations—particularly chronic pain.

There is a growing body of evidence linking PTSD with chronic pain. Both conditions share overlapping brain pathways and neurochemical changes. Just as PTSD alters how the brain processes fear and memory, chronic pain alters how the brain processes sensory input and emotional response. Chronic pain—unlike acute pain, which is usually short-lived and tied to a clear injury or illness—often lacks a clear ongoing physical source. Instead, it becomes embedded in the brain’s emotional and cognitive centers, particularly within the prefrontal cortex and the anterior cingulate cortex, which also play a role in emotional regulation. This overlap means that individuals with PTSD often experience chronic pain, and conversely, those suffering from long-term pain conditions may go on to develop PTSD.

Neurotransmitter imbalances—particularly involving serotonin, norepinephrine, and dopamine—are found in both PTSD and chronic pain. These chemical changes contribute to alterations in mood, cognition, and sensitivity to pain. Furthermore, both conditions involve a heightened stress response, sustained activation of the hypothalamic-pituitary-adrenal (HPA) axis, and elevated levels of stress hormones such as cortisol. Over time, this state of chronic physiological stress can wear down the body and mind, creating a feedback loop that reinforces both emotional trauma and physical pain.

What’s particularly compelling is that chronic pain can sometimes be the trigger for PTSD. A severe injury, an invasive medical procedure, or prolonged illness can leave an individual feeling helpless, violated, or overwhelmed—all hallmarks of trauma. When the pain persists, especially without adequate relief or validation, the individual may develop the intrusive thoughts, emotional numbing, and hyperarousal seen in PTSD. The line between physical and psychological suffering begins to blur.

Understanding this intimate connection between PTSD and chronic pain is crucial for providing effective treatment. Addressing one without acknowledging the other often leads to incomplete care and ongoing distress. Multidisciplinary approaches—integrating psychotherapy, medication, physical therapy, and holistic interventions—are often necessary. Interventions such as Cognitive Behavioral Therapy (CBT), EMDR (Eye Movement Desensitization and Reprocessing), and trauma-informed pain management strategies can provide meaningful relief.

In sum, PTSD and chronic pain are not merely coexisting conditions; they are interwoven, each shaping and reinforcing the other through shared neurological pathways and emotional responses. For veterans, first responders, trauma survivors, and individuals living with long-term pain, recognizing this connection opens the door to more compassionate, comprehensive care—and ultimately, to healing.

—Dr. Howard Friedman, MD

Board-Certified | Internal Medicine | Veteran | U.S. Army Medical Corps

Founder of Howard’s House of Medicine (HHOM LLC)

https://www.hhomllc.com

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Frequently Asked Questions:

Question: How does PTSD affect the brain?

Answer: PTSD disrupts the brain’s fear and memory circuits. The amygdala becomes hyperactive, the prefrontal cortex loses regulatory control, and the hippocampus struggles to separate past trauma from present reality. This creates a constant state of hyperarousal and emotional distress.

Question: Can chronic pain cause PTSD?

Answer: Yes. Painful injuries, invasive medical procedures, or prolonged illness can act as traumatic events, especially when they leave a person feeling helpless, violated, or unsupported. In these cases, chronic pain can be the trigger for PTSD symptoms.

Question: What is the connection between PTSD and chronic pain?

Answer: PTSD and chronic pain share overlapping brain pathways, neurochemical imbalances, and stress responses. Both conditions involve changes in emotional regulation and sensory processing, creating a feedback loop where trauma fuels pain—and pain fuels trauma.