Post-traumatic stress disorder (PTSD) often occurs in individuals with chronic pain at a greater rate compared to individuals without pain.1,2 A key factor known to increase the risk of the development of PTSD in people with chronic pain is trauma exposure in early childhood.3

Herein, we review the impact of attachment style on social support for the treatment of comorbid chronic pain and PTSD.

Prevalence of Comorbid Chronic Pain and PTSD

Between 10% and 50% of people with chronic pain also meet diagnostic criteria for PTSD.1 In comparison, the rates of PTSD in samples without chronic pain range between 7% and 12%.4 A national study showed that approximately 35% of people with musculoskeletal pain were found to be four times more likely to develop PTSD compared to those without pain.2

Rates also vary based on population groups. For example, about 50% of veterans were found to have the comorbidity, whereas around 10% were found in the general population.5 These high rates warrant investigations into the factors that impact the development and treatment of the comorbidity.

Early Childhood Experiences and Attachment Style

As noted, a key predictor of PTSD and trauma symptom severity is early infant and adverse childhood experiences (ACEs) with caregivers, which inform a person’s attachment style and impact:

  • whether or not their needs will be reliably met
  • what to expect from social relationships
  • how to manage the ups and downs of the human condition

These templates set the stage for negative appraisal bias and can be classified as secure or insecure.6 Attachment style has also been found to have a wide-reaching impact on many later life experiences, such as emotional regulation and emotional reactivity.7,8

Insecure attachment style has been found to be a predictor for the development of PTSD,9,10 whereas secure attachment is related to more adaptive coping and lower symptom severity. Moreover, those with insecure attachment styles are more likely to experience anxiety sensitivity. Anxiety sensitivity is the fear of anxiety symptoms and has been found to be positively correlated with PTSD symptoms.11 Taken together, ACEs with caregivers impact how individuals approach interpersonal relationships and actual and/or perceived social support.

Social support can buffer PTSD symptom severity.12,13 The perception that relationships that are unpredictable and/or unsupportive serves as a barrier to the benefits of social support. Three primary models inform research on the impact of PTSD and social support:14,15

  • Stress Buffering Model: asserts that social support serves as a stress buffer13
  • Erosion Model: describes the phenomenon whereby social support diminishes over time in response to the symptoms of PTSD, such as adverse emotions and patient avoidance behaviors
  • Matching Model: states that the effectiveness of social support is dependent on the need of the individual, type of trauma, type of support, and timing of support

As an example of the Matching Model, a recent study found that victims of natural disasters were less affected by social support, suggesting that these individuals may need different, perhaps more practical support and/or community support.13 Whereas, in the same study, veterans were found to benefit from social support more compared to nonveterans.

The question remains, how can this information be used to better treat patients with comorbid chronic pain and PTSD? One place to start is with the assessment. Individuals with chronic pain should be assessed for PTSD. Attachment style and/or anxiety sensitivity should also be assessed.

The Anxiety Sensitivity Inventory16 is a brief measure that can be included with intake forms. In addition, the six-item Perceived Social Support Questionnaire17 can be used to learn about how the patient views their own support network and to begin discussions about this important aspect of addressing comorbid symptoms.

Tailor Treatment

With a better understanding of the patient’s perceptions of social support availability and utility, the provider can make tailored treatment suggestions. For example, if a patient has high anxiety sensitivity and low perception of social support, it would not likely be useful to simply recommend increased social activity. Rather, the provider may also want to explore the patient’s perceptions of social support utility and find exceptions to their social avoidance.

Moreover, providers can work to inoculate the patient against negative social reactions. A recent study has shown that, although social support positively impacts patients with PTSD, negative social reactions had a bigger adverse impact.13

Interoceptive Exposure Therapy

Behavioral health referrals are needed, and have shown to be effective, to support anxiety-sensitive and socially avoidant patients. Treatment for anxiety sensitivity can include interoceptive exposure therapy (IET).18 IET takes a unique approach, bringing on internal physical sensations to help patients learn how to manage fear, anxiety, or phobia. This unique method tackles the senses directly, rather than targeting thoughts and beliefs regarding the event or activity. Interoceptive exposure therapy attempts to recreate feared physical sensations through different exercises. Examples include:

  • spinning around on a swivel chair or turning your head from side to side to simulate feelings of dizziness or light-headedness
  • fast, shallow breathing to recreate a racing heart
  • running up stairs and experiencing being out of breath to simulate breathlessness

The above actions recreate sensations that often accompany phobias or panic and may be more feared than the object or event itself.

Cognitive Behavioral Conjoint Therapy

For couples, cognitive behavioral conjoint therapy (CBCT) has been shown to reduce PTSD and improve relationship functioning satisfaction.19 CBCT focuses on improving individual PTSD symptoms and enhancing relationship functioning. Treatment involves learning about PTSD and its impact on relationship functioning, increasing safety, enhancing communication skills, learning skills to overcome avoidance, and enhancing strategies to change problematic appraisals and beliefs.

There are several areas that contribute to the maintenance of PTSD and exacerbation of relationship problems that CBCT focuses on, including:

  • safety/trust
  • power/control
  • esteem/intimacy

CBCT is typically comprised of 15 weekly 75-minute sessions that involve both the patient and their partner.

Other Therapies

There are a number of other treatments that are effective for trauma-related care, depending on the clinician’s and patient’s preferences and stage of recovery:

  • Prolonged Exposure Therapy is a specific type of CBT that teaches individuals to gradually approach trauma-related memories, feelings, and situations. By facing what has been avoided, a patient can decrease symptoms of PTSD by actively learning that the trauma-related memories and cues are not dangerous and do not need to be avoided.
  • Cognitive Processing Therapy (see Cognitive Component of Pain)20
  • Dialectical Behavior Therapy (see Cognitive Component of Pain)20
  • Interpersonal Psychotherapy (see Affective Component of Pain)21
  • Mindfulness-Based Cognitive Therapy (see Cognitive Component of Pain)20


Medication management is also an option to consider. Acute, post-trauma beta blockers, such as propranolol, have been found to be effective in managing the development of PTSD.22 Propranolol slows down the patient’s heart rate and makes it easier for their heart to pump blood around the body. It can also help with the physical signs of anxiety, like sweating and shaking.

Understanding how underlying factors can increase the likelihood of comorbid pain and PTSD involves clinical assessment of early childhood experiences, anxiety sensitivity, and the patient’s actual and perceived social support. Social support can buffer the symptoms of the comorbidity, but social support awareness and access vary based on ACEs and anxiety sensitivity. Providers can take a curious stance to better understand their patients in order to increase the likelihood that patients will access and benefit from formal and/or informal social support.


  1. 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
  2. Cox BJ, McWilliams L. Mood and anxiety disorders in relation to chronic pain: Evidence from the National Comorbidity Study. Pain Res Manag. 2002;7 (Suppl A):11A.
  3. Cox BJ, McWilliams L. Mood and anxiety disorders in relation to chronic pain: Evidence from the National Comorbidity Study. Pain Res Manag. 2002;7 (Suppl A):11A.
  4. van der Kolk B.A, McFarlane AC. The black hole of trauma. In B. A. van der Kolk, A. C. McFarlane, and L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society (pp. 3–23). The Guilford Press, 1996.Seedat S, Stein MB. Post-traumatic stress disorder: a review of recent findings. Curr Psychiatry Rep. 2001;3(4):288-294. doi:10.1007/s11920-001-0021-2
  5. 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
  6. Bowlby J. The role of childhood experience in cognitive disturbance. In M.J. Mahoney and A. Freeman (Eds.), Cognition and psychotherapy (pp. 181-200). Plenum Press.
  7. Gerhardt S. Why love matters: How affection shapes a baby’s brain. Routledge, 2014.
  8. Strelau J. Temperament as a regulator of behavior: After fifty years of research. Eliot Werner Publications, 2008.
  9. Sharp C, Fonagy P, Allen JG. Posttraumatic stress disorder: A social‐cognitive perspective. Clin Psychol Sci Pract. 2012;19.3: 229.
  10. Woodhouse S, Ayers S, Field AP. The relationship between adult attachment style and post-traumatic stress symptoms: A meta-analysis. J Anxiety Disord. 2015;35:103-117. doi:10.1016/j.janxdis.2015.07.002
  11. Federoff IC, Taylor S, Asmundson GJG, Koch WJ. Cognitive factors in traumatic stress reactions: predicting PTSD symptoms from anxiety sensitivity and beliefs about harmful events. Behav Cogn Psychother. 2000;28:5-15.
  12. Ozer EJ, Best SR, Lipsey TL, Weiss DS. Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull. 2003;129(1):52-73. doi:10.1037/0033-2909.129.1.52
  13. Zalta AK, Tirone V, Orlowska D, et al. Examining moderators of the relationship between social support and self-reported PTSD symptoms: A meta-analysis. Psychol Bull. 2021;147(1):33-54. doi:10.1037/bul0000316
  14. Cohen S, Wills TA. Stress, social support, and the buffering hypothesis. Psychol Bull. 1985;98(2):310-357.
  15. King DW, Taft C, King LA, et al. Directionality of the association between social support and Posttraumatic Stress Disorder: A longitudinal investigation 1. J Appl Soc Psychol. 2006;36.12: 2980-2992.
  16. Peterson RA, Reiss S. Anxiety sensitivity index revised test manual. IDS Publ., 1993.
  17. Kliem S, Mößle T, Rehbein F, et al. A brief form of the Perceived Social Support Questionnaire (F-SozU) was developed, validated, and standardized. J Clin Epidemiol. 2015;68(5):551-562. doi:10.1016/j.jclinepi.2014.11.003
  18. Wald J, Taylor S. Efficacy of interoceptive exposure therapy combined with trauma-related exposure therapy for posttraumatic stress disorder: a pilot study. J Anxiety Disord. 2007;21(8):1050-1060. doi:10.1016/j.janxdis.2006.10.010
  19. Monson CM, Fredman SJ, Macdonald A, et al. Effect of cognitive-behavioral couple therapy for PTSD: a randomized controlled trial. JAMA. 2012;308(7):700-709. doi:10.1001/jama.2012.9307
  20. Cosio D, Demyan A. Cognitive strategies and mindful awareness for integrative pain care. Pract Pain Manag. 2020;20(4).
  21. Cosio D, Demyan A. Cognitive strategies and mindful awareness for integrative pain care. Pract Pain Manag. 2020;20(4).Cosio D, Demyan A. Behavioral pain medicine: Managing the affective components of pain. Pract Pain Manag. 2020;20(3).
  22. Pitman RK, Sanders KM, Zusman RM, et al. Pilot study of secondary prevention of posttraumatic stress disorder with propranolol. Biol Psychiatry. 2002;51(2):189-192.