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Pain perception and processing in individuals with posttraumatic stress disorder: a systematic review with meta-analysis. Pain Rep 2021; 5:e849. [PMID: 33490843 PMCID: PMC7808684 DOI: 10.1097/pr9.0000000000000849] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/13/2020] [Accepted: 07/17/2020] [Indexed: 11/30/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. Posttraumatic stress disorder encompasses latent subgroups of individuals with qualitative differences in pain perception. Posttraumatic stress disorder (PTSD) is a known risk factor for the development of chronic pain conditions, and almost 1 in 5 individuals with chronic pain fulfills the criteria for PTSD. However, the relationship between PTSD and pain is poorly understood and studies on pain perception in patients with PTSD show inconsistent results suggesting that different sensory profiles exist among individuals with PTSD. Here, we (1) systematically summarize the current literature on experimentally evoked pain perception in patients with PTSD compared to subjects without PTSD, and (2) assess whether the nature of the traumatic event is associated with different patterns in pain perception. The main outcome measures were pain threshold, pain tolerance, and pain intensity ratings as well as measures of temporal summation of pain and conditioned pain modulation. A systematic search of MEDLINE, EMBASE, Web of Science, PsycINFO, and CINAHL identified 21 studies for the meta-analysis, including 422 individuals with PTSD and 496 PTSD-free controls. No main effect of PTSD on any outcome measure was found. However, stratification according to the nature of trauma revealed significant differences of small to medium effect sizes. Combat-related PTSD was associated with increased pain thresholds, whereas accident-related PTSD was associated with decreased pain thresholds. No clear relationship between PTSD and experimentally evoked pain perception exists. The type of trauma may affect pain thresholds differently indicating the presence of different subgroups with qualitative differences in pain processing.
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The Prevalence of Post-Traumatic Stress Disorder among People Living with HIV/AIDS: a Systematic Review and Meta-Analysis. Psychiatr Q 2020; 91:1317-1332. [PMID: 32981021 DOI: 10.1007/s11126-020-09849-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2020] [Indexed: 01/26/2023]
Abstract
Numerous studies have reported that the prevalence estimates of post-traumatic stress disorder (PTSD) might be substantially high among people with HIV/AIDS (PLWHA) when compared to the general population. However, there are no previous systematic reviews and meta-analysis studies that reported the pooled prevalence of PTSD among PLWHA. To fill this gap in research, this study aims to analyze data from observational studies concerning the prevalence of PTSD among PLWHA and formulate a recommendation for future research and clinical practice. Three electronic databases (PubMed, EMBASE, and SCOPUS) were searched to identify relevant studies that reported the prevalence of PTSD among PLWHA. A comprehensive meta-analysis software was used to conduct the meta-analysis. Subgroup and sensitivity analysis was conducted the I2 test was utilized to evaluate heterogeneity. Publication bias was assessed by using Egger's test and visual inspection of the symmetry in funnel plots. Nineteen-studies with 9094 participants were included in this systematic review and meta-analysis. The pooled prevalence estimate of PTSD among PLWHA was found to be 32.67% (95% CI; 25.29-41.01). The prevalence of PTSD was 25.17% (95% CI; 19.72-31.55) for studies that used diagnostic instrument to assess PTSD and it was 34.68% (95% CI; 25.42-45.26) for studies that used screening instruments. Furthermore, the prevalence of PTSD among PLWHA was comparable between high-income (31.19%) and low, and middle-income countries (34.87%). We also found that the pooled prevalence of PTSD was remarkably higher for moderate and low-quality studies (42.64%) than for high-quality studies (24.84%). The prevalence of PTSD among PLWHA in the current study showed a significant variation by the location of the studies, the instruments used to measure PTSD as well as the quality of the included studies. The present review demonstrated that the prevalence estimates of PTSD among PLWHA (32.67%) was notably high and requires clinical attention. The estimated prevalence of PTSD was found to be comparable between high income and low, and middle-income countries. In addition, we found that the prevalence of PTSD was notably lower when measured by the diagnostic instrument than the screening instrument, although the variation was not statistically significant. Early screening and treatment of PTSD among PLWHA is needed to alleviate suffering.
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Zheng Z, Curtis K, Bhatia A. Letter to the editor: regarding a recent publication on the association between abuse and adverse effects of analgesic medications. Reg Anesth Pain Med 2020; 46:462-463. [PMID: 33159005 DOI: 10.1136/rapm-2020-101785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 06/10/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Zhongxi Zheng
- Department of Anesthesia and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Kathryn Curtis
- Department of Anesthesia and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Anuj Bhatia
- Anesthesia and Pain Management, University of Toronto and University Health Network-Toronto Western Hospital, Toronto, Ontario, Canada.,University of Toronto Institute of Health Policy Management and Evaluation, Toronto, Ontario, Canada
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Burns JW, Janssen I, Lillis T, Mulcahy M, Purim-Shem-Tov YA, Bruehl S, Burgess HJ, Fischer A, Rim K, Aranda F, Pinkerton L, Hobfoll S. The transition from acute to persistent pain: the identification of distinct trajectories among women presenting to an emergency department. Pain 2020; 161:2511-2519. [PMID: 32569094 PMCID: PMC10853846 DOI: 10.1097/j.pain.0000000000001960] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Posttraumatic stress disorder (PTSD) symptoms and other negative psychosocial factors have been implicated in the transition from acute to persistent pain. Women (N = 375) who presented to an inner-city emergency department (ED) with complaints of acute pain were followed up for 3 months. They completed a comprehensive battery of questionnaires at an initial visit and provided ratings of pain intensity at the site of pain presented in the ED during 3 monthly phone calls. Latent class growth analyses were used to detect possible trajectories of change in pain intensity from the initial visit to 3 months later. A 3-trajectory solution was found, which identified 3 groups of participants. One group (early recovery; n = 93) had recovered to virtually no pain by the initial visit, whereas a second group (delayed recovery; n = 120) recovered to no pain only after 1 month. A third group (no recovery; n = 162) still reported elevated pain at 3 months after the ED visit. The no recovery group reported significantly greater PTSD symptoms, anger, sleep disturbance, and lower social support at the initial visit than both the early recovery and delayed recovery groups. Results suggest that women with high levels of PTSD symptoms, anger, sleep disturbance, and low social support who experience an acute pain episode serious enough to prompt an ED visit may maintain elevated pain at this pain site for at least 3 months. Such an array of factors may place women at an increased risk of developing persistent pain following acute pain.
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Affiliation(s)
- John W Burns
- Rush University Medical Center, Chicago, IL, United States
| | - Imke Janssen
- Rush University Medical Center, Chicago, IL, United States
| | - Teresa Lillis
- Rush University Medical Center, Chicago, IL, United States
| | - Morgan Mulcahy
- Rush University Medical Center, Chicago, IL, United States
| | | | - Stephen Bruehl
- Vanderbilt University Medical Center, Nashville, TN, United States
| | | | | | - Katie Rim
- University of Maryland, College Park MD, United States
| | - Frances Aranda
- University of Illinois at Chicago, Chicago, IL, United States
| | - Linzy Pinkerton
- Northwestern University, Feinberg School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Stevan Hobfoll
- Star-Stress Anxiety and Resilience Consultants, Salt Lake City, UT, United States
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Zhang Y, Standifer KM. Exacerbated Headache-Related Pain in the Single Prolonged Stress Preclinical Model of Post-traumatic Stress Disorder. Cell Mol Neurobiol 2020; 41:1009-1018. [PMID: 32930941 PMCID: PMC8159770 DOI: 10.1007/s10571-020-00962-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 09/03/2020] [Indexed: 11/29/2022]
Abstract
Chronic headache pain is one of the most commonly reported comorbid pain conditions with post-traumatic stress disorder (PTSD) patients and resistant to effective treatment, yet no combined preclinical model of the two disorders has been reported. Here, we used a modified chronic headache pain model to investigate the contribution of single prolonged stress (SPS) model of PTSD with sodium nitroprusside (SNP)-induced hyperalgesia. Injection of SNP (2 mg/kg, i.p.) occurred every other day from day 7 to day 15 after initiation of SPS in rats. Paw withdrawal threshold (PWT) to von Frey stimuli and tail flick latencies (TFL) dramatically decreased as early as 7 days after SPS and lasted until at least day 21. Basal PWT and TFL also significantly decreased during the SNP treatment period. The lower nociceptive thresholds recovered in 6 days following the final SNP injection in SNP group, but not in SPS + SNP group. Elevated nociceptin/OFQ (N/OFQ) levels observed in cerebrospinal fluid of SPS rats were even higher in SPS + SNP group. Glial fibrillary acidic protein (GFAP) and N/OFQ peptide (NOP) receptor mRNA expression increased in dorsal root ganglia (DRG) 21 days after SPS exposure; mRNA increases in the SPS/SNP group was more pronounced than SPS or SNP alone. GFAP protein expression was upregulated in trigeminal ganglia by SPS. Our results indicate that traumatic stress exaggerated chronic SNP-induced nociceptive hypersensitivity, and that N/OFQ and activated satellite glia cells may play an important role in the interaction between both conditions.
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Affiliation(s)
- Yong Zhang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Kelly M Standifer
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA. .,Oklahoma Center for Neuroscience, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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Andersen TE, Ellegaard H, Schiøttz-Christensen B, Mejldal A, Manniche C. Somatic Experiencing® for patients with low back pain and comorbid posttraumatic stress symptoms - a randomised controlled trial. Eur J Psychotraumatol 2020; 11:1797306. [PMID: 33029333 PMCID: PMC7473216 DOI: 10.1080/20008198.2020.1797306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Low back pain (LBP) and comorbid post-traumatic stress symptoms (PTSS) are common after traumatic injuries, and a high level of PTSS is associated with more severe pain and pain-related disability. Few randomised controlled trials (RCT) exist targeting comorbid PTSS and chronic pain, and only one has assessed the effect of Somatic Experiencing®. OBJECTIVE The aim of this study was to assess the effect of Somatic Experiencing® (up to 12 sessions) + physiotherapeutic intervention (4-8 sessions) (SE+PT) compared with the physiotherapeutic intervention alone (4-8 sessions) (PT) for pain-related disability in LBP with comorbid PTSS. METHODS The study was a two-group RCT in which participants (n = 114) were recruited consecutively from a large Danish Spine Centre. Patients were randomly allocated to either SE+PT or PT alone. Outcomes were collected at baseline before randomisation, 6 and 12-month post-randomisation. The primary outcome was pain-related disability as measured with the modified version of the Roland Morris Disability Questionnaire at 6-month post-randomisation. Secondary outcomes were PTSS, pain intensity, pain-catastrophising, kinesiophobia, anxiety and depression. RESULTS No significant group differences were found on any of the outcomes at any timepoints. Both groups achieved a significant reduction in pain-related disability (20-27%) as measured by the Roland Morris Disability Questionnaire at 6 and 12-month follow up. Also, both groups achieved a small reduction in PTSS. CONCLUSIONS Although significant effects were achieved for both groups, the additional SE intervention did not result in any additional benefits in any of the outcomes.
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Affiliation(s)
| | - Hanne Ellegaard
- Spine Centre of Southern Denmark, University of Southern Denmark, Odense, Denmark
| | | | - Anna Mejldal
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Claus Manniche
- Spine Centre of Southern Denmark, University of Southern Denmark, Odense, Denmark
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Special High-Risk Populations in Dentistry: The Adolescent Patient, the Elderly Patient, and the Woman of Childbearing Age. Dent Clin North Am 2020; 64:585-595. [PMID: 32448461 DOI: 10.1016/j.cden.2020.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Comprehensive and compassionate treatment of vulnerable patients is an important service to the community, although dental treatment of special populations can represent a challenge. The dental provider must be able to recognize the issues surrounding substance use and abuse, coordinate care with medical providers, and build a trusting provider-patient relationship to achieve success. Open conversations regarding expectations of pain, and the risks, benefits, and alternatives to opioids are important aspects of the best care of these patients.
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58
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Which Psychological Factors Are Involved in the Onset and/or Persistence of Musculoskeletal Pain? An Umbrella Review of Systematic Reviews and Meta-Analyses of Prospective Cohort Studies. Clin J Pain 2020; 36:626-637. [PMID: 32379072 DOI: 10.1097/ajp.0000000000000838] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of this study was to summarize the current status of knowledge about the longitudinal association between vulnerability or protective psychological factors and the onset and/or persistence of musculoskeletal (MSK) pain. METHODS PubMed, CINAHL, PsycINFO, PubPsych, Scopus, Web of Science, gray literature, and manual screening of references were searched from inception to June 15, 2019. Systematic reviews with or without meta-analysis that explored the longitudinal association between psychological factors and the onset and/or persistence of MSK pain were identified. The AMSTAR-2 tool was used to assess the risk of bias. RESULTS Fifty-nine systematic reviews that included 286 original research studies were included, with a total of 249,657 participants (127,370 with MSK pain and 122,287 without MSK pain at baseline). Overall, our results found that exposure to many psychological vulnerability factors such as depression, anxiety, psychological distress, and fear, among others, may increase the risk of the onset and persistence of MSK pain across time. In addition, our results also showed that a range of psychological factors considered to be "protective" such as self-efficacy beliefs, better mental health, active coping strategies, or favorable expectations of recovery may reduce the risk of the onset and persistence of MSK pain. However, all these systematic reviews were evaluated to have critically low confidence based on the AMSTAR-2 tool, indicating that findings from these reviews may be informative, but should be interpreted with caution. DISCUSSION The large number of methodological flaws found across reviews gives rise to a call to action to develop high-quality systematic reviews in this field.
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59
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Linnemørken LTB, Granan LP, Reme SE. Prevalence of Posttraumatic Stress Symptoms and Associated Characteristics Among Patients With Chronic Pain Conditions in a Norwegian University Hospital Outpatient Pain Clinic. Front Psychol 2020; 11:749. [PMID: 32431641 PMCID: PMC7215085 DOI: 10.3389/fpsyg.2020.00749] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 03/26/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction Comorbid posttraumatic stress disorder (PTSD) in patients with chronic pain may have a negative effect on the course and outcome of both disorders. Nevertheless, the co-occurrence of the two conditions is often overlooked in clinical settings. Further, little is known about how PTSD is associated with biopsychosocial characteristics in this patient group. The first objective was to assess the prevalence of posttraumatic stress symptoms (PTSS) in patients with chronic pain in a Norwegian university hospital outpatient pain clinic. The second objective was to investigate possible associations between PTSS and adverse outcomes such as pain intensity, disability, and distress. The third objective was to compare the PTSS prevalence rates between primary versus secondary pain conditions. Materials and methods Six hundred and ninety-two patients meeting for pain assessment completed self-report questionnaires about PTSS and possibly associated factors. The Life Events Checklist and the Stressful Life Events Screening Questionnaire were used to screen for potentially traumatic life events. The Impact of Events Scale - Revised and the PTSD Checklist for DSM-5 were used to assess PTSS. Differences between patients with and without severe PTSS on the possibly associated variables were analyzed by chi-squared-, and t-tests. Results 20.7% of the participants reported a level of PTSS qualifying for a PTSD diagnosis. These patients reported higher levels of pain intensity, pain bothersomeness, disability, and psychological distress, as well as lower levels of self-efficacy. They also reported higher levels of pain catastrophizing, perceived injustice, fatigue, and sleep difficulties. Finally, there was not a significant difference in prevalence rates between primary and secondary pain conditions. Discussion PTSS are frequent in patients with chronic pain, and a range of psychological characteristics is associated with a high level of such symptoms in this patient group. Patients with both conditions report a significantly higher symptom load, and the potential impact on the individual's life is major. In terms of pain condition, there were no differences in PTSS between primary pain conditions and secondary pain conditions in this pain population. This study emphasizes the importance of increased attention on PTSS when seeing patients with chronic pain conditions in clinical practice.
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Affiliation(s)
- Lene Therese Bergerud Linnemørken
- Division of Emergencies and Critical Care, Department of Research and Development, Oslo University Hospital, Oslo, Norway.,Division of Emergencies and Critical Care, Department of Pain Management and Research, Oslo University Hospital, Oslo, Norway
| | - Lars-Petter Granan
- Division of Emergencies and Critical Care, Department of Pain Management and Research, Oslo University Hospital, Oslo, Norway
| | - Silje Endresen Reme
- Division of Emergencies and Critical Care, Department of Pain Management and Research, Oslo University Hospital, Oslo, Norway.,Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway
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60
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Tang C, Goldsamt L, Meng J, Xiao X, Zhang L, Williams AB, Wang H. Global estimate of the prevalence of post-traumatic stress disorder among adults living with HIV: a systematic review and meta-analysis. BMJ Open 2020; 10:e032435. [PMID: 32345695 PMCID: PMC7213849 DOI: 10.1136/bmjopen-2019-032435] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Although people living with HIV (PLWH) have been disproportionately affected by post-traumatic stress disorder (PTSD), the global prevalence of PTSD among PLWH is unknown. This study aimed to systematically review the prevalence of PTSD among PLWH worldwide and explore variation in prevalence across sociodemographic and methodological factors. DESIGN A meta-analysis using a random-effects model was conducted to pool the prevalence estimated from individual studies, and subgroup analyses were used to analyse heterogeneities. SETTING, PARTICIPANTS AND MEASURES Observational studies providing PTSD prevalence data in an adult HIV population were searched from January 2000 to November 2019. Measurements were not restricted, although the definition of PTSD had to align with the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases diagnostic criteria. RESULTS A total of 38 articles were included among 2406 records identified initially. The estimated global prevalence of PTSD in PLWH was 28% (95% CI 24% to 33%). Significant heterogeneity was detected in the proportion of PLWH who reported PTSD across studies, which was partially explained by geographic area, population group, measurement and sampling method (p<0.05). CONCLUSION PTSD among PLWH is common worldwide. This review highlights that PTSD should be routinely screened for and that more effective prevention strategies and treatment packages targeting PTSD are needed in PLWH.
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Affiliation(s)
- Chulei Tang
- Xiangya Nursing School, Central South University, Changsha, Hunan, China
| | - Lloyd Goldsamt
- New York University Rory Meyers College of Nursing, New York, New York, USA
| | - Jingjing Meng
- Xiangya Nursing School, Central South University, Changsha, Hunan, China
| | - Xueling Xiao
- Xiangya Nursing School, Central South University, Changsha, Hunan, China
| | - Li Zhang
- New York University Rory Meyers College of Nursing, New York, New York, USA
| | | | - Honghong Wang
- Xiangya Nursing School, Central South University, Changsha, Hunan, China
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61
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Rometsch C, Denkinger JK, Engelhardt M, Windthorst P, Graf J, Gibbons N, Pham P, Zipfel S, Junne F. Pain, somatic complaints, and subjective concepts of illness in traumatized female refugees who experienced extreme violence by the "Islamic State" (IS). J Psychosom Res 2020; 130:109931. [PMID: 31981895 DOI: 10.1016/j.jpsychores.2020.109931] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 08/21/2019] [Accepted: 01/11/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Refugees with a history of war or sexual violence often experience somatic symptoms along with mental disorders. After being held in captivity by the so-called "Islamic State" (IS), 1100 especially vulnerable Yazidi women and children (around 400 women) received special medical and psychological support. We report on their (psycho-) somatic complaints and concepts of illness. METHODS Female refugees (N = 116) were surveyed regarding their somatic complaints and concepts of illness. The Impact of Event Scale-Revised (IES-R) and self-developed questionnaire items with ratings on a five-point Likert scale from 0 ("not at all") to 4 ("extremely") were used. Subgroup analyses and a multiple linear regression model were computed. RESULTS Pain (M = 2.43, SD = 1.70) is the main somatic complaint with a moderate rated severity, followed by feelings of suffocation (M = 2.37, SD = 1.53), and movement disorders (M = 1.62, SD = 1.70). In a linear regression model, pain explains variance (R2 = 0.325) in the refugees' self-reported health-related wellbeing. Somatic symptoms are mainly attributed to psychological causes, followed by physical (e.g., physical origin of symptoms), religious, and supernatural causes. Women with pain symptoms attributed their symptoms more to physical causes (M = 1.90, SD = 1.78) than did women without pain symptoms (M = 1.07, SD = 1.59). CONCLUSION Female Yazidi refugees being kept in IS captivity mainly suffer from pain, which is attributed to an explanatory psychological model. The study results show the specific psychosomatic and psychotherapeutic needs and demands for specifically tailored psychotherapy.
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Affiliation(s)
- Caroline Rometsch
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, Tuebingen, Germany.
| | - Jana Katharina Denkinger
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, Tuebingen, Germany
| | - Martha Engelhardt
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, Tuebingen, Germany
| | - Petra Windthorst
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, Tuebingen, Germany
| | - Johanna Graf
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, Tuebingen, Germany
| | - Niamh Gibbons
- Harvard Humanitarian Initiative, Harvard University, Cambridge, MA, USA
| | - Phuong Pham
- Harvard Humanitarian Initiative, Harvard University, Cambridge, MA, USA; Harvard Medical School, Harvard TH Chan School of Public Health, Boston, MA, United States of America
| | - Stephan Zipfel
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, Tuebingen, Germany
| | - Florian Junne
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, Tuebingen, Germany
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You DS, Ziadni MS, Gilam G, Darnall BD, Mackey SC. Evaluation of Candidate Items for Severe PTSD Screening for Patients With Chronic Pain: Pilot Data Analysis With the IRT Approach. Pain Pract 2020; 20:262-268. [PMID: 31646748 PMCID: PMC7083588 DOI: 10.1111/papr.12848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 10/03/2019] [Accepted: 10/18/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Post-traumatic stress disorder (PTSD) commonly co-occurs with chronic pain. Although PTSD symptoms are associated with negative health outcomes in patients with chronic pain, PTSD is typically under-detected and under-treated in outpatient pain settings. There is a need for rapid, brief screening tools to identify those at greatest risk for severe PTSD symptoms. To achieve that goal, our aim was to use item response theory (IRT) to identify the most informative PTSD symptoms characterizing severe PTSD in patients with chronic pain. METHODS Fifty-six patients (71% female, 61% White) with mixed etiology chronic pain completed the PTSD Checklist-Civilian Version (PCL-C) as part of their appointment with a pain psychologist at a tertiary outpatient pain clinic. We used an IRT approach to evaluate each item's discriminant (a) and severity (b) parameters. RESULTS Findings revealed that "feeling upset at reminders" (a = 3.67, b = 2.44) and "avoid thinking or talking about it" (a = 3.61, b = 2.17) as being highly discriminant for severe PTSD. CONCLUSIONS We identified 2 candidate items for a brief PTSD screener as they were associated with severe PTSD symptoms. These 2 items may provide clinical utility in outpatient pain treatment settings to identify those suffering from severe PTSD, enabling physicians to refer them to trauma-specific evaluation or therapy. Future research is needed to further validate and confirm these candidate PTSD items in a larger clinic sample. LAY SUMMARY The current study used the IRT approach to identify candidate items for a brief screener for severe PTSD. We examined 17 items of the PCL-C, and identified 2 items that were highly discriminant for severe PTSD. The 2 items were "feeling upset at reminders" and "avoid thinking or talking about it." These 2 items may provide clinical utility, since they may enable physicians to screen and make a referral for further assessment or treatment for PTSD.
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Affiliation(s)
- Dokyoung S You
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Maisa S Ziadni
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Gadi Gilam
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Beth D Darnall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, U.S.A
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63
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Åkerblom S, Perrin S, Fischer MR, McCracken LM. Treatment outcomes in group-based cognitive behavioural therapy for chronic pain: An examination of PTSD symptoms. Eur J Pain 2020; 24:807-817. [PMID: 31904136 DOI: 10.1002/ejp.1530] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/19/2019] [Accepted: 12/31/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The relevance of post-traumatic stress disorder (PTSD) symptoms to outcomes of cognitive behavioural therapy (CBT) for chronic pain is unclear. This study examines whether (a) traumatic exposure or the severity of PTSD symptoms at pre-treatment predicts the outcomes (pain intensity/interference), (b) participation in this treatment is associated with reduced PTSD symptoms and (c) any observed changes in PTSD symptoms are mediated by changes in psychological mechanisms that have been shown to be of importance to PTSD and chronic pain. METHODS Participants were 159 chronic pain patients who were consecutively admitted for a multidisciplinary, group-based CBT program at the Pain Rehabilitation Unit at Skåne University Hospital. A self-report measure of traumatic exposure and PTSD symptoms was administered before and after treatment, and at a 12-month follow-up, along with measures of depression, anxiety, pain intensity, pain interference, psychological inflexibility, life control and kinesiophobia. RESULTS Traumatic exposure and PTSD symptom severity did not predict pain intensity or interference at 12-month follow-up. There were no overall significant changes in PTSD symptom severity at post-treatment or follow-up, but 24.6% of the participants showed potential clinically significant change at follow-up. Psychological inflexibility mediated the changes that occurred in PTSD symptoms during treatment. CONCLUSIONS Neither traumatic exposure nor baseline symptoms of PTSD predicted the treatment outcomes examined here. Despite improvements in both comorbid depression and anxiety, participation in this pain-focused CBT program was not associated with improvements in comorbid PTSD. To the extent that changes in PTSD symptoms did occur, these were mediated by changes in psychological inflexibility during treatment. SIGNIFICANCE Pain-focused CBT programs yield clinically meaningful improvements in pain and comorbid symptoms of depression and anxiety, but may have little effect on comorbid PTSD. This raises the issue of whether current pain-focused CBT programs can be modified to improve outcomes for comorbid conditions, perhaps by better targeting of psychological flexibility, and/or whether separate treatment of PTSD may be associated with improved pain outcomes.
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Affiliation(s)
- Sophia Åkerblom
- Department of Pain Rehabilitation, Skåne University Hospital, Lund, Sweden.,Department of Psychology, Lund University, Lund, Sweden
| | - Sean Perrin
- Department of Psychology, Lund University, Lund, Sweden
| | - Marcelo Rivano Fischer
- Department of Pain Rehabilitation, Skåne University Hospital, Lund, Sweden.,Department of Health Sciences, Lund University, Lund, Sweden
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Abstract
PURPOSE OF REVIEW Post-traumatic stress disorder (PTSD) and chronic pain often co-occur. Understanding the shared mechanisms, signs to identify PTSD, and treatment options is integral in allowing providers to better serve their patients. RECENT FINDINGS Individuals with comorbid PTSD and chronic pain report greater PTSD symptoms, pain, anxiety, depression, disability, and opioid use than those with only one of these conditions. There are several empirically supported therapies for chronic pain, and for PTSD, as well as pilot data for a treatment of comorbid pain and PTSD. The purpose of this paper is to review and synthesize current literature investigating the interaction between chronic pain and PTSD, and provide treatment recommendations for providers treating patients with chronic pain and PTSD.
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Affiliation(s)
| | - John D Otis
- United States of America Department of Veterans Affairs, VA Boston Healthcare System, Boston, MA, USA. .,Center for Anxiety and Related Disorders, Department of Psychological and Brain Sciences, Boston University, Boston, MA, 02115, USA.
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65
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Aaron R, Noel M, Dudeney J, Wilson A, Holley A, Palermo T. The role of sleep quality on the relationship between posttraumatic stress symptoms and pain in women. J Behav Med 2019; 42:924-933. [PMID: 30762157 PMCID: PMC6813767 DOI: 10.1007/s10865-019-00016-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 01/30/2019] [Indexed: 12/25/2022]
Abstract
Pain frequently co-occurs with elevated posttraumatic stress symptoms (PTSS); women are at elevated risk for their co-occurrence. PTSS and pain are associated with poor sleep quality; yet, little research has examined how sleep impacts their co-occurrence. The current study examines the indirect role of sleep on the relationship between PTSS and pain. A community sample of 182 women completed psychometrically-sound questionnaires assessing PTSS, sleep quality, pain characteristics, depression and anxiety symptoms, and anxiety sensitivity. We examined how sleep quality impacted associations among PTSS and pain intensity and pain interference, while controlling for key psychological factors. Greater PTSS was associated with worse pain interference, and poor sleep quality had a significant indirect effect on this relationship. Sleep may represent a modifiable behavioral mechanism that contributes to the mutual maintenance of PTSS and pain in women. Future research is needed to further clarify the role of sleep quality in their co-occurrence.
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Affiliation(s)
- Rachel Aaron
- Seattle Children's Research Institute, University of Washington, Seattle, USA.
- Johns Hopkins Medicine, 1800 Orleans St., Baltimore, MD, 21287, USA.
| | - Melanie Noel
- Alberta Children's Hospital and Research Institute, University of Calgary, Calgary, Canada
| | - Joanne Dudeney
- Seattle Children's Research Institute, University of Washington, Seattle, USA
| | - Anna Wilson
- Oregon Health & Science University, Portland, USA
| | - Amy Holley
- Oregon Health & Science University, Portland, USA
| | - Tonya Palermo
- Seattle Children's Research Institute, University of Washington, Seattle, USA
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66
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Attentional bias and its temporal dynamics among war veterans suffering from chronic pain: Investigating the contribution of post-traumatic stress symptoms. J Anxiety Disord 2019; 66:102115. [PMID: 31394483 DOI: 10.1016/j.janxdis.2019.102115] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 07/01/2019] [Accepted: 07/11/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cognitive models propose that attentional dysregulation, including an attentional bias towards threat, is one of the factors through which chronic pain and post-traumatic stress symptoms (PTSS) maintain and exacerbate one another. The current investigation assessed the attentional bias for painful facial expressions and its relationship with PTSS, using both traditional and variability-based attentional bias measures, among veterans with chronic pain and PTSS and controls. METHOD Fifty-four veterans with chronic pain and 30 age/education-matched controls participated in this investigation. Participants completed a self-report measure of PTSS and a modified version of the dot-probe task with painful, happy, and neutral facial expressions. Attention was assessed using both traditional and variability-based reaction time measures of attentional bias. RESULTS Veterans directed attention away from painful facial expressions (i.e., avoidance) relative to both the control group (between-subject effect) and relative to neutral faces (within-subject effect). Veterans also showed significantly elevated attentional bias variability for both happy and painful facial expressions compared to controls. Attentional bias variability for happy and painful facial expressions was correlated with PTSS among all participants. CONCLUSION Veterans with chronic pain and PTSS avoided pain-related stimuli and displayed an overall attentional dysregulation for emotional facial expressions. Avoidance of pain cues may be a coping strategy that these individuals develop under stressful conditions. Implications, limitations, and directions for future research are discussed.
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67
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Mills SEE, Nicolson KP, Smith BH. Chronic pain: a review of its epidemiology and associated factors in population-based studies. Br J Anaesth 2019; 123:e273-e283. [PMID: 31079836 PMCID: PMC6676152 DOI: 10.1016/j.bja.2019.03.023] [Citation(s) in RCA: 682] [Impact Index Per Article: 136.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 03/22/2019] [Indexed: 12/18/2022] Open
Abstract
Chronic pain is a common, complex, and distressing problem that has a profound impact on individuals and society. It frequently presents as a result of a disease or an injury; however, it is not merely an accompanying symptom, but rather a separate condition in its own right, with its own medical definition and taxonomy. Studying the distribution and determinants of chronic pain allows us to understand and manage the problem at the individual and population levels. Targeted and appropriate prevention and management strategies need to take into account the biological, psychological, socio-demographic, and lifestyle determinants and outcomes of pain. We present a narrative review of the current understanding of these factors.
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Affiliation(s)
- Sarah E E Mills
- Population Health and Genomics Division, University of Dundee School of Medicine, Ninewells Hospital and Medical School, Dundee, Scotland, UK.
| | - Karen P Nicolson
- Population Health and Genomics Division, University of Dundee School of Medicine, Ninewells Hospital and Medical School, Dundee, Scotland, UK
| | - Blair H Smith
- Population Health and Genomics Division, University of Dundee School of Medicine, Ninewells Hospital and Medical School, Dundee, Scotland, UK
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68
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Morris MC, Bailey B, Ruiz E. Pain in the Acute Aftermath of Stalking: Associations With Posttraumatic Stress Symptoms, Depressive Symptoms, and Posttraumatic Cognitions. Violence Against Women 2019; 26:1343-1361. [PMID: 31359841 DOI: 10.1177/1077801219857829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This longitudinal study examined whether posttraumatic stress and depressive symptoms, posttraumatic cognitions, and ongoing cyberstalking exposures were independently associated with changes in pain outcomes among 82 young adult women with recent exposure to stalking. Multilevel models indicated that higher sensory pain intensity and pain-related interference were associated with more negative cognitions about the self. Higher affective pain intensity was associated with higher posttraumatic stress and depressive symptoms. Cyberstalking exposures were not associated with pain intensity or pain-related interference. Results reveal persistent pain complaints in recent stalking victims and highlight distinct psychological risk factors for pain intensity and pain-related interference.
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69
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Abstract
Objectives: We provide a review of the literature on posttraumatic stress disorder (PTSD) in older adults, focusing largely on older U.S. military veterans in two primary areas: 1) assessment and diagnosis and 2) non-pharmacological treatment of PTSD in late life. Methods: We performed a search using PubMed and Academic Search Premier (EBSCO) databases and reviewed reference sections of selected papers. We also drew on our own clinical perspectives and reflections of seven expert mental health practitioners. Results: Rates of PTSD are lower in older compared with younger adults. The presence of sub-syndromal/partial PTSD is important and may impact patient functioning. Assessment requires awareness and adaptation for potential differences in PTSD experience and expression in older adults. Psychotherapies for late-life PTSD appear safe, acceptable and efficacious with cognitively intact older adults, although there are relatively few controlled studies. Treatment adaptations are likely warranted for older adults with PTSD and co-morbidities (e.g., chronic illness, pain, sensory, or cognitive changes). Conclusions: PTSD is an important clinical consideration in older adults, although the empirical database, particularly regarding psychotherapy, is limited. Clinical Implications: Assessment for trauma history and PTSD symptoms in older adults is essential, and may lead to increased recognition and treatment.
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Affiliation(s)
- Anica Pless Kaiser
- National Center for PTSD at VA Boston Healthcare System, Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
| | - Joan M. Cook
- Department of Psychiatry, Yale School of Medicine and National Center for PTSD, West Haven, CT, USA
| | | | - Jennifer Moye
- New England Geriatric Research Education and Clinical Center and Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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70
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Kosiba JD, Maisto SA, Ditre JW. Patient-reported use of medical cannabis for pain, anxiety, and depression symptoms: Systematic review and meta-analysis. Soc Sci Med 2019; 233:181-192. [PMID: 31207470 DOI: 10.1016/j.socscimed.2019.06.005] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 05/17/2019] [Accepted: 06/03/2019] [Indexed: 12/20/2022]
Abstract
RATIONALE Certifications for medical cannabis are generally restricted to a small number of specific medical conditions, yet patients frequently report symptoms of pain, anxiety, and depression as reasons for use. This is a critical concern for researchers, healthcare providers, and policymakers, yet research in this area is currently obstructed by the lack of a focused review or empirical synthesis on patient-reported reasons for medical cannabis use. OBJECTIVES AND METHOD: The first aim of this project was to conduct the first systematic review and meta-analysis of empirical studies of patient-reported symptoms of pain, anxiety, and depression as reasons for medical cannabis use. The second aim was to conduct an empirical assessment of the methodological quality of extant research, test for publication bias, and test sex composition and quality scores of individual studies as possible sources of observed heterogeneity. RESULTS Meta-analytic results indicated that pain (64%), anxiety (50%), and depression/mood (34%) were common reasons for medical cannabis use. No evidence for publication bias was detected, despite heterogeneity in prevalence rates. A comprehensive assessment of study quality identified a number of specific methodological limitations of the existing research, including challenges in patient recruitment, use of restrictive sampling frames, and a lack of randomized recruitment methods and validated assessment measures. CONCLUSION Findings are discussed with regard to possible explanations for current results, clinical considerations, and areas of future research that are needed to move the field forward.
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Affiliation(s)
- Jesse D Kosiba
- Department of Psychology, Syracuse University, United States.
| | | | - Joseph W Ditre
- Department of Psychology, Syracuse University, United States
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71
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McAndrew LM, Lu SE, Phillips LA, Maestro K, Quigley KS. Mutual maintenance of PTSD and physical symptoms for Veterans returning from deployment. Eur J Psychotraumatol 2019; 10:1608717. [PMID: 31164966 PMCID: PMC6534228 DOI: 10.1080/20008198.2019.1608717] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 02/10/2019] [Accepted: 04/06/2019] [Indexed: 10/26/2022] Open
Abstract
Background: The mutual maintenance model proposes that post-traumatic stress disorder (PTSD) symptoms and chronic physical symptoms have a bi-directional temporal relationship. Despite widespread support for this model, there are relatively few empirical tests of the model and these have primarily examined patients with a traumatic physical injury. Objective: To extend the assessment of this model, we examined the temporal relationship between PTSD and physical symptoms for military personnel deployed to combat (i.e., facing the risk of death) who were not evacuated for traumatic injury. Methods: The current study used a prospective, longitudinal design to understand the cross-lagged relationships between PTSD and physical symptoms before, immediately after, 3 months after, and 1 year after combat deployment. Results: The cross-lagged results showed physical symptoms at every time point were consistently related to greater PTSD symptoms at the subsequent time point. PTSD symptoms were related to subsequent physical symptoms, but only at one time-point with immediate post-deployment PTSD symptoms related to physical symptoms at three months after deployment. Conclusion: The findings extend prior work by providing evidence that PTSD and physical symptoms may be mutually maintaining even when there is not a severe traumatic physical injury.
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Affiliation(s)
- Lisa M. McAndrew
- War Related Illness and Injury Study Center, Veterans Affairs, New Jersey Health Care System, East Orange, NJ, USA
- Department of Educational and Counseling Psychology, University at Albany, Albany, NY, USA
| | - Shou-En Lu
- War Related Illness and Injury Study Center, Veterans Affairs, New Jersey Health Care System, East Orange, NJ, USA
- Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, New Brunswick, NJ, USA
| | - L. Alison Phillips
- War Related Illness and Injury Study Center, Veterans Affairs, New Jersey Health Care System, East Orange, NJ, USA
- Psychology Department, Iowa State University, Ames, USA
| | - Kieran Maestro
- War Related Illness and Injury Study Center, Veterans Affairs, New Jersey Health Care System, East Orange, NJ, USA
- Department of Educational and Counseling Psychology, University at Albany, Albany, NY, USA
| | - Karen S. Quigley
- Department of Veterans Affairs, Bedford Memorial Hospital, Bedford, MA, USA
- Interdisciplinary Affective Science Laboratory, Northeastern University, Boston, USA
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72
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McKernan LC, Johnson BN, Crofford LJ, Lumley MA, Bruehl S, Cheavens JS. Posttraumatic Stress Symptoms Mediate the Effects of Trauma Exposure on Clinical Indicators of Central Sensitization in Patients With Chronic Pain. Clin J Pain 2019; 35:385-393. [PMID: 30730446 PMCID: PMC6450707 DOI: 10.1097/ajp.0000000000000689] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Evidence supports high rates of co-occurrence of posttraumatic stress disorder (PTSD) and chronic pain disorders involving central sensitization (CS). The nature of this relationship, however, remains relatively unexplored. In this study, we aimed to (1) assess how both trauma exposure and current PTSD symptoms are related to clinical manifestations of CS, and (2) test whether PTSD symptoms explain the relationship between trauma exposure and CS. Because experiential avoidance has been shown to impact the relationship between trauma and health outcomes, we (3) explored experiential avoidance as a possible mediator or moderator of the trauma-CS relationship. METHODS A sample of 202 adult patients (79% female) with chronic pain completed validated self-report measures of trauma exposure, current PTSD symptoms, experiential avoidance, and 3 manifestations of CS: widespread pain, greater pain severity, and polysomatic symptom reporting. We used path analysis and multivariate regression to assess our study aims. RESULTS Both trauma exposure and PTSD symptoms were significantly associated with all 3 clinical indicators of CS. PTSD symptoms partially explained the relationship between trauma exposure and widespread pain, pain intensity, and polysomatic symptoms. Experiential avoidance did not mediate or moderate the trauma-CS relationship. CONCLUSIONS Our findings suggest that trauma exposure is linked to elevated clinical markers of CS but a critical factor in this relationship is the mediating effect of current PTSD symptoms.
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Affiliation(s)
- Lindsey C. McKernan
- Department of Psychiatry & Behavioral Sciences, Vanderbilt University Medical Center
- Department of Physical Medicine & Rehabilitation, Vanderbilt University Medical Center
| | | | | | | | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center
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Adverse Childhood Experiences and Trauma-Informed Care in Rehabilitation Clinical Practice. Arch Rehabil Res Clin Transl 2019; 1:100003. [PMID: 33543043 PMCID: PMC7853397 DOI: 10.1016/j.arrct.2019.100003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Adverse childhood experiences (ACEs) contribute to physical, behavioral, and mental health issues throughout the lifespan and, because of their prevalence, constitute a significant public health issue. Practitioners in all health care disciplines need to be knowledgeable about ACEs and prepared to address them. ACEs can contribute to conditions that lead patients to seek rehabilitation care, and therefore a framework is needed that enables rehabilitation professionals to understand the effects of ACEs and how to discuss them with patients. This article summarizes ACE research and its clinical relevance, presents an overview of the related topic of trauma-informed care, and introduces rehabilitation professionals to practical tools for incorporating ACE- and trauma-informed care into clinical practice. There is growing acknowledgement across all health care disciplines of the impact of ACEs. ACEs are understood as stressful, potentially traumatic events that may have lasting negative effects on health and well-being. Since the 1990s, when landmark research found striking associations between early life stress and adversity and a wide range of chronic physical, behavioral, and mental health issues, international attention to ACEs as a major public health issue has grown.1, 2 ACE-related research has identified strong correlations between chronic disease, stress, and prior experience. Eighty-six percent of health care dollars in the United States are spent on chronic diseases, and a population health strategy should include empowering, person-centered, low-risk, low-cost, self-management skill-building practices to help patients manage the stress response.3 Though a relevant consideration for all care provision, the biopsychosocial framework may be particularly important for understanding and working with chronic health conditions.4, 5, 6, 7 For example, chronic pain affects 116 million in the United States8 and may be a key force in driving patients to seek rehabilitation services. Patients need their providers to skillfully and comprehensively navigate the intersection of mental, emotional, and physical components of their healing process. Given the prevalence of ACEs and their potential contribution to chronic pain, among other conditions, rehabilitation professionals should be prepared to address ACEs in the clinical setting as a possible underlying contributor to the condition for which treatment is sought. This article provides an overview of ACEs research and the health effects that can result from ACEs and introduces a trauma-informed practical guide for rehabilitation professionals to use in clinical encounters. Adverse childhood experiences (ACEs) contribute to a broad spectrum of health challenges across the lifespan and constitute a significant public health issue. Rehabilitation professionals routinely work with individuals experiencing health challenges that may be linked to ACEs. Models of trauma-informed care and resilience-building approaches assist rehabilitation professionals in contributing to a solution to the prevalence of ACEs and chronic stress in the population. A novel schema is presented to assist rehabilitation professionals in navigating the topic of ACEs in clinical care.
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Do post-traumatic pain and post-traumatic stress symptomatology mutually maintain each other? A systematic review of cross-lagged studies. Pain 2019; 159:2159-2169. [PMID: 29994992 DOI: 10.1097/j.pain.0000000000001331] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
After traumatic exposure, individuals are at risk of developing symptoms of both pain and post-traumatic stress disorder (PTSD). Theory and research suggest a complex and potentially mutually maintaining relationship between these symptomatologies. However, findings are inconsistent and the applied methods are not always well suited for testing mutual maintenance. Cross-lagged designs can provide valuable insights into such temporal associations, but there is a need for a systematic review to assist clinicians and researchers in understanding the nature of the relationship. Thus, the aim of this systematic review was to identify, critically appraise, and synthesize results from cross-lagged studies on pain and PTSD symptomatology to assess the evidence for longitudinal reciprocity and potential mediators. Systematic searches resulted in 7 eligible studies that were deemed of acceptable quality with moderate risk of bias using the cohort study checklist from Scottish Intercollegiate Guidelines Network. Furthermore, synthesis of significant pathways in the cross-lagged models showed inconsistent evidence of both bidirectional and unidirectional interaction patterns between pain and PTSD symptomatology across time, hence not uniformly supporting the theoretical framework of mutual maintenance. In addition, the synthesis suggested that hyperarousal and intrusion symptoms may be of particular importance in these cross-lagged relationships, while there was inconclusive evidence of catastrophizing as a mediator. In conclusion, the findings suggest an entangled, but not necessarily mutually maintaining relationship between pain and PTSD symptomatology. However, major variations in findings and methodologies complicated synthesis, prompting careful interpretation and heightening the likelihood that future high-quality studies will change these conclusions.
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75
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Serrano-Ibáñez ER, Ramírez-Maestre C, Esteve R, López-Martínez AE. The behavioural inhibition system, behavioural activation system and experiential avoidance as explanatory variables of comorbid chronic pain and posttraumatic stress symptoms. Eur J Psychotraumatol 2019; 10:1581013. [PMID: 30891160 PMCID: PMC6419650 DOI: 10.1080/20008198.2019.1581013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 01/22/2019] [Accepted: 01/29/2019] [Indexed: 02/08/2023] Open
Abstract
Background: The variables that underlie comorbid chronic pain and posttraumatic stress symptoms (PTSS) are not yet clearly established. Objective: The aim of the present study was to analyse the role of the behavioural inhibition system (BIS), behavioural approach system (BAS) and experiential avoidance (EA) in pain adjustment (i.e. pain intensity, daily functioning and pain-related impairment) in patients with chronic pain and PTSS. Methods: A battery of instruments was administered to 388 chronic pain patients. The sample was divided into those with PTSS (n = 194) and those without PTSS (n =194). Results: Significant differences were found between groups in the BIS, EA, impairment and daily functioning. No differences were found between groups in the BAS. Structural equation modelling showed that the BIS and EA were associated with worse adjustment in the 194 patients with both chronic pain and PTSS. The BAS was associated with a lower level of pain and greater daily functioning. Conclusion: The findings provide evidence that BIS and BAS activation and EA play a role in adjustment to chronic pain in patients with concurrent PTSS. These results may help guide the development of psychological treatments for patients with both conditions.
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Affiliation(s)
- Elena R Serrano-Ibáñez
- Facultad de Psicología, Instituto de Investigaciones Biomédicas (IBIMA), Universidad de Málaga, Málaga, Spain
| | - Carmen Ramírez-Maestre
- Facultad de Psicología, Instituto de Investigaciones Biomédicas (IBIMA), Universidad de Málaga, Málaga, Spain
| | - Rosa Esteve
- Facultad de Psicología, Instituto de Investigaciones Biomédicas (IBIMA), Universidad de Málaga, Málaga, Spain
| | - Alicia E López-Martínez
- Facultad de Psicología, Instituto de Investigaciones Biomédicas (IBIMA), Universidad de Málaga, Málaga, Spain
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76
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Dai W, Liu A, Kaminga AC, Deng J, Lai Z, Wen SW. Prevalence of Posttraumatic Stress Disorder among Children and Adolescents following Road Traffic Accidents: A Meta-Analysis. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2018; 63:798-808. [PMID: 30081648 PMCID: PMC6309043 DOI: 10.1177/0706743718792194] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Children and adolescents are among the most vulnerable road users, and road traffic accidents (RTAs) can lead to not only physical injuries but also adverse psychological outcomes, particularly posttraumatic stress disorder (PTSD). However, estimates of the prevalence of PTSD among children and adolescents following RTAs varied considerably across studies. Therefore, this study aimed to estimate the pooled prevalence of PTSD among this population. METHODS A systematic search for literature was performed in the electronic databases of PubMed, Web of Science, PsycINFO, and Embase. Heterogeneity was assessed using the Cochran's chi-square test and quantified by the I2 value. Meta-regression analyses were carried out to identify the effects of some potential moderators on the overall heterogeneity. Subgroup analyses were performed to estimate the pooled prevalence of PTSD according to some sample characteristics. RESULTS Eleven eligible studies with a total of 1532 children and adolescents who were involved in RTAs were included. The overall heterogeneity (I2 = 89.7, P < 0.001) was high across the eligible studies, and the pooled prevalence of PTSD was 19.95% (95% confidence interval, 13.63% to 27.09%) by a random-effects model. No significant moderators of the overall heterogeneity were identified using meta-regression analyses. Subgroup analyses showed that the pooled prevalence of PTSD differed significantly according to the study location and gender (P < 0.05). CONCLUSIONS One-fifth of children and adolescents developed PTSD in the aftermath of RTAs, indicating the need for regular assessment of PTSD and timely and effective psychological interventions among this population. Furthermore, more population-based studies with a large sample size are warranted. The protocol was registered in the PROSPERO database (No. CRD42018087941).
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Affiliation(s)
- Wenjie Dai
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan, China.,Department of Obstetrics and Gynecology, Faculty of Medicine, OMNI Research Group, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada.,School of Epidemiology, Public Health, and Preventive Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Aizhong Liu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan, China
| | - Atipatsa C Kaminga
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan, China.,Department of Mathematics, Mzuzu University, Mzuzu, Malawi
| | - Jing Deng
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan, China
| | - Zhiwei Lai
- Immunization Programme Department, Hunan Provincial Center for Disease Control and Prevention, Changsha, Hunan, China
| | - Shi Wu Wen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan, China.,Department of Obstetrics and Gynecology, Faculty of Medicine, OMNI Research Group, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada.,School of Epidemiology, Public Health, and Preventive Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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77
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Rometsch-Ogioun El Sount C, Denkinger JK, Windthorst P, Nikendei C, Kindermann D, Renner V, Ringwald J, Brucker S, Tran VM, Zipfel S, Junne F. Psychological Burden in Female, Iraqi Refugees Who Suffered Extreme Violence by the "Islamic State": The Perspective of Care Providers. Front Psychiatry 2018; 9:562. [PMID: 30467483 PMCID: PMC6236063 DOI: 10.3389/fpsyt.2018.00562] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 10/17/2018] [Indexed: 01/09/2023] Open
Abstract
Introduction: A large number of refugees suffer from mental disorders such as post-traumatic stress disorder (PTSD). In the context of a special quota project, 1100 Yazidi women from Northern Iraq who had suffered extreme violence by the so-called Islamic State (IS) were brought to Germany to receive specialized treatment. This study aims to investigate the psychological burden and trauma-related symptoms of these female IS-victims from the perspectives of their care providers. Material and methods: Care providers with various professional backgrounds (N = 96) were asked to complete a self-developed questionnaire on a Likert-type scale ranging from 1 (very low) to 7 (very high) analyzing the psychological burden and trauma-related symptoms of the IS-traumatized women since their arrival in Germany. We controlled for potential confounders, namely the care providers' personal experiences of trauma and flight, by using chi-square tests. Results: The mean psychological burden for the whole period in Germany as perceived by care providers was M = 5.51 (SD = 0.94). As the main factors of distress the care providers reported: worries about family members in Iraq (M = 6.69; SD = 0.69), worries about relatives' possibilities to be granted asylum in Germany (M = 6.62; SD = 0.68), and uncertainties regarding their future (M = 5.89; SD = 1.02). The most prominent trauma-related psychological symptoms were nightmares (M = 6.43; SD = 0.54). The care providers reported that somatic complaints have been present among the refugees in the following manifestation: pain (M = 6.24; SD = 1.08), gastrointestinal complaints (M = 4.62; SD = 1.62), and dizziness (M = 4.40; SD = 1.59). The care providers' personal experiences of trauma and flight had no significant influence on their response behavior. Discussion: Care providers working with IS-traumatized female refugees evaluate the psychological burden and trauma-related somatic and psychological symptom loads of their clients as very high. The results of this study provide important information about the perceptions of care providers working in a refugee-services context and may provide insights for the progression of specialized treatment programs and interventions for highly traumatized refugees and culture-sensitive training programs for their care providers.
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Affiliation(s)
| | - Jana Katharina Denkinger
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
| | - Petra Windthorst
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
| | - Christoph Nikendei
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
| | - David Kindermann
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
| | - Viola Renner
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy for children and Youth, University Hospital Tübingen, Tübingen, Germany
| | - Johanna Ringwald
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
| | - Sara Brucker
- Department of Gynecology, University Hospital Tübingen, Tubingen, Germany
| | - Virginia M. Tran
- Harvard Humanitarian Initiative, Harvard University, Cambridge, MA, United States
- Harvard Medical School, Harvard University, Boston, MA, United States
| | - Stephan Zipfel
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
| | - Florian Junne
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
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78
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Dai W, Liu A, Kaminga AC, Deng J, Lai Z, Yang J, Wen SW. Prevalence of acute stress disorder among road traffic accident survivors: a meta-analysis. BMC Psychiatry 2018; 18:188. [PMID: 29895273 PMCID: PMC5998549 DOI: 10.1186/s12888-018-1769-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/29/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Road traffic accident (RTA), an unexpected traumatic event, may not only lead to death and serious physical injuries, but also could put survivors at an increased risk for a wide range of psychiatric disorders, particularly acute stress disorder (ASD). Early assessment of trauma-related psychological responses is important because acute trauma responses in the early post-traumatic period are among the robust predictors of long-term mental health problems. However, estimates of the prevalence of ASD among RTA survivors varied considerably across studies. Therefore, this meta-analysis aimed to identify the pooled prevalence of ASD among RTA survivors. METHODS A systematic literature search in the databases of PubMed, PsycINFO, PsycARTICLES, Embase and Web of Science was performed from their inception dates to December 2017. Subject headings were used to identify relevant articles, and the search strategy was adjusted across databases. Heterogeneity across studies was evaluated by Cochran's χ2 test and quantified by the I2 statistic. Subgroup analyses were performed to identify the pooled prevalence in relation to the country of study, instrument used to identify ASD, age, gender and traumatic brain injury. When significant heterogeneity was observed, the influence of some potential moderators was explored using meta-regression analyses. RESULTS Thirteen eligible studies conducted in 8 countries were included. A total of 2989 RTA survivors were assessed, of which 287 were identified with ASD. The overall heterogeneity was high across studies (I2=96.8%, P < 0.001), and the pooled prevalence of ASD among RTA survivors was 15.81% (95% confidence interval: 8.27-25.14%). Subgroup analyses indicated that the prevalence of ASD among RTA survivors differed significantly with regard to the country of study, instrument used to identify ASD, age and gender (P < 0.05). Meta-regression analyses showed that mean age of participants and quality assessment score were significant moderators for heterogeneity (P < 0.05). CONCLUSIONS Nearly one-sixth of RTA survivors suffer from ASD, indicating the need for regular assessment of early trauma responses among RTA survivors, as well as the importance of implementing early psychological interventions.
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Affiliation(s)
- Wenjie Dai
- 0000 0001 0379 7164grid.216417.7Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan China ,0000 0001 2182 2255grid.28046.38OMNI Research Group, Department of Obstetrics and Gynecology, Faculty of Medicine, University of Ottawa, Ottawa, ON Canada ,0000 0000 9606 5108grid.412687.eOttawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON Canada ,0000 0001 2182 2255grid.28046.38School of Epidemiology, Public Health, and Preventive Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Aizhong Liu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan, China.
| | - Atipatsa C. Kaminga
- 0000 0001 0379 7164grid.216417.7Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan China ,grid.442592.cDepartment of Mathematics, Mzuzu University, Mzuzu, Malawi
| | - Jing Deng
- 0000 0001 0379 7164grid.216417.7Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan China
| | - Zhiwei Lai
- Immunization Programme Department, Hunan Provincial Center for Disease Control and Prevention, Changsha, Hunan China
| | - Jianzhou Yang
- grid.254020.1Department of Preventive Medicine, Changzhi Medical College, Changzhi, Shanxi China
| | - Shi Wu Wen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan, China. .,OMNI Research Group, Department of Obstetrics and Gynecology, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada. .,School of Epidemiology, Public Health, and Preventive Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
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79
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Comorbid Pain and PTSD: Integrating Research and Practice with MVC Survivors. PSYCHOLOGICAL INJURY & LAW 2018. [DOI: 10.1007/s12207-018-9316-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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80
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Van Loey NE, Klein-König I, de Jong AEE, Hofland HWC, Vandermeulen E, Engelhard IM. Catastrophizing, pain and traumatic stress symptoms following burns: A prospective study. Eur J Pain 2018; 22:1151-1159. [PMID: 29436110 DOI: 10.1002/ejp.1203] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Pain and posttraumatic stress disorder (PTSD) symptoms are significant problems in the aftermath of a burn injury and they often co-occur. Catastrophizing has been linked to both phenomena. The aim of this study was to investigate the underlying role of catastrophizing in PTSD symptoms and pain following burns. METHODS This prospective study included 216 patients with burns. PTSD symptoms and pain were measured during hospitalization (T1) and 6 (T2) and 12 months (T3) postburn. The Impact of Event Scale-Revised (IES-R) indexed PTSD symptoms. Acute pain (T1) was the mean pain during the first two weeks of hospitalization measured using an 11-point graphic numeric rating scale. Chronic pain was indexed using the single item 'average' pain from the Brief Pain Inventory (BPI). Catastrophizing was measured at T1 and T2 using the Cognitive Emotion Regulation Questionnaire (CERQ). Data were analysed using structural equation modelling (SEM). RESULTS The results showed that T2 catastrophizing mediated between acute and chronic PTSD symptoms, and T3 pain. Furthermore, the study revealed significant associations between catastrophizing, PTSD symptoms and pain at the respective measurements, and significant longitudinal associations between the constructs. CONCLUSION A negative cognitive-affective response to a burn event, such as catastrophizing, mediated the relationship between acute and chronic PTSD symptoms and later chronic pain. Screening for catastrophizing and acute PTSD symptoms is recommended to identify persons at risk for chronic PTSD symptoms and pain. SIGNIFICANCE The identification of individuals who have the tendency to catastrophize may assist in finding those at risk for development of both chronic PTSD symptoms and chronic pain. Individuals may benefit from early psychological therapy focussing on catastrophizing and acute PTSD symptoms that may ameliorate both chronic PTSD symptoms and pain.
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Affiliation(s)
- N E Van Loey
- Behavioural Research, Association of Dutch Burn Centers, Beverwijk, The Netherlands.,Clinical Psychology, Utrecht University, The Netherlands
| | - I Klein-König
- OCRN Child and Youth Mental Health Care, Groningen, The Netherlands
| | - A E E de Jong
- Burn Center, Red Cross Hospital, Beverwijk, The Netherlands
| | - H W C Hofland
- Burn Center, Maasstad Hospital, Rotterdam, The Netherlands
| | - E Vandermeulen
- Burn Center, Queen Astrid Military Hospital, Brussels, Belgium
| | - I M Engelhard
- Clinical Psychology, Utrecht University, The Netherlands
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