Disaggregating the relationship between posttraumatic stress disorder symptom clusters and chronic orofacial pain: implications for the prediction of health outcomes with PTSD symptom clusters

Posttraumatic Stress Disorder Symptom Clusters as Predictors of Pain Interference in Burn Survivors: A Burn Model System National Database Study

Individuals who experience burns are at higher risk of developing posttraumatic stress disorder and chronic pain. A synergistic relationship exists between posttraumatic stress disorder and chronic pain. We sought to evaluate the role of individual posttraumatic stress disorder symptom clusters as predictors of pain interference. We hypothesized that the hyperarousal and emotional numbing symptom clusters would be predictive of pain interference, even when accounting for the other two posttraumatic stress disorder symptom clusters, pain intensity, and other covariates. Multivariate linear regression analyses were completed using data from the Burn Model System National Database. A total of 439 adult participants had complete responses on self-report measures assessing posttraumatic stress disorder symptoms, pain intensity, and pain interference at 6-month after discharge and were included in analyses. Results indicate hyperarousal (B = .10, p = .03) and emotional numbing (B = .13, p = .01) posttraumatic stress disorder symptom clusters were each significantly associated with pain interference, even when accounting for pain intensity (B = .64, p < .001). Results highlight the importance of the emotional numbing and hyperarousal posttraumatic stress disorder symptom clusters in explaining pain interference. Findings suggest that when posttraumatic stress disorder symptoms or chronic pain are present, screening for and treating either condition may be warranted to reduce pain interference. Further, psychological interventions that target emotional numbing and hyperarousal posttraumatic stress disorder symptoms may be fruitful for promoting better coping with chronic pain and reducing pain interference.

The Association Between Post-Traumatic Stress Disorder and Temporomandibular Disorders: A Systematic Review

The purpose of this systematic study was to discover a connection between temporomandibular joint disorders and post-traumatic stress disorder. A systematic review of observational studies on post-traumatic stress disorder and the incidence of temporomandibular joint disorders (TMD) was conducted. Electronic searches of PubMed, the Saudi Digital Library, Science Direct, the Virtual Health Library (VHL), Scopus, Web of Science, Sage, EBSCO Information Services, and Ovid were performed. There was a consensus among the reviewing examiners. Only studies with the following Medical Subject Headings (MeSH) terms were included: "Posttraumatic stress disorder" combined with "temporomandibular joint disorder," "myofascial pain," "orofacial pain," "internal derangement," "disc displacement with reduction," or "disc displacement without reduction." Only full-text studies in the English language published between 2010 and June 2020 were considered. Of a total of 381 articles meeting the initial screening criteria, only eight were included in the qualitative analysis. Overall, pain is exacerbated in patients with PTSD; that is, their TMD is heightened in all aspects of pain, chronicity, decreased response to conventional therapies, and the need for more potent treatment options as compared with patients with just TMD. The evidence, albeit weak, obtained from the studies included in this review suggests a relationship between PTSD and TMDs.

An Examination of Chronic Pain Indices and the Updated Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental-Disorders-Fifth Edition

INTRODUCTION

Chronic pain and post-traumatic stress disorder (PTSD) comorbidity is prevalent among veterans and is associated with increased levels of pain severity and pain-related disability. An improved understanding of the relationship between these co-occurring disorders, in addition to effective integrated treatments, will develop by considering the changes to the PTSD diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The current study examined the relationship between the revised PTSD Checklist for DSM-5 (PCL-5) symptom clusters (i.e., intrusion, avoidance, negative alterations in cognition and mood [NACM], and arousal) and chronic pain measurements (i.e., pain severity, interference, and disability).

MATERIALS AND METHODS

Participants included 103 veterans (ages 26-70, mean = 45.33) participating in a randomized clinical trial examining the efficacy of an interdisciplinary pain management program for chronic musculoskeletal pain. The study was approved by a university system Institutional Review Board and affiliated healthcare system.

RESULTS

The participants with a provisional PTSD diagnosis based on PCL-5 responses (N = 76) had significantly greater pain severity, interference, and disability than the participants without a provisional diagnosis (N = 23). Correlations between symptom clusters and pain measurements were mostly significant and positive with varying strengths. The avoidance symptom cluster, however, had relatively weaker correlations with pain measurements and was not significantly associated with the numeric rating scale of pain severity. Path analyses revealed that, after controlling for avoidance symptoms, significant associations remained between NACM and all the pain measurements. After controlling for NACM symptoms, however, there were no significant associations between avoidance symptoms and pain measurements.

CONCLUSION

The current study highlights a need to re-examine the leading theories about the mutual maintenance of these disorders in order to develop effective integrative treatment approaches. PTSD-related avoidance may have a relatively weaker role in co-occurring chronic pain than the other symptom clusters and may have a qualitatively different role than chronic pain-related avoidance. Future research should explore the relationship between the avoidance in PTSD and the avoidance in chronic pain as well as identify which chronic pain measurements are the most useful when examining the relationship between PTSD and chronic pain. The potential impact of trauma-related cognition and mood on chronic pain indicates that this is an important area for intervention and should be considered in the development of integrated treatments for chronic pain and PTSD among veterans.

Association of fear-avoidance and self-efficacy on pain disability in individuals with co-morbid post-traumatic stress and chronic pain

This study investigated relationships between post-traumatic stress symptoms (PTSS) and pain disability. Fifty people with chronic pain (probable PTSD, n = 22) completed measures assessing pain interference, PTSS, fear avoidance, and pain self-efficacy. We hypothesized that people with probable PTSD would have higher fear avoidance and lower pain self-efficacy; and that PTSS would be indirectly associated with pain disability via fear avoidance and self-efficacy. People with probable PTSD had higher fear avoidance, but there were no differences in self-efficacy, pain severity or disability. There was an indirect association between PTSS and pain disability via fear avoidance, but not via self-efficacy.

The role of posttraumatic stress symptoms on chronic pain outcomes in chronic pain patients referred to rehabilitation

Objectives

Posttraumatic stress symptoms (PTSS) are highly prevalent in chronic pain patients and may affect pain symptomatology negatively, but there is still a great need to explore exactly how this occurs. Therefore, this study investigated differences in pain intensity, pain-related disability, and psychological distress between chronic pain patients not exposed to a trauma, patients exposed to a trauma with no PTSS, and patients exposed to a trauma with PTSS. Moreover, the moderating effects of PTSS on the associations between pain intensity and pain-related disability and psychological distress were investigated.

Methods

In this cross-sectional cohort study, data were consecutively collected over the course of a year in patients with chronic non-malignant pain referred for multidisciplinary pain rehabilitation at a Danish university hospital pain center using questionnaires assessing pain, pain-related disability, PTSS, anxiety, and depression.

Results

The final sample consisted of 682 chronic pain patients, who were divided into three subgroups (no trauma, 40.6%; trauma/no PTSS, 40.5%; trauma/PTSS, 18.9%). Chronic pain patients with PTSS reported significantly higher levels of pain intensity, pain-related disability, depression, and anxiety compared to chronic pain patients without a trauma and chronic pain patients without PTSS. Moreover, PTSS significantly moderated the associations between pain intensity and pain-related psychosocial disability, depression, and anxiety.

Conclusion

These results highlight the importance of assessing PTSS in chronic pain patients and suggest that PTSS have a specific influence on the association between pain intensity and more psychosocial aspects of the pain condition.

Number and Type of Post-Traumatic Stress Disorder Symptom Domains Are Associated With Patient-Reported Outcomes in Patients With Chronic Pain

Post-traumatic stress disorder (PTSD) commonly accompanies complex chronic pain, yet PTSD is often overlooked in chronic pain management. Using the 4-item Primary Care (PC)-PTSD screening tool, we evaluated the relationship between the number and type of PC-PTSD symptoms endorsed and a set of patient-reported outcomes, including: pain intensity and interference, function, mood, quality of life, and substance abuse risk in a consecutive sample of patients with chronic pain (n = 4,402). Patients completed PainTracker, a Web-based patient-reported outcome tool that provides a multidimensional evaluation of chronic pain, as part of their intake evaluation at a specialty pain clinic in a community setting. Twenty-seven percent of the sample met PC-PTSD screening criteria for PTSD by endorsing 3 of the 4 symptom domains. Significant ordinal trends were observed between increasing number of PTSD symptoms and all outcomes evaluated. The occurrence of even 1 PTSD symptom was associated with overall poorer outcomes, suggesting that subsyndromal PTSD is clinically significant in the context of chronic pain. Among the 4 PTSD domains assessed, "numbness/detachment" was most strongly associated with negative pain outcomes in relative weight analysis. Results from this cross-sectional study suggest that a range of pain-related outcomes may be significantly related to comorbid PTSD.

PERSPECTIVE

We present evidence that PTSD symptoms are significantly related to a broad set of pain-related patient-reported outcomes. These findings highlight the need to evaluate for PTSD symptoms in patients with chronic pain, especially feelings of numbness or detachment from others, to improve understanding and management of chronic pain.

Trauma-Related Pain, Reexperiencing Symptoms, and Treatment of Posttraumatic Stress Disorder: A Longitudinal Study of Veterans

Research has demonstrated a strong positive association between posttraumatic stress disorder (PTSD) symptoms and physical pain. However, few studies have explored the impact of pain problems on the symptoms and treatment of PTSD, and results remain inconsistent. This longitudinal study examined whether trauma-related and trauma-unrelated pain differentially and uniquely predicted reexperiencing symptoms. We also examined whether levels of reexperiencing symptoms mediated the relationship between pain intensity and posttreatment symptoms of avoidance, numbing, and hyperarousal (ANH). Analyses were conducted using archival data from 99 treatment-seeking veterans who reported the etiology and intensity of their pain and severity of PTSD symptoms pre- and posttreatment. Among veterans with trauma-related pain, pain intensity (a) uniquely corresponded to greater posttreatment reexperiencing symptoms (b = 1.09), and (b) was indirectly predictive of ANH symptoms via the reexperiencing symptoms (b = 1.93). However, veterans with trauma-unrelated pain evidenced no associations between pain intensity and reexperiencing (b = 0.04) or ANH symptoms (b = 0.06). We thus found that trauma-related pain was indirectly related to poor PTSD treatment outcomes via reexperiencing symptoms. These findings offer additional insight into factors that may influence PTSD treatment outcomes for pain-suffering trauma survivors.

Sleep Disturbance in Posttraumatic Stress Disorder: Epiphenomenon or Causal Factor?

PURPOSE OF REVIEW

The goal of this review is to integrate recent findings on sleep disturbance and PTSD, examine sleep disturbance as a causal factor in the development of PTSD, and identify future directions for research, treatment, and prevention.

RECENT FINDINGS

Recent research highlights a relationship between both objective and subjective sleep disturbance and PTSD across diverse samples. Sleep disturbance also predicts PTSD over time. Finally, treatments targeting sleep disturbance lead to decreased PTSD symptoms, while standard PTSD treatments conclude with residual sleep disturbance. Sleep disturbance may be more than a mere epiphenomenon of PTSD. Future research examining the causal role of sleep disturbance in the development of PTSD, as well as the utility of targeting sleep disturbance in prevention and treatment, is necessary to fully understand the likely bidirectional relationship between sleep disturbance and PTSD.

Smoking and Posttraumatic Stress Disorder Symptomatology in Orofacial Pain

To explore the impact of interactions between smoking and symptoms of posttraumatic stress disorder (PTSD) on pain intensity, psychological distress, and pain-related functioning in patients with orofacial pain, a retrospective review was conducted of data obtained during evaluations of 610 new patients with a temporomandibular disorder who also reported a history of a traumatic event. Pain-related outcomes included measures of pain intensity, psychological distress, and pain-related functioning. Main effects of smoking status and PTSD symptom severity on pain-related outcomes were evaluated with linear regression analyses. Further analyses tested interactions between smoking status and PTSD symptom severity on pain-related outcomes. PTSD symptom severity and smoking predicted worse pain-related outcomes. Interaction analyses between PTSD symptom severity and smoking status revealed that smoking attenuated the impact of PTSD symptom severity on affective distress, although this effect was not found at high levels of PTSD symptom severity. No other significant interactions were found, but the present results identifying smoking as an ineffective coping mechanism and the likely role of inaccurate outcome expectancies support the importance of smoking cessation efforts in patients with orofacial pain. Smoking is a maladaptive mechanism for coping with pain that carries significant health- and pain-related risks while failing to fulfill smokers' expectations of affect regulation, particularly among persons with orofacial pain who also have high levels of PTSD symptom severity. Addressing smoking cessation is a critical component of comprehensive treatment. Further research is needed to develop more effective ways to help patients with pain and/or PTSD to replace smoking with more effective coping strategies.

A systematic literature review of PTSD's latent structure in the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV to DSM-5

The factor structure of posttraumatic stress disorder (PTSD) has been widely researched, but consensus regarding the exact number and nature of factors is yet to be reached. The aim of the current study was to systematically review the extant literature on PTSD's latent structure in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in order to identify the best-fitting model. One hundred and twelve research papers published after 1994 using confirmatory factor analysis and DSM-based measures of PTSD were included in the review. In the DSM-IV literature, four-factor models received substantial support, but the five-factor Dysphoric arousal model demonstrated the best fit, regardless of gender, measurement instrument or trauma type. The recently proposed DSM-5 PTSD model was found to be a good representation of PTSD's latent structure, but studies analysing the six- and seven-factor models suggest that the DSM-5 PTSD factor structure may need further alterations.

Posttraumatic Stress Disorder and Orofacial Pain

Chronic orofacial pain occurs frequently in patients with posttraumatic stress disorder (PTSD) and at the same time any pathological process involving orofacial area can be reflected in emotional interpretation of pain and can trigger a series of reactions associated with the PTSD group of symptoms in patients with PTSD. Painful stimuli caused in this way may occur after the primary cause ceased, and because of convergence can cause referred pain outside of the anatomical site where the primary injury occurred. Chronic orofacial pain and PTSD are diagnosed on the basis of subjective testimony and this regularly occurs in the context of social interaction between patients, doctors, medical staff or researchers making it difficult to standardize the results and introduces many cultural phenomena.

An examination of the structural link between post-traumatic stress symptoms and chronic pain in the framework of fear-avoidance models

BACKGROUND

The tendency to respond with fear and avoidance can be seen as a shared vulnerability contributing to the development of post-traumatic stress disorder (PTSD) and chronic pain. Although several studies have examined which specific symptoms of PTSD (re-experiencing, avoidance, emotional numbing and hyperarousal) are associated with chronic pain, none has considered this association within the framework of fear-avoidance models.

METHODS

Seven hundred fourteen patients with chronic musculoskeletal pain were assessed. Of these, 149 patients were selected for the study based upon the following inclusion criteria: exposure to a traumatic event before the onset of pain (with scores equal to or higher than 8 points on the fear and hopelessness scales of the Stressful Life Event Screening Questionnaire Revised) and scores equal to or higher than 30 on the Davidson Trauma Scale.

RESULTS

Structural equation modelling was used to test the association between PTSD symptoms and pain outcomes (pain intensity and disability) using the mediating variables considered in the fear-avoidance models. The results show that emotional numbing and hyperarousal symptoms, but neither re-experiencing nor avoidance, affected pain outcome via anxiety sensitivity (AS), catastrophizing and fear of pain. PTSD symptoms increased the levels of AS, which predisposes to catastrophizing and, in turn, had an effect on the tendency of pain patients to respond with more fear and avoidance.

CONCLUSIONS

This study provides empirical support for the potential role of PTSD symptoms in fear-avoidance models of chronic pain and suggests that AS is a relevant variable in the relationship between both disorders.

A multi-sample confirmatory factor analysis of PTSD symptoms: what exactly is wrong with the DSM-IV structure?

Within the DSM-IV, PTSD symptoms are rationally classified as assessing one of three symptom domains: reexperiencing, avoidance/numbing, or hyperarousal. However, two alternative four-factor models have been advocated as superior to the DSM-IV framework, based on confirmatory factor analysis. In the Numbing model, symptoms of emotional numbing are differentiated from avoidance. In the Dysphoria model, several symptoms of numbing and hyperarousal are combined to form a factor purported to assess general psychological distress. Examination of these models, within 29 separate data sets, supports two conclusions. First, contrary to its conceptual underpinnings, the Dysphoria model differs empirically from the Numbing model solely in the correlation predicted between two hyperarousal symptoms; all other predicted correlations made by the two models are substantively identical. Second, when the factor analytic presumption of simple structure is relaxed to allow for potential presentation order effects, other plausible symptom structures emerge. In particular, the fit of the DSM-IV model improved dramatically and was a better fit to the data than either four-factor model. The ostensible inferiority of the DSM-IV model may be due to a methodological artifact stemming from the order in which symptoms are typically assessed. The provisional decision to revise the structure of PTSD symptoms in the DSM-5 in light of confirmatory factor analytic results may be misguided.

Impact of posttraumatic stress disorder on sinonasal symptoms and quality of life in patients with chronic rhinosinusitis

BACKGROUND

Severity of chronic rhinosinusitis (CRS), measured by disease-specific health-related quality-of-life questionnaires, is expected to increase in patients who also suffer from posttraumatic stress disorder (PTSD). Altered pain perception, sleep disorders, and fatigue may be associated with this comorbidity.

METHODS

Severity of CRS was compared between a group of 28 patients with CRS and a group of 28 patients with CRS and concomitant PTSD using different disease-specific and generic instruments, such as visual analog scale (VAS), Short Form-36 test (SF-36), and Sino-Nasal Outcome Test-22 (SNOT 22).

RESULTS

SNOT-22 test showed significantly higher CRS severity in patients with CRS and PTSD, compared to patients with CRS without PTSD.

CONCLUSION

Patients with less severe CRS, measured by objective outcome measures, due to the impact of comorbid PTSP, are classified as having severe rhinosinusitis, and are exposed to the risk of unnecessary diagnostic and therapeutic procedures. In patients with difficult-to-treat rhinosinusitis, diagnosis should be revised, and one item that should be evaluated is whether they suffer from PTSD.