The Impact of PTSD on Functioning in Patients Seeking Treatment for Chronic Pain and Validation of the Posttraumatic Diagnostic Scale

A novel animal model for understanding secondary traumatic stress and visceral pain in male rats

Empathetic relationships and the social transference of behaviours have been shown to occur in humans, and more recently through the development of rodent models, where both fear and pain phenotypes develop in observer animals. Clinically, observing traumatic events can induce 'trauma and stressor-related disorders' as defined in the DSM 5. These disorders are often comorbid with pain and gastrointestinal disturbances; however, our understanding of how gastrointestinal - or visceral - pain can be vicariously transmitted is lacking. Visceral pain originates from the internal organs, and despite its widespread prevalence, remains poorly understood. We established an observation paradigm to assess the impact of witnessing visceral pain. We utilised colorectal distension (CRD) to induce visceral pain behaviours in a stimulus rodent while the observer rodent observed. Twenty four hours post-observation, the observer rodent's visceral sensitivity was assessed using CRD. The observer rodents were found to have significant hyperalgesia as determined by lower visceral pain threshold and higher number of total pain behaviours compared with controls. The behaviours of the observer animals during the observation were found to be correlated with the behaviours of the stimulus animal employed. We found that observer animals had hypoactivity of the hypothalamic-pituitary-adrenal (HPA) axis, highlighted by reduced corticosterone at 90 minutes post-CRD. Using c-Fos immunohistochemistry we showed that observer animals also had increased activation of the anterior cingulate cortex, and decreased activation of the paraventricular nucleus, compared with controls. These results suggest that witnessing another animal in pain produces a behavioural phenotype and impacts the brain-gut axis.

High level of post-traumatic stress symptoms in patients with chronic neck pain is associated with poor mental health but does not moderate the outcome of a multimodal physiotherapy programme

INTRODUCTION

Chronic traumatic neck pain has a high prevalence of post-traumatic stress symptoms (PTSS). However, whether PTSS moderates treatment effects is unknown. This study investigated: 1) whether PTSS was associated with patient-reported outcomes and clinical test results at baseline; 2) whether PTSS moderated the effect of a multimodal physiotherapy intervention of exercise therapy and patient education; and 3) whether adherence to the intervention differed across PTSS groups.

METHODS

Secondary data analysis from a randomized controlled trial on chronic neck pain with 12-month follow-up was conducted. Patients were divided into three groups (NT = non-traumatic, LT = traumatic low PTSS, HT = traumatic high PTSS) based on self-reported onset of pain and the Impact of Event Scale. The baseline data were used to analyze the association of PTSS with patient demographics and scores of physical and mental health-related quality of life, depression, neck-related disability, kinesiophobia, and clinical tests. Baseline, 4-month and 12-month follow-up data were analyzed to investigate possible moderating effects on outcomes. Data on adherence were collected at four months.

RESULTS

115 participants were included (NT n = 45; LT n = 46; HT n = 24). The HT group reported lower mental health scores and more depressive symptoms at baseline. PTSS did not significantly moderate the treatment effect on any outcomes. The HT group tended to have lower adherence to the multimodal physiotherapy intervention than the LT group.

CONCLUSION

For patients with traumatic neck pain, high levels of PTSS are associated with poorer psychological outcomes but do not affect the outcomes of multimodal physiotherapy intervention.

Initial validation of the 12-item Tampa Scale of Kinesiophobia in a retrospective sample of adults with chronic headache

INTRODUCTION

An area of emerging interest in chronic pain populations concerns fear of pain and associated fear of movement (kinesiophobia)-a cognitive appraisal pattern that is well-validated in non-headache chronic pain. However, there is limited research on whether this construct can be measured in a similar manner in headache populations.

METHODS

The current project details a confirmatory factor analysis of the 12-Item Tampa Scale of Kinesiophobia (TSK-12) using a clinical data set from 210 adults with diverse headache diagnoses presenting for care at a multidisciplinary pain clinic. One item (concerning an "accident" that initiated the pain condition) was excluded from analysis.

RESULTS

Results of the confirmatory factor analysis for the remaining 12 items indicated adequate model fit for the previously established 2-factor structure (activity avoidance and bodily harm/somatic focus subscales). In line with previous literature, total TSK-12 scores showed moderate correlations with pain severity, pain-related interference, positive and negative affect, depressive and anxious symptoms, and pain catastrophizing.

DISCUSSION

The current study is the first to examine the factor structure of the TSK-12 in an adult headache population. The results support the relevance of pain-related fear to the functional and psychosocial status of adults with chronic headache, although model fit of the TSK-12 could be characterized as adequate rather than optimal. Limitations of the study include heterogeneity in headache diagnosis and rates of comorbid non-headache chronic pain in the sample. Future studies should replicate these findings in more homogenous headache groups (eg, chronic migraine) and examine associations with behavioral indices and treatment response.

Somatic symptoms and insomnia among bereaved parents and siblings eight years after the Utøya terror attack

Background: Levels of prolonged grief symptoms (PGS) and post-traumatic stress symptoms (PTSS) can be high, many years following bereavement after terror, but knowledge concerning somatic health is scarce. Terrorism is a serious public health challenge, and increased knowledge about long-term somatic symptoms and insomnia is essential for establishing follow-up interventions after terrorism bereavement.Objective: To study the prevalence of somatic symptoms and insomnia and their association with PGS, PTSS, and functional impairment among terrorism-bereaved parents and siblings.Methods: A cross-sectional quantitative study included 122 bereaved individuals from the Utøya terror attack in Norway in 2011. The sample comprised 88 parents and 34 siblings aged 19 years and above (Mage = 49.7 years, SDage = 13.8 years, 59.8% females). The participants completed questionnaires 8 years after the attack assessing somatic symptoms (Children's Somatic Symptoms Inventory) and insomnia (Bergen Insomnia Scale) along with measures of PGS (Inventory of Complicated Grief), PTSS (Impact of Event Scale-Revised), and functional impairment (Work and Social Adjustment Scale).Results: Fatigue was the most frequently reported somatic symptom (88% of females and 65% of males). Females reported statistically significantly more somatic symptoms than males. In total, 68% of the bereaved individuals scored above the cut-off for insomnia. There were no statistically significant gender differences for insomnia. Female gender, intrusion, and arousal were associated with somatic symptoms. Intrusion and somatic symptoms were associated with insomnia. Somatic symptoms, avoidance, and hyperarousal were associated with functional impairment.Conclusion: Many bereaved parents and siblings report somatic symptoms and insomnia eight years after the terror attack. Somatic symptoms are associated with functional impairment. Long-term follow-up and support after traumatic bereavement should focus on somatic symptoms and insomnia.

Relations between PTSD symptom clusters and pain in three trauma-exposed samples with pain

OBJECTIVES

Little is known about how the individual PTSD symptom clusters relate to intensity and interference of pain and whether these relationships differ across clinical groups. The present study examines relations between PTSD symptom clusters and pain in three trauma-exposed, unique clinical groups: 1) adults seeking treatment for chronic pain with current symptoms of PTSD, 2) trauma affected refugees seeking treatment for PTSD and chronic pain; and 3) individuals identified at admission to the emergency ward after whiplash injury.

METHODS

Network analysis was used to assess unique relations between pain intensity, pain interference, re-experiencing, avoidance, numbing, hyperarousal, depression, and anxiety separately in each sample. Links between PTSD clusters and pain were then compared within and between samples.

RESULTS

No within-group differences were identified for the links between pain and any of PTSD clusters in the chronic pain and refugee groups. In the whiplash group, hyperarousal was more strongly related to pain than re-experiencing, avoidance, and numbing. Between group comparisons revealed a more pronounced relationship between hyperarousal and pain in the whiplash group, with no between-group differences between the chronic pain and refugee groups.

CONCLUSIONS

The findings suggest that when depression and anxiety are accounted for, few unique associations are found between pain and the PTSD symptom clusters in trauma-exposed samples with pain, with the exception of a link between pain and hyperarousal in individuals with whiplash-related PTSD symptoms.

Performance and acceptability of the Stressful Life Events Screening Questionnaire in a chronic pain population: a mixed-methods study

Introduction

Pain-related fear, anxiety, and avoidance may play key roles in the chronification of pain and related disability. For practitioners, knowledge about the source or drivers of these fears, including patients' exposure to potentially traumatic events (PTEs) and related posttraumatic stress symptoms, could be particularly helpful in guiding their treatment approach.

Objectives

We aimed to investigate whether the use of a brief screening for PTEs could help inform chronic pain treatment.

Methods

The performance and acceptability of the Stressful Life Events Screening Questionnaire (SLESQ) was assessed among 567 adult patients (59% women, mean age 48.1 years) meeting at a hospital outpatient pain clinic. The sensitivity, specificity, and 20 months temporal stability of the SLESQ, assessing exposure to 14 specific trauma types followed by a 15th item capturing exposure to "other events," were assessed through digital administration and follow-up interviews with 55 participants. The qualitative responses of 158 participants reporting exposure to "other events" were reviewed and assessed based on fulfillment of the A Criterion for traumatic events in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. The acceptability of the SLESQ was assessed in clinical interviews with 12 participants.

Results

The SLESQ demonstrated acceptable sensitivity (70.0%), high specificity (94.9%), and moderate temporal stability (κ = 0.66, P < 0.001). Participants' qualitative elaborations of "other events" were largely (76.3%) consistent with Criterion A events. The screening was well accepted and welcomed.

Conclusion

The results indicate that the use of a brief screening for potential trauma may be helpful to guide clinical practice in chronic pain settings.

Traumatic Events, Posttraumatic Stress Disorder, and Central Sensitization in Chronic Pain Patients of a German University Outpatient Pain Clinic

OBJECTIVE

Posttraumatic stress disorder (PTSD) and traumatic life events are often coupled to chronic pain, possibly linked by central sensitization. We wanted to assess the prevalence of traumatic events and PTSD in chronic pain patients of a German university hospital outpatient pain clinic. Moreover, we evaluated the extent of indicators and co-occurring traits of central sensitization in comorbid patients.

METHODS

We retrospectively divided 914 chronic pain patients into four groups depending on their trauma severity: no trauma, accidental trauma, interpersonal trauma, and PTSD. We collected electronic pain drawings focusing on pain area and widespreadness, as well as information about pain intensity, sleep impairment, disability, stress, anxiety, depression, and somatization. Differences between groups were calculated using Kruskal-Wallis with post-hoc Mann-Whitney tests.

RESULTS

Of 914 patients, 231 (25%) had no trauma, 210 (23%) had accidental traumas, 283 (31%) had interpersonal traumas, 99 (11%) had PTSD, and 91 (10%) could not be classified. We observed statistically significant differences between groups in pain area and widespreadness, as well as maximal pain, sleep impairment, disability, stress, anxiety, depression, and somatization. The severity of symptoms increased with trauma severity.

CONCLUSIONS

Traumatic life events and PTSD are frequent in chronic pain patients. The increased pain area and widespreadness, as well as the increased negative impact on co-occurring traits of sensory sensitivity (anxiety, depression, somatization), are compatible with central sensitization in comorbid patients. Therefore, a heightened awareness of the comorbidity between traumatic experiences and chronic pain is recommended.

Mapping the availability of translated versions of posttraumatic stress disorder screening questionnaires for adults: A scoping review

Background: The most used questionnaires for PTSD screening in adults were developed in English. Although many of these questionnaires were translated into other languages, the procedures used to translate them and to evaluate their reliability and validity have not been consistently documented. This comprehensive scoping review aimed to compile the currently available translated and evaluated questionnaires used for PTSD screening, and highlight important gaps in the literature.Objective: This review aimed to map the availability of translated and evaluated screening questionnaires for posttraumatic stress disorder (PTSD) for adults.Methods: All peer-reviewed studies in which a PTSD screening questionnaire for adults was translated, and which reported at least one result of a qualitative and /or quantitative evaluation procedure were included. The literature was searched using Embase, MEDLINE, and APA PsycInfo, citation searches and contributions from study team members. There were no restrictions regarding the target languages of the translations. Data on the translation procedure, the qualitative evaluation, the quantitative evaluation (dimensionality of the questionnaire, reliability, and performance), and open access were extracted.Results: A total of 866 studies were screened, of which 126 were included. Collectively, 128 translations of 12 different questionnaires were found. Out of these, 105 (83.3%) studies used a forward and backward translation procedure, 120 (95.2%) assessed the reliability of the translated questionnaire, 60 (47.6%) the dimensionality, 49 (38.9%) the performance, and 42 (33.3%) used qualitative evaluation procedures. Thirty-four questionnaires (27.0%) were either freely available or accessible on request.Conclusions: The analyses conducted and the description of the methods and results varied substantially, making a quality assessment impractical. Translations into languages spoken in middle- or low-income countries were underrepresented. In addition, only a small proportion of all translated questionnaires were available. Given the need for freely accessible translations, an online repository was developed.HIGHLIGHTS We mapped the availability of translated PTSD screening questionnaires.The quality of the translation and validation processes is very heterogenous.We created a repository for translated, validated PTSD screening questionnaires.

The "STOP Pain" Questionnaire: using the Plan-Do-Study-Act model to implement a patient-family preferences-informed questionnaire into a pediatric transitional pain clinic

BACKGROUND

Patient engagement is an important tool for quality improvement (QI) and optimizing the uptake of research findings. The Plan-Do-Study-Act (PDSA) model is a QI tool that encourages ongoing evaluation of clinical care, thus improving various aspects of patient care. Ascertaining pediatric patient priorities for a pain questionnaire in the post-acute, or transitional pain, setting is important to guide clinical care since active engagement with the population of interest can optimize uptake. We used the PDSA model to adapt a chronic pain questionnaire for the pediatric transitional pain setting to reflect pediatric patient and parent/guardian preferences and to form an example of how the PDSA model can be used to improve clinical care through patient engagement.

METHODS

This project employed the PDSA model to adapt the pediatric Ontario Chronic Pain Questionnaire for use in the pediatric Transitional Pain Service (pedTPS) setting. Plan: Following reviewing the Ontario Chronic Pain Questionnaire and literature on pain questionnaire development, goal-based questions, questions on pain location, relevant Patient-Reported Outcomes Measurement Information System (PROMIS^®) measures and the Pain Catastrophizing Scale, child (PCS-C) and parent (PCS-P), informed the questionnaire. Do: The questionnaire and a satisfaction survey were sent to patients and families through Research Electronic Data Capture (REDCap™).

STUDY

Results from the satisfaction survey were analyzed. Act: Using descriptive statistics employing ordinal mixed-models with random effects, ANOVA, and double-blinded qualitative thematic coding, questionnaire preferences were analyzed and the questionnaire was adapted accordingly before implementation into the (pedTPS).

RESULTS

Eighty-eight questionnaires and satisfaction surveys were analyzed from 69 respondents (32 patients; 37 parents/guardians). Sixty-six (75.00%) surveys indicated satisfaction with the questionnaire. A combined 77 (87.50%) "strongly agreed" (25/88) or "agreed" (52/88) that the questionnaire language was clear. The application of suggested changes to the questionnaire resulted in four versions across the project timeline, which reflected patient and parent/guardian preferences for questions that reflect the themes, "Story"; "Time-Optimal"; and "Pertinent" ("STOP"). There were no statistically significant differences in satisfaction across the versions due to sample size.

CONCLUSION

Most respondents were satisfied with the questionnaire and prefer "STOP" questions. Future studies will focus on testing the questionnaire for validity and reliability across pedTPS populations.

Prolonged exposure for pain and comorbid PTSD: a single-case experimental study of a treatment supplement to multiprofessional pain rehabilitation

OBJECTIVES

It is unclear how to address PTSD in the context of chronic pain management. Here we examine the potential benefits of an addition of prolonged exposure (PE) therapy for PTSD for adults attending multidisciplinary CBT for chronic pain.

METHODS

Four adults seeking treatment for chronic pain from a specialized pain rehabilitation service were offered PE for PTSD using a replicated, randomized, single-case experimental phase design, prior to commencing a 5-week multidisciplinary CBT program for chronic pain. Pre-, post-, follow-up, and daily measures allowed examination of PTSD and pain outcomes, potential mediators, and the trajectory of these outcomes and potential mediators during the subsequent pain-focused CBT program.

RESULTS

Visual inspection of the daily data demonstrated changes in all outcome variables and potential mediators during the PE phase. Changes came at different times and at different rates for the four participants, highlighting the individual nature of putative change mechanisms. Consistent with expectation, PE produced reliable change in the severity of PTSD symptoms and trauma-related beliefs for all four participants, either by the end of the PE phase or the PE follow-up, with these gains maintained by the end of the 5-week pain-focused CBT program. However, few reductions in pain intensity or pain interference were seen either during the PE phase or after.

CONCLUSIONS

Although "disorder specific" approaches have dominated the conceptualising, study, and treatment of conditions like PTSD and chronic pain, such approaches may not be optimal. It may be better instead to approach cases in an individual and process-focused fashion.

ETHICAL COMMITTEE NUMBER

2013/381.

Autism and chronic ill health: an observational study of symptoms and diagnoses of central sensitivity syndromes in autistic adults

BACKGROUND

Autistic adults, particularly women, are more likely to experience chronic ill health than the general population. Central sensitivity syndromes (CSS) are a group of related conditions that are thought to include an underlying sensitisation of the central nervous system; heightened sensory sensitivity is a common feature. Anecdotal evidence suggests autistic adults may be more prone to developing a CSS. This study aimed to investigate the occurrence of CSS diagnoses and symptoms in autistic adults, and to explore whether CSS symptoms were related to autistic traits, mental health, sensory sensitivity, or gender.

METHODS

The full sample of participants included 973 autistic adults (410 men, 563 women, mean age = 44.6) registered at the Netherlands Autism Register, who completed questionnaires assessing autistic traits, sensory sensitivity, CSS, physical and mental health symptoms. The reliability and validity of the Central Sensitization Inventory (CSI) in an autistic sample was established using exploratory and confirmatory factor analyses. Chi2 analyses, independent t-tests, hierarchical regression and path analysis were used to analyse relationships between CSS symptoms, autistic traits, measures of mental health and wellbeing, sensory sensitivity, age and gender.

RESULTS

21% of participants reported one or more CSS diagnosis, and 60% scored at or above the clinical cut-off for a CSS. Autistic women were more likely to report a CSS diagnosis and experienced more CSS symptoms than men. Sensory sensitivity, anxiety, age and gender were significant predictors of CSS symptoms, with sensory sensitivity and anxiety fully mediating the relationship between autistic traits and CSS symptoms.

LIMITATIONS

Although this study included a large sample of autistic adults, we did not have a control group or a CSS only group. We also could not include a non-binary group due to lack of statistical power.

CONCLUSIONS

CSS diagnoses and symptoms appear to be very common in the autistic population. Increased awareness of an association between autism and central sensitisation should inform clinicians and guide diagnostic practice, particularly for women where CSS are common and autism under recognised.

The association of probable PTSD at baseline and pain-related outcomes after chronic pain rehabilitation: A comparison of DSM-5 and ICD-11 criteria for PTSD

BACKGROUND

There is a high prevalence of posttraumatic stress disorder (PTSD) in patients with chronic pain. However, different patients are identified depending on the diagnostic system used. Moreover, it is unclear if the conceptualizations of PTSD are differently associated with outcomes of pain rehabilitation. Hence, the aims of the present study were first to explore the prevalence rates and diagnostic agreement of probable PTSD according to the ICD-11 and the DSM-5 screening tools (International Trauma Questionnaire [ITQ] vs. PTSD Checklist [PCL-5]), and secondly, to explore the associations of probable PTSD determined by ITQ and PCL-5 with psychological distress measures at baseline, and thirdly, the associations with pain and disability after pain rehabilitation adjusting for psychological covariates.

METHODS

A consecutive cohort of patients with chronic non-malignant pain (n = 152) referred to a Danish interdisciplinary pain center was assessed at baseline prior to their first visit and at follow-up three days after completed treatment.

RESULTS

The estimated probable PTSD baseline prevalence rates were 15.8% (ITQ) and 16.4% (PCL-5). However, the diagnostic agreement between the PCL-5 and the ITQ was only moderate (k = 0.64). Overall, compared to the ITQ probable PTSD according to the PCL-5 correlated more strongly with psychological distress. Only the ITQ was associated with poorer outcomes after rehabilitation, explaining alone 7-8% of the variance in disability and pain intensity adjusted for covariates.

CONCLUSIONS

The results underline the importance of taking the conceptualization and assessment of PTSD into consideration when investigating the impact of PTSD on pain rehabilitation.

SIGNIFICANCE

There is a high prevalence of probable PTSD in patients with chronic pain. However, different patients with probable PTSD are identified depending on the diagnostic system used. Although similar probable PTSD prevalence rates (about 16%) were found using DSM-5 and ICD-11 PTSD screening tools (PCL-5 and ITQ, respectively), the diagnostic agreement between the systems was only moderate (k = 0.64). At the same time, only probable PTSD estimated according to the ITQ and not the PCL-5 was a significant predictor of disability after pain rehabilitation.

Role of post-trauma stress symptoms in the development of chronic musculoskeletal pain and disability: a protocol for a systematic review

INTRODUCTION

Post-traumatic stress symptoms (PTSS), pain and disability frequently co-occur following traumatic injuries. Although the coexistence of these symptoms is common, the relation between these symptoms and the impact on longer-term outcome remains poorly understood. This systematic review aims to determine the role of PTSS on the development of chronic pain and/or pain-related disability following musculoskeletal trauma.

METHODS/ANALYSIS

This protocol is developed and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Protocol. The review will include studies that recruited individuals aged ≥16 years sustaining any traumatic event that resulted in one or more musculoskeletal injuries and where a recognised measure for the presence of PTSS symptoms, pain and disability using either validated questionnaires or symptom checklists was employed. The following citation databases MEDLINE, PsycINFO, EMBASE, CINAHL, ZETOC, Web of Science, PubMed and Google Scholar, as well as reference lists from key journals and grey literature, will be searched from inception to 31 November 2021. Two independent reviewers will search, screen studies, extract data and assess risk of bias. The relationship of PTSS, pain and pain-related disability by injury type and severity will be estimated with 95% CI. If possible, study results will be pooled into a meta-analysis. However, if heterogeneity between studies is high, data analyses will be presented descriptively. The overall quality of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation guidelines.

ETHICS AND DISSEMINATION

Ethical approval will not be required for this systematic review since only data from existing studies will be used. This review is expected to provide a better understanding of the factors associated with PTSS, pain and pain-related disability following musculoskeletal trauma, and help with the development of targeted therapeutic interventions. Results of this review will be disseminated in peer-reviewed publications and via national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42021285243.

Self-reported traumatic etiology of pain and psychological function in tertiary care pain clinic patients: a collaborative health outcomes information registry (CHOIR) study

Background and aims A sizable body of research has elucidated the significant role of psychological reactions to trauma on pain coping and outcomes. In order to best inform intervention development and clinical care for patients with both trauma and pain at the tertiary care level, greater clarity is needed regarding the magnitude of these effects and the specific pathways through which they may or may not function at the time of first presentation to such a treatment setting. To achieve this, the current study examined the cross-sectional relationships between traumatic etiology of pain, psychological distress (anger, depressive symptoms, and PTSD symptoms), and pain outcomes (pain catastrophizing, physical function, disability status). Methods Using a structural path modeling approach, analyses were conducted using a large sample of individuals with chronic pain (n = 637) seeking new medical evaluation at a tertiary pain management center, using the Collaborative Health Outcomes Information Registry (CHOIR). We hypothesized that the relationships between traumatic etiology of pain and poorer pain outcomes would be mediated by higher levels of psychological distress. Results Our analyses revealed modest relationships between self-reported traumatic etiology of pain and pain catastrophizing, physical function, and disability status. In comparison, there were stronger relationships between indices of psychological distress and pain catastrophizing, but a weaker pattern of associations between psychological distress and physical function and disability measures. Conclusions To the relatively small extent that self-reported traumatic etiology of pain correlates with pain-related outcomes, these relationships appear to be due primarily to the presence of psychiatric symptoms and manifest most notably in the context of psychological responses to pain (i.e. catastrophizing about pain). Implications Findings from this study highlight the need for early intervention for patients with traumatic onset of pain and for clinicians at tertiary pain centers to include more detailed assessments of psychological distress and trauma as a component of comprehensive chronic pain treatment.

There's Nothing Broken. You've Had a Whiplash, That's It: A Qualitative Study of Comorbid Posttraumatic Stress Disorder and Whiplash Associated Disorders

BACKGROUND

Posttraumatic stress disorder (PTSD) symptoms are common in chronic Whiplash associated disorders (WAD) and have been found to be associated with higher levels of pain and disability. Theoretical frameworks have suggested that PTSD and pain not only coexist, but also mutually maintain one another. Although the comorbidity has been subject to increasing quantitative research, patients' experiences of the comorbidity and symptom interaction remain largely uninvestigated using qualitative methods.

OBJECTIVE

The present study set out to explore the potential relationship of PTSD and pain in people with WAD and properly assessed PTSD after motor vehicle accidents.

METHODS

A qualitative explorative study of eight individual face-to-face semistructured interviews were conducted. Interviews were recorded and transcribed verbatim and analyzed using framework analysis.

RESULTS

Through the analysis, we developed three overarching themes. The first theme illustrated the complex and burdensome comorbidity with overlapping and transdiagnostic symptoms, whereas the second theme highlighted how several circumstances, some related to the health care system, could extend and amplify the traumatic response. The final theme illustrated symptom associations and interactions, particularly between pain and PTSD, both supporting and rejecting parts of the mutual maintenance framework.

CONCLUSIONS

These findings underlined the great complexity and variability of the comorbidity and the traumatic event, but also emphasized how experiences of psyche and soma seem closely connected in these patients. The results provide support for the importance of thorough assessment by multidisciplinary teams, minimizing distress post-injury, and a critical approach to the idea of mutual maintenance between pain and PTSD.

Disturbed Sleep Connects Symptoms of Posttraumatic Stress Disorder and Somatization: A Network Analysis Approach

Posttraumatic stress disorder (PTSD) and physical health problems, particularly somatic symptom disorder, are highly comorbid. Studies have only examined this co-occurrence at the disorder level rather than assessing the associations between specific symptoms. Using network analysis to identify symptoms that act as bridges between these disorders may allow for the development of interventions to specifically target this comorbidity. We examined the association between somatization and PTSD symptoms via network analysis. This included 349 trauma-exposed individuals recruited through the National Centre for Mental Health PTSD cohort who completed the Clinician-Administered PTSD Scale for DSM-5 and the Patient Health Questionnaire-15. A total of 215 (61.6%) individuals met the DSM-5 diagnostic criteria for PTSD. An exploratory graph analysis identified four clusters of densely connected symptoms within the overall network: PTSD, chronic pain, gastrointestinal issues, and more general somatic complaints. Sleep difficulties played a key role in bridging PTSD and somatic symptoms. Our network analysis demonstrates the distinct nature of PTSD and somatization symptoms, with this association connected by disturbed sleep.

Unwillingly traumatizing: is there a psycho-traumatologic pathway from general surgery to postoperative maladaptation?

BACKGROUND

Surgery may possibly be undermined by psychologic, psychiatric and psychosomatic problems, as long as these problems interfere with a patient's capacity to cope with surgery adaptively. Recent studies have shown that interpersonal trauma, e.g. abuse or neglect, and its correlates are involved in the adaptation to surgery. This observation is heuristically coherent, given the respective traumatization is an interpersonal event occurring in a relationship. Notably, surgery inevitably leads to the violation of physical boundaries within a doctor-patient relationship. Based on the principles of psycho-traumatologic thinking, such a constellation is deemed qualified to activate posttraumatic symptoms in the traumatized.

METHOD

The present topical review summarizes the respective findings which point to a subgroup of patients undergoing surgery, in whom difficulty bearing tension and confiding in others may cause adaptive problems relevant to surgery. Although this theorizing is empirically substantiated primarily with respect to total knee arthroplasty (TKA), a pubmed-research reveals psychopathologic distress to occur prior to surgery beyond TKA. Likewise, posttraumatic distress occurs in large numbers in the context of several operations, including cardiac, cancer and hernia surgery.

CONCLUSION

Aspects of psychological trauma may be linked to the outcomes of general surgery, as well, e.g. biliary, hernia or appendix surgery. The mechanisms possibly involved in this process are outlined in terms of a hierarchical organization of specific anxiety and negative affect as well as in terms of psychodynamics which imply the unconscious action of psychologic defenses at their core.

IMPLICATIONS

Not least, we encourage the screening for trauma and its correlates including defenses prior to general surgery in order to identify surgical candidates at risk of, e.g. chronic postoperative pain, before the operation.

Trauma Exposure and Problem Drinking in Late Adolescence: A Latent Profile Analysis

Exposure to early traumatic events has been implicated in problem drinking during late adolescence, and this association may be stronger among youth with emotion regulation deficits. The purpose of this study was to identify subgroups of late adolescents based on trauma type, including loss, posttraumatic stress disorder (PTSD) symptoms; and emotion regulation deficits that confer the risk for problematic drinking behaviors. A sample of 946 participants (M age = 18.84 years, SD = 1.06) was analyzed with mixed-indicator latent profile analysis to identify subgroups and explore whether these subgroups displayed significant differences regarding elevated drinking frequency, alcohol quantity, and problematic alcohol use. A four-profile model yielded the best fit to the data, and four groups were identified and labeled "high functioning" (29.4%), "loss regulated" (32.3%), "loss dysregulated" (28.1%), and "multiple trauma dysregulated" (10.1%). Individuals in the high functioning group reported the lowest rates on all three measures of alcohol misuse (14.6-24.9%), whereas those in the multiple trauma dysregulated group reported the highest rates on all three measures (31.6-71.5%). Individuals in the multiple trauma dysregulated group (M = 0.25) differed significantly from those in the other three groups (Ms = 0.42-0.72) on the measure of problematic alcohol use but scored similarly to those in the loss dysregulated group on measures of drinking frequency (M = 0.32 and 0.24, respectively) and quantity (M = 0.43 and 0.39, respectively). These findings have implications for prevention programs targeted for alcohol use disorders among older adolescents.

Neurophysiological relationship of neuromuscular fatigue and stress disorder in PTSD patients

INTRODUCTION

Apart from mental disorders, other complications that have been reported in some patients with Post-Traumatic Stress Disorder (PTSD), include physical pain and being quick to fatigue, which can severely affect the patients' daily life. Therefore, this study aims to evaluate the relationship between PTSD and physical fatigue in people with PTSD.

METHOD

18 military men with (n = 9) and without PTSD (n = 9), with an age range of 45-60 years, volunteered to participate. They were randomly assigned into two groups: PTSD and non-PTSD groups. Recording of the surface electromyography (EMG) in a specific muscle was conducted twice in both groups, once at baseline and then again after a single session of fatiguing exercise. Data were analyzed by ANOVA with repeated measure (2✕2) at the significance level of 0.05.

RESULTS

Results showed that there was a significant main effect of intervention on electrical activity and neural conduction variables in the PTSD group (p = 0.04, p = 0.02). There was also an effect of time for the both variables (P < 0.001).

CONCLUSION

Stress disorders may affect the time to fatigue in PTSD patients and subsequently cause some difficulties in their daily life.

Comparing MMPI-2-Restructured Form Scores by Service Era for Veterans Assessed Within the Veteran Affairs Healthcare System

This study compares profiles of Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) scale scores from 1492 VA test-takers who served during the Vietnam or Gulf War service eras. The sample includes all such cases collected at any VA posttraumatic stress disorder Clinical Teams across the United States between January 1, 2008 and May 31, 2015 using the MMPI-2 or MMPI-2-RF (via the VA Mental Health Assistant suite). Associations between gender and score differences were also examined. In contrast to past research using the MMPI-2, results of this study suggest that veterans are generally homogeneous in their MMPI-2-RF profiles across different periods of service. Specifically, the magnitudes of mean differences are small and not clinically significant. Thus, responses on the MMPI-2-RF do not appear influenced by service era. Implications for the clinical use of, and research with, the MMPI-2-RF are discussed within the VA healthcare system.

Pain and Evil: From Local Nociception to Misery Following Social Harm

Experiencing pain, especially when chronic, is an excruciating condition that should be regarded as a syndrome, if not a disease. People suffering from chronic pain tend to develop psychological discomfort mostly due to lack of acceptance, disbelief, blame. The complexity of pain pathophysiology, plus a wide range of negative psychosocial factors, leads to a more complex suffering that deserves attention and multidisciplinary treatments. The possibility that chronic pain may occur following physical aggression, torture, or persecution raises the issue of evil as a major contributor to pain in its worst representation - when individuals or groups are attacked based on racial, social, gender, religious, political, or other grounds. To explore the complex issue of chronic pain following physical or psychological harm, and to underscore the need for a multidisciplinary approach to reduce the burden of chronic pain, we discuss the biological mechanisms underlying pain state. We seek to clarify those factors leading to pain chronification, as well as personal and social attitudes that confound patients with chronic pain. The importance of family and social environment is also investigated, as well as personality traits of chronic pain patients that may further hamper successful treatment. The presence of chronic pain, modulated by, for example, acceptance of being a victim of premeditated physical and social violence, makes the issue more difficult to comprehend.

Prevalence of Posttraumatic Stress Symptoms and Associated Characteristics Among Patients With Chronic Pain Conditions in a Norwegian University Hospital Outpatient Pain Clinic

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.

Anxiety sensitivity and opioid misuse and dependence among trauma-exposed adults with chronic pain

It is unclear if anxiety sensitivity may serve as mechanism underlying the relation between posttraumatic stress symptom severity and opioid misuse and dependence among trauma-exposed persons with chronic pain. Therefore, the current study evaluated the explanatory role of anxiety sensitivity in the relations between posttraumatic stress symptom severity and opioid misuse and dependence. Participants included 294 trauma-exposed adults with chronic pain (71.4% female, M_age = 37.79 years, SD = 10.85, M_{pain rating} = 7.32/10) that reported current moderate to severe chronic pain and prescription opioid use. Participants were recruited via an online national survey in the United States of America. There were statistically significant indirect effects of posttraumatic stress symptom severity via anxiety sensitivity in relation to opioid misuse and dependence. The indirect effects of the reverse models for opioid misuse and dependence also were significant and suggest the potential for bi-directional relations; however, the magnitude of the effect was smaller in the tests of specificity than in the original models. The present findings provide initial empirical evidence that greater posttraumatic stress symptom severity is related to anxiety sensitivity, which in turn, is associated with increased opioid misuse and dependence among trauma-exposed individuals with chronic pain.

Treatment outcomes in group-based cognitive behavioural therapy for chronic pain: An examination of PTSD symptoms

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.

Disrupted Rhythmicity and Vegetative Functions Relate to PTSD and Gender in Earthquake Survivors

Background: Increasing evidence indicates that survivors to traumatic events may show disruption of sleep pattern, eating and sexual behaviors, and somatic symptoms suggestive of alterations of biorhythmicity and vegetative functions. Therefore, the aim of this study was to investigate these possible alterations in a sample of survivors in the aftermath of earthquake exposure, with particular attention to gender differences and impact of post-traumatic stress disorder (PTSD). Methods: High school senior students, who had been exposed to the 2009 L'Aquila earthquake, were enrolled 21 months after the traumatic event and evaluated by the Trauma and Loss Spectrum Self-Report to investigate PTSD rates and by a domain of the Mood Spectrum Self-Report-Lifetime Version (MOODS-SR), to explore alterations in circadian/seasonal rhythms and vegetative functions. Results: The rates of endorsement of MOODS-SR rhythmicity and vegetative functions domain and subdomain scores were significantly higher in survivors with PTSD with respect to those without it. Among all earthquake survivors, women reported higher scores than men on the rhythmicity and vegetative functions domain and subdomain scores, except for the rhythmicity and sexual functions ones. Female survivors without PTSD showed significantly higher scores than men in the rhythmicity and vegetative functions total scores and the sleep and weight and appetite subdomains. Potentially traumatic events burden predicted rhythmicity and vegetative functions impairment, with a moderation effect of re-experiencing symptoms. Conclusions: We report impairments in rhythmicity, sleep, eating, and sexual and somatic health in survivors to a massive earthquake, particularly among subjects with PTSD and higher re-experiencing symptoms, with specific gender-related differences. Evaluating symptoms of impaired rhythmicity and vegetative functions seems essential for a more accurate assessment and clinical management of survivors to a mass trauma.

The Impact of Psychological Interventions on Posttraumatic Stress Disorder and Pain Symptoms: A Systematic Review and Meta-Analysis

OBJECTIVES

Posttraumatic stress disorder (PTSD) and pain often co-occur, introducing clinical challenges and economic burden. Psychological treatments are considered effective for each condition, yet it is not known which therapies have the potential to concurrently address PTSD and pain-related symptoms.

MATERIALS AND METHODS

To conduct a systematic review and meta-analysis, databases were searched for articles published between January 2007 and December 2017 describing results from clinical trials of interventions addressing PTSD and pain-related symptoms in adults. Two independent reviewers finalized data extraction and risk of bias assessments. A random-effects model was used for meta-analysis and to calculate pooled and subgroup effect sizes (ESs) of psychological-only (single modality) and multimodal interventions.

RESULTS

Eighteen trials (7 uncontrolled, 11 randomized controlled trials, RCTs), totaling 1583 participants, were included in the systematic review. RCT intervention types included exposure-based, cognitive-behavioral, and mindfulness-based therapies. Data from 10 RCTs (N=1, 35) were available for meta-analysis, which demonstrated moderate effect for reduced PTSD severity (ES=-0.55, confidence interval [CI]: -0.83, -0.26) and nonsignificant effect for pain intensity (ES=-0.14, CI: -0.43, 0.15) and pain interference (ES=-0.07, CI: -0.35, 0.20) outcomes. Findings from uncontrolled trials supported meta-analytic results from RCTs. Using GRADE assessment, the quality of evidence was deemed as moderate for RCTs and low for non-RCTs.

DISCUSSION

Findings indicated that the majority of the interventions appeared to have a greater impact on reducing PTSD rather than pain-related symptoms. There remains a need to further develop interventions that consistently impact PTSD and pain-related outcomes when these 2 conditions co-occur.

Mutual maintenance of PTSD and physical symptoms for Veterans returning from deployment

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.

Do post-traumatic pain and post-traumatic stress symptomatology mutually maintain each other? A systematic review of cross-lagged studies

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.

The behavioural inhibition system, behavioural activation system and experiential avoidance as explanatory variables of comorbid chronic pain and posttraumatic stress symptoms

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.

Intramuscular fat is present in cervical multifidus but not soleus in patients with chronic whiplash associated disorders

The presence of intramuscular fat (IMF) in the cervical spine muscles of patients with whiplash associated disorders (WAD) has been consistently found. The mechanisms underlying IMF are not clear but preliminary evidence implicates a relationship with stress system responses. We hypothesised that if systemic stress system responses do play a role then IMF would be present in muscles remote to the cervical spine. We aimed to investigate if IMF are present in muscle tissue remote (soleus) to the cervical spine in people with chronic WAD. A secondary aim was to investigate associations between IMF and posttraumatic stress symptom levels. Forty-three people with chronic WAD (25 female) and 16 asymptomatic control participants (11 female) participated. Measures of pain, disability and posttraumatic stress symptoms were collected from the WAD participants. Both groups underwent MRI measures of IMF in cervical multifidus and the right soleus muscle. There was significantly greater IMF in cervical multifidus in patients with WAD and moderate/severe disability compared to controls (p = 0.009). There was no difference in multifidus IMF between the mild and moderate/severe disability WAD groups (p = 0.64), or the control and mild WAD groups (p = 0.21). IMF in the right soleus was not different between the groups (p = 0.47). In the WAD group, we found no correlation between PDS symptoms and cervical multifidus IMF or between PDS symptoms and soleus IMF. Global differences in IMF are not a feature of chronic WAD, with differences in IMF limited to the cervical spine musculature. While the mechanisms for the development of IMF in the cervical spine following whiplash injury remain unclear, our data indicate that local factors more likely contribute to these differences.

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.