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Son E, Gaither R, Lobo J, Zhao Y, McKibben LA, Arora R, Albertorio-Sáez L, Mickelson J, Wanstrath BJ, Bhatia S, Stevens JS, Jovanovic T, Koenen K, Kessler R, Ressler K, Beaudoin FL, McLean SA, Linnstaedt SD. Further evidence that peritraumatic 17β-estradiol levels influence chronic posttraumatic pain outcomes in women, data from both humans and animals. Pain 2024:00006396-990000000-00704. [PMID: 39287098 DOI: 10.1097/j.pain.0000000000003408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 08/14/2024] [Indexed: 09/19/2024]
Abstract
ABSTRACT Chronic posttraumatic pain (CPTP) is common after traumatic stress exposure (TSE) and disproportionately burdens women. We previously showed across 3 independent longitudinal cohort studies that, in women, increased peritraumatic 17β-estradiol (E2) levels were associated with substantially lower CPTP over 1 year. Here, we assessed this relationship in a fourth longitudinal cohort and also assessed the relationship between E2 and CPTP at additional time points post-TSE. Furthermore, we used a well-validated animal model of TSE to determine whether exogenous E2 administration protects against mechanical hypersensitivity. Using nested samples and data from the Advancing Understanding of RecOvery afteR traumA study (n = 543 samples, 389 participants), an emergency department-based prospective study of TSE survivors, we assessed the relationship between circulating E2 levels and CPTP in women and men using multivariate repeated-measures mixed modeling. Male and ovariectomized female Sprague Dawley rats were exposed to TSE and administered E2 either immediately after or 3 days post-TSE. Consistent with previous results, we observed an inverse relationship between peritraumatic E2 and longitudinal CPTP in women only (β = -0.137, P = 0.033). In animals, E2 protected against mechanical hypersensitivity in female ovariectomized rats only if administered immediately post-TSE. In conclusion, peritraumatic E2 levels, but not those at post-TSE time points, predict CPTP in women TSE survivors. Administration of E2 immediately post TSE protects against mechanical hypersensitivity in female rats. Together with previous findings, these data indicate that increased peritraumatic E2 levels in women have protective effects against CPTP development and suggest that immediate post-TSE E2 administration in women could be a promising therapeutic strategy for reducing risk of CPTP.
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Affiliation(s)
- Esther Son
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, United States
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States
| | - Rachel Gaither
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, United States
| | - Jarred Lobo
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, United States
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States
| | - Ying Zhao
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, United States
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States
| | - Lauren A McKibben
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, United States
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States
| | - Rhea Arora
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, United States
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States
| | - Liz Albertorio-Sáez
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, United States
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States
| | - Jacqueline Mickelson
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, United States
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States
| | - Britannia J Wanstrath
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, United States
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States
| | - Simran Bhatia
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, United States
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States
| | - Jennifer S Stevens
- Department of Psychiatry, Emory University School of Medicine, Atlanta, GA, United States
| | - Tanja Jovanovic
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, MI, United States
| | - Karestan Koenen
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, United States
| | - Ronald Kessler
- Department of Healthcare Policy, Harvard Medical School, Boston, MA, United States
| | - Kerry Ressler
- Department of Psychiatry at McLean Hospital, Harvard Medical School, Boston, MA, United States
| | - Francesca L Beaudoin
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, United States
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States
| | - Samuel A McLean
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC, United States
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC, United States
| | - Sarah D Linnstaedt
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, United States
- Institute for Trauma Recovery, University of North Carolina, Chapel Hill, NC, United States
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Hudock NL, Kshir SA, Taylor KF. Post-traumatic Stress Disorder as an Independent Risk Factor for Increased Opioid Use Following Carpal Tunnel Surgery. Hand (N Y) 2024; 19:1012-1018. [PMID: 36959761 PMCID: PMC11342694 DOI: 10.1177/15589447231160207] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND Carpal tunnel release (CTR) is one of the most common hand surgeries. Studies have highlighted a mental-physical connection to hand pathologies and psychological connections to postoperative pain burden. Post-traumatic stress disorder (PTSD) has been identified as a medical-psychological comorbidity like other mental health disorders such as generalized anxiety disorder (GAD). There remains a gap in the literature regarding PTSD as a comorbidity for hand surgeries, where there is this mental-physical connection. We hypothesize PTSD will be associated with increased risk of postoperative pain, evidenced by greater prevalence of opioid usage. METHODS The authors performed a retrospective analysis using the TriNetX Research Database. Patients who underwent elective CTR were identified within the database. Two groups were created and compared against individual controls: the first was identified based on the diagnosis of PTSD, and the second was identified based on the diagnosis of GAD. Cohorts were matched and opioid usage was compared postoperatively. RESULTS Patients with PTSD who underwent CTR were found to be at significantly increased risk of postoperative opioid use (P = .033) and more likely to present to the emergency department (ED) (P = .001). Patients with GAD were found to be significantly less likely to require postoperative opioids (P = .040). CONCLUSIONS We found patients with PTSD to be at increased risk of opioid use and more likely to present to ED following CTR. Patients with GAD were found to be at decreased risk of opioid use after CTR. Owing to the independent significant risks not found in GAD, further research of postoperative pain in patients with PTSD is needed.
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Affiliation(s)
- Nicholas L. Hudock
- Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
- Penn State College of Medicine, Hershey, PA, USA
| | - Sean A. Kshir
- Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
- Penn State College of Medicine, Hershey, PA, USA
| | - Kenneth F. Taylor
- Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
- Penn State College of Medicine, Hershey, PA, USA
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Yarns BC, Jackson NJ, Alas A, Melrose RJ, Lumley MA, Sultzer DL. Emotional Awareness and Expression Therapy vs Cognitive Behavioral Therapy for Chronic Pain in Older Veterans: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2415842. [PMID: 38869899 PMCID: PMC11177167 DOI: 10.1001/jamanetworkopen.2024.15842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/09/2024] [Indexed: 06/14/2024] Open
Abstract
Importance Chronic pain is common and disabling in older adults, and psychological interventions are indicated. However, the gold standard approach, cognitive-behavioral therapy (CBT), produces only modest benefits, and more powerful options are needed. Objectives To evaluate whether emotional awareness and expression therapy (EAET) is superior to CBT for treatment of chronic pain among predominantly male older veterans and whether higher baseline depression, anxiety, or posttraumatic stress disorder (PTSD) symptoms-key targets of EAET-moderate treatment response. Design, Setting, and Participants This 2-arm randomized clinical trial was conducted from May 16, 2019, to September 14, 2023, in the US Department of Veterans Affairs Greater Los Angeles Healthcare System. The trial included a racially and ethnically diverse group of veterans aged 60 to 95 years with at least 3 months of musculoskeletal pain. Interventions Emotional awareness and expression therapy or CBT, conducted concurrently, each presented as one 90-minute individual session followed by eight 90-minute group sessions. Main Outcomes and Measures The primary outcome was Brief Pain Inventory pain severity (range, 0 to 10) from baseline to posttreatment (week 10, primary end point) and 6-month follow-up. Secondary outcomes included Patient Reported Outcomes Institute Measurement System Anxiety, Depression, Fatigue, General Life Satisfaction (NIH Toolbox), Pain Interference, and Sleep Disturbance Short Forms, Patient Global Impression of Change (PGIC), and Satisfaction with Therapy and Therapist Scale-Revised. A subset of participants completed the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). All analyses were for the intention-to-treat population and included all randomized participants. Results Among 126 randomized participants (66 in the EAET group and 60 in the CBT group; mean [SD] age, 71.9 [5.9] years; 116 [92%] male), 111 (88%) completed posttreatment, and 104 (82%) completed the 6-month follow-up. The EAET was superior to CBT for the primary outcome of reduction in pain severity at posttreatment (estimate, -1.59 [95% CI, -2.35 to -0.83]; P < .001) and follow-up (estimate, -1.01 [95% CI, -1.78 to -0.24]; P = .01). A greater percentage of participants in EAET vs CBT had clinically significant (at least 30%) pain reduction (63% vs 17%; odds ratio, 21.54 [95% CI, 4.66-99.56]; P < .001) at posttreatment. In addition, EAET was superior to CBT on 50% pain reduction (35% vs 7%; odds ratio, 11.77 [95% CI, 2.38-58.25]; P = .002), anxiety (estimate, -2.49 [95% CI, -4.30 to -0.68]; P = .006), depression (estimate, -3.06 [95% CI, -5.88 to -0.25]; P = .03), general life satisfaction (estimate, 1.23 [95% CI, 0.36-2.10]; P = .005), PTSD symptoms (estimate, -4.39 [95% CI, -8.44 to -0.34]; P = .03), PGIC score (estimate, 1.46 [95% CI, 0.77-2.15]; P < .001), and global treatment satisfaction (estimate, 0.28 [95% CI, 0.12-0.45]; P < .001) at posttreatment. Higher baseline depression (estimate, -1.55 [95% CI, -0.37 to 2.73]; P < .001), anxiety (estimate, -1.53 [95% CI, -2.19 to -0.88]; P < .001), and PTSD symptoms (estimate, -1.69 [95% CI, -2.96 to -0.42]; P = .009) moderated greater reduction in pain severity after EAET but not CBT. Conclusions and Relevance The results of this randomized clinical trial suggest that EAET may be a preferred intervention for medically and psychiatrically complex patients with pain. The societal burden of chronic pain could be improved by further incorporating the principles of EAET into mainstream clinical pain medicine. Trial Registration ClinicalTrials.gov Identifier: NCT03918642.
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Affiliation(s)
- Brandon C. Yarns
- Department of Mental Health, VA Greater Los Angeles Healthcare System, California
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles
| | - Nicholas J. Jackson
- Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Alexander Alas
- Department of Mental Health, VA Greater Los Angeles Healthcare System, California
| | - Rebecca J. Melrose
- Department of Mental Health, VA Greater Los Angeles Healthcare System, California
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles
| | - Mark A. Lumley
- Department of Psychology, Wayne State University, Detroit, Michigan
| | - David L. Sultzer
- Department of Mental Health, VA Greater Los Angeles Healthcare System, California
- Department of Psychiatry and Human Behavior, University of California, Irvine School of Medicine, Irvine
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Zimmer Z, Akbulut-Yuksel M, Young Y, Toan TK. The long-term association between exposure to wartime bombing earlier in life and post-traumatic stress later in life among today's older Vietnamese population. Acta Psychol (Amst) 2024; 246:104293. [PMID: 38670044 DOI: 10.1016/j.actpsy.2024.104293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 04/17/2024] [Accepted: 04/23/2024] [Indexed: 04/28/2024] Open
Abstract
This analysis examines the relationship between exposure to American wartime bombardments earlier in life and later-life PTSD among current surviving Vietnamese aged 59+. It also assesses whether the relationship varies by military status during the war - formal military, informal military, or civilian - and whether associations are explained by exposure to violence and malevolent conditions. Data link survey responses from the 2018 Vietnam Health and Aging Study to provincial-wide level bombing intensity using U.S. Department of Defense records from the Theater History of Operations Vietnam database. PTSD measured using nine items from the PTSD Checklist. Analyses employ multivariate logistic quantile regression. Findings examined for a sample of 2290 Vietnamese survivors and a subsample of 736 Vietnamese that moved at least once during wartime. Results show a robust and significant positive association between province-wide bombing intensity and later-life PTSD scores. Interaction effects indicate civilians have overall lower levels of PTSD than those that were in the formal or informal military, but the association between bombing and PTSD is stronger among civilians. Much of the association is a function of exposure to violence and less is a function of exposure to malevolent conditions. Findings confirm earlier studies that have shown severe deleterious impacts of war trauma, and arial bombardments particularly, on long-term psychological health, while extending extant literature to civilian populations living in Vietnam during intense aerial bombing episodes.
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Affiliation(s)
| | | | - Yvette Young
- Max-Planck Institute for Demographic Research, Rostock, Germany.
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5
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Emrich M, Gnall KE, Garnsey CL, George JR, Park CL, Mazure CM, Hoff RA. Associations of Posttraumatic Stress Disorder Symptom Clusters and Pain Interference in Post-9/11 Veterans: Exploring Sleep Impairment and Physical Activity as Underlying Mechanisms. Int J Behav Med 2024:10.1007/s12529-024-10268-4. [PMID: 38438749 DOI: 10.1007/s12529-024-10268-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) symptoms and pain are highly prevalent and comorbid, particularly in veterans, but mechanisms explaining their linkage remain unclear. The aims of this study were to determine: (1) whether sleep impairment and physical activity (PA) mediate relations between PTSD symptoms and pain interference (assessed both longitudinally and as residual change) and (2) the unique roles of each PTSD symptom cluster in those relationships. METHODS The present study is a secondary analysis of a longitudinal observational investigation of 673 post-9/11 veterans (45.8% women). Surveys were administered at baseline and 3-month and 6-month follow-ups. RESULTS PTSD symptoms were significantly associated with pain interference longitudinally and worsening pain interference over time. Sleep impairment, but not PA, significantly mediated the relationship between PTSD symptoms and subsequent pain interference. Hyperarousal symptoms were found to be the primary driver of the relationship between PTSD symptoms and pain interference and re-experiencing symptoms were associated with change in pain interference via sleep impairment. Men and women did not differ on any of the study variables with the exception of PA. CONCLUSION Findings underscore the importance of targeting sleep as a key modifiable health factor linking PTSD symptoms to pain interference in post-9/11 veterans.
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Affiliation(s)
- Mariel Emrich
- Department of Psychological Sciences, University of Connecticut, Storrs, CT, 06269-1020, USA.
| | - Katherine E Gnall
- Department of Psychological Sciences, University of Connecticut, Storrs, CT, 06269-1020, USA
| | - Camille L Garnsey
- Department of Psychological Sciences, University of Connecticut, Storrs, CT, 06269-1020, USA
| | - Jamilah R George
- Department of Psychological Sciences, University of Connecticut, Storrs, CT, 06269-1020, USA
| | - Crystal L Park
- Department of Psychological Sciences, University of Connecticut, Storrs, CT, 06269-1020, USA
| | - Carolyn M Mazure
- Department of Psychiatry, Women's Health Research at Yale, Yale University School of Medicine, New Haven, CT, USA
| | - Rani A Hoff
- Northeast Program Evaluation Center (NEPEC), VA Connecticut Healthcare System, West Haven, CT, USA
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6
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Kazlou A, Bornukova K, Wickham A, Slaykovskiy V, Peven K, Klepchukova A, Ponzo S, Garfinkel S. Effects of stress on pain in females using a mobile health app in the Russia-Ukraine conflict. NPJ MENTAL HEALTH RESEARCH 2024; 3:2. [PMID: 38609485 PMCID: PMC10956037 DOI: 10.1038/s44184-023-00043-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 10/27/2023] [Indexed: 04/14/2024]
Abstract
The chronic and acute effects of stress can have divergent effects on health; long-term effects are associated with detrimental physical and mental health sequelae, while acute effects may be advantageous in the short-term. Stress-induced analgesia, the attenuation of pain perception due to stress, is a well-known phenomenon that has yet to be systematically investigated under ecological conditions. Using Flo, a women's health and wellbeing app and menstrual cycle tracker, with a world-wide monthly active usership of more than 57 million, women in Ukraine were monitored for their reporting of stress, pain and affective symptoms before, and immediately after, the onset of the Russian-Ukrainian conflict. To avoid potential selection (attrition) or collider bias, we rely on a sample of 87,315 users who were actively logging multiple symptoms before and after the start of the war. We found an inverse relationship between stress and pain, whereby higher reports of stress predicted lower rates of pain. Stress did not influence any other physiological symptoms with a similar magnitude, nor did any other symptom have a similar effect on pain. This relationship generally decreased in magnitude in countries neighbouring and surrounding Ukraine, with Ukraine serving as the epicentre. These findings help characterise the relationship between stress and health in a real-world setting.
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Affiliation(s)
| | - Kateryna Bornukova
- BEROC Economic Research Center, Minsk, Belarus
- Universidad Carlos III de Madrid, Department of Economics, Madrid, Spain
| | | | | | | | | | - Sonia Ponzo
- Flo Health UK Limited, London, United Kingdom
- University College London, Institute of Health Informatics, London, United Kingdom
| | - Sarah Garfinkel
- University College London, Institute of Cognitive Neuroscience, London, United Kingdom
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Yarns BC, Molaie AM, Lumley MA, Zhu TA, Jazi AN, Ganz DA, Melrose RJ. Video telehealth emotional awareness and expression therapy for older U.S. military veterans with chronic pain: A pilot study. Clin Gerontol 2024; 47:136-148. [PMID: 36541672 DOI: 10.1080/07317115.2022.2159909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Emotional Awareness and Expression Therapy (EAET) targets trauma and emotional conflict to reduce or eliminate chronic pain, but video telehealth administration is untested. This uncontrolled pilot assessed acceptability, feasibility, and preliminary efficacy of group-based video telehealth EAET (vEAET) for older veterans with chronic musculoskeletal pain. METHODS Twenty veterans were screened, and 16 initiated vEAET, delivered as one 60-minute individual session and eight 90-minute group sessions. Veterans completed posttreatment satisfaction ratings and pain severity (primary outcome), pain interference, anxiety, depression, functioning, social connectedness, shame, and anger questionnaires at baseline, posttreatment, and 2-month follow-up. RESULTS Satisfaction was high, and veterans attended 7.4 (SD = 0.6) of 8 group sessions; none discontinued treatment. Veterans attained significant, large reductions in pain severity from baseline to posttreatment (p < .001, Hedges' g = -1.54) and follow-up (p < .001, g = -1.20); 14 of 16 achieved clinically significant (≥ 30%) pain reduction, and 3 achieved 90-100% pain reduction. Secondary outcomes demonstrated significant, medium-to-large improvements. CONCLUSIONS In this small sample, vEAET produced better attendance, similar benefits, and fewer dropouts than in-person EAET in prior studies. Larger, controlled trials are needed. CLINICAL IMPLICATIONS Group vEAET appears feasible and highly effective for older veterans with chronic pain.
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Affiliation(s)
- Brandon C Yarns
- Department of Psychiatry/Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Ali M Molaie
- Department of Psychiatry/Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Mark A Lumley
- Department of Psychology, Wayne State University, Detroit, Michigan, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Tongtong A Zhu
- Department of Psychiatry/Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Ali Najafian Jazi
- Department of Psychiatry/Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - David A Ganz
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Psychology, Wayne State University, Detroit, Michigan, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Geriatric Research, Education, and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Rebecca J Melrose
- Department of Psychiatry/Mental Health, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles (UCLA), Los Angeles, California, USA
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Pratt AA, Hadlandsmyth K, Mengeling MA, Thomas EBK, Miell K, Norman SB, Lund BC. The Impact of Comorbid Chronic Pain on Pharmacotherapy for Veterans with Post-Traumatic Stress Disorder. J Clin Med 2023; 12:4763. [PMID: 37510878 PMCID: PMC10380889 DOI: 10.3390/jcm12144763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/22/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
OBJECTIVE Chronic pain can worsen PTSD symptomatology and may increase the risk of the prescription of multiple central nervous system (CNS)-active medications. The objective is to determine the impact of chronic pain on the number of CNS medications, including psychiatric medications, as well as the amount of medication changes. METHODS Veterans Affairs (VA) administrative data were used to identify VA-served Veterans with PTSD (N = 637,428) who had chronic pain (50.3%) and did not have chronic pain (49.7%) in 2020. The outcomes included the number of changes in psychiatric medications and the number of currently prescribed CNS-active mediations during a one-year observation period. RESULTS The number of changes in psychiatric medications was significantly higher for those with chronic pain (mean (M) = 1.8) versus those without chronic pain (M = 1.6) (Z = 38.4, p < 0.001). The mean number of concurrent CNS-active medications were significantly higher for those with chronic pain (M = 2.7) versus those without chronic pain (M = 2.0) (Z = 179.7, p < 0.001). These differences persisted after adjustment for confounding factors using negative binomial regression. CONCLUSIONS Veterans with comorbid chronic pain and PTSD are at increased risk for a higher number of medication changes and for receiving CNS-active polytherapy.
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Affiliation(s)
- Alessandra A Pratt
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, 601 Highway 6 West, Building 42, Iowa City, IA 52246, USA
| | - Katherine Hadlandsmyth
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, 601 Highway 6 West, Building 42, Iowa City, IA 52246, USA
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, 601 Highway 6 West, Iowa City, IA 52246, USA
- Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Michelle A Mengeling
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, 601 Highway 6 West, Building 42, Iowa City, IA 52246, USA
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, 601 Highway 6 West, Iowa City, IA 52246, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Emily B K Thomas
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, 601 Highway 6 West, Iowa City, IA 52246, USA
- Department of Psychological and Brain Sciences, University of Iowa College of Liberal Arts and Sciences, 340 Iowa Ave, Iowa City, IA 52246, USA
| | - Kelly Miell
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, 601 Highway 6 West, Building 42, Iowa City, IA 52246, USA
| | - Sonya B Norman
- National Center for PTSD, 215 North Main Street, White River Junction, VT 05009, USA
- Department of Psychiatry, University of California San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Brian C Lund
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, 601 Highway 6 West, Building 42, Iowa City, IA 52246, USA
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, 601 Highway 6 West, Iowa City, IA 52246, USA
- Department of Biostatistics, University of Iowa College of Public Health, 145 N Riverside Drive, Iowa City, IA 52242, USA
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Hunter LD, Boer T, Saltzman LY. The Intersectionality of Sex and Race in the Relationship Between Posttraumatic Stress Disorder and Cardiovascular Disease: A Scoping Review. Public Health Rev 2023; 44:1605302. [PMID: 37441026 PMCID: PMC10333493 DOI: 10.3389/phrs.2023.1605302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 06/07/2023] [Indexed: 07/15/2023] Open
Abstract
Objectives: Posttraumatic stress disorder (PTSD) has been linked with cardiovascular disease (CVD), suggesting a risk for negative health outcomes among individuals with PTSD. This review synthesizes the temporal relationship between PTSD and CVD and highlights the intersection of sex and race. Methods: Covidence was used to systematically review the literature published between 1980 and 2020. Results: 176 studies were extracted. 68 (38.64%) of the studies were a predominantly male sample. 31 studies (17.61%) were a predominantly female sample. Most reported participants of both sexes (n = 72; 40.91%) and only 5 (2.84%) did not report respondent sex. No studies reported transgender participants. 110 (62.5%) studies reported racial and ethnic diversity in their study population, 18 (10.22%) described a completely or predominantly white sample, and 48 (27.27%) did not report race or ethnicity of their study population. Conclusion: A compelling number of studies did not identify sex differences in the link between PTSD and CVD or failed to report race and ethnicity. Investigating sex, race, ethnicity, and the temporal relationship between PTSD and CVD are promising avenues for future research.
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Affiliation(s)
- Lauren D. Hunter
- Tulane Center for Aging and Department of Medicine, Tulane University, New Orleans, LA, United States
| | - Tara Boer
- Tulane School of Social Work, Tulane University, New Orleans, LA, United States
| | - Leia Y. Saltzman
- Tulane School of Social Work, Tulane University, New Orleans, LA, United States
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10
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Cypel YS, DePhilippis D, Davey VJ. Substance Use in U.S. Vietnam War Era Veterans and Nonveterans: Results from the Vietnam Era Health Retrospective Observational Study. Subst Use Misuse 2023; 58:858-870. [PMID: 37096682 DOI: 10.1080/10826084.2023.2188427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
Background: Substance use (SU) is associated with physical injury and mental health disorders in older persons, but recent research has scarcely examined SU in U.S. Vietnam-era veterans who are mostly in or near their eighth decade of life. Objectives: We compared the prevalence of self-reported lifetime and current SU and modeled current usage patterns in a nationally representative sample of veterans versus a matched nonveteran cohort. Methods: Cross-sectional, self-reported survey data were analyzed from the 2016-2017 Vietnam Era Health Retrospective Observational Study (VE-HEROeS) (n = 18,866 veterans, n = 4,530 nonveterans). We assessed lifetime and current alcohol and drug use disorders; lifetime and current use of cannabis, opioids, stimulants, sedatives, "other drugs" (psychedelics, prescription or over-the-counter drugs not prescribed/used as intended); and current SU patterns (alcohol-use-only, drug-use-only, dual-SU, no SU). Weighted descriptive, bivariable, and multivariable statistics were calculated. Covariates in multinomial modeling included sociodemographic characteristics, lifetime cigarette smoking, depression, potentially traumatic events (PTEs), and current pain (SF-8TM). Results: Prevalence of lifetime opioid and sedative use (p ≤ .01), drug and alcohol use disorders (p < .001), and current "other drug" use (p < .001) were higher in veterans versus nonveterans. Current use of alcohol and cannabis was high in both cohorts. In veterans, very severe/severe pain, depression, and PTEs were highly associated with drug-use-only (p < .001) and dual-SU (p < .01), but these associations were fewer for nonveterans. Conclusion: This research confirmed existing concerns over substance misuse in older individuals. Vietnam-era veterans may be at particular risk due to service-related experiences and later-life tribulations. Era veterans' unique perceptions toward healthcare assistance for SU may need greater provider focus to maximize self-efficacy and treatment.
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Affiliation(s)
- Yasmin S Cypel
- Epidemiology Program, Health Outcomes Military Exposures (HOME) (12POP5), Office of Patient Care Services, U.S. Department of Veterans Affairs, Washington, District of Columbia, USA
| | - D DePhilippis
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, District of Columbia, USA
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - V J Davey
- Office of Research & Development (14RD), U.S. Department of Veterans Affairs, Washington, District of Columbia, USA
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11
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Yarns BC, Zhu TA, Najafian Jazi A. Chronic Pain in Older Adults: A Neuroscience-Based Psychological Assessment and Treatment Approach. Am J Geriatr Psychiatry 2022; 30:1342-1350. [PMID: 35999127 DOI: 10.1016/j.jagp.2022.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 01/25/2023]
Abstract
Chronic pain remains a serious healthcare challenge, particularly for older adults who suffer substantial disability and are susceptible to serious risks from pain medications and invasive procedures. Psychotherapy is a promising option for older adults with chronic pain, since it does not contribute to medical or surgical risks. However, standard psychotherapies for chronic pain, including cognitive-behavioral therapy (CBT), acceptance and commitment therapy, and mindfulness-based interventions, produce only modest and time-limited benefits for older adults. In this article, we describe a novel, evidence-based psychological assessment and treatment approach for older adults with chronic pain, including a detailed case example. The approach begins with reviewing patients' pain, psychosocial, and medical histories to elicit evidence of a subtype of chronic pain called centralized (primary, nociplastic, or psychophysiologic) pain, which is highly influenced and may even be caused by life stress, emotions, and alterations in brain function. Patients then undertake a novel psychotherapy approach called emotional awareness and expression therapy (EAET) that aims to reduce or eliminate centralized pain by resolving trauma and emotional conflicts and learning healthy communication of adaptive emotions. Our published preliminary clinical trial (n = 53) indicated that EAET produced statistically significant and large effect size advantages over CBT in pain reduction and marginally greater improvements in pain interference than CBT for older adults with chronic musculoskeletal pain. Geriatric mental healthcare providers may learn this assessment and treatment approach to benefit many of their patients with chronic pain.
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Affiliation(s)
- Brandon C Yarns
- Department of Psychiatry/Mental Health (BCY,TAZ,ANJ), VA Greater Los Angeles Healthcare System, Los Angeles, CA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine (BCY,TAZ,ANJ), University of California, Los Angeles (UCLA), Los Angeles, CA.
| | - Tongtong A Zhu
- Department of Psychiatry/Mental Health (BCY,TAZ,ANJ), VA Greater Los Angeles Healthcare System, Los Angeles, CA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine (BCY,TAZ,ANJ), University of California, Los Angeles (UCLA), Los Angeles, CA
| | - Ali Najafian Jazi
- Department of Psychiatry/Mental Health (BCY,TAZ,ANJ), VA Greater Los Angeles Healthcare System, Los Angeles, CA; Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine (BCY,TAZ,ANJ), University of California, Los Angeles (UCLA), Los Angeles, CA
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12
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Mellor R, Khoo A, Saunders-Dow E, Raguz E, Taing MW, Hanjani LS, Freeman C, Crawford D. Polypharmacy in Australian Veterans with Post-traumatic Stress Disorder upon Admission to a Mental Health Facility: A Retrospective Chart Review. Drugs Real World Outcomes 2022; 9:347-357. [PMID: 35581527 PMCID: PMC9392669 DOI: 10.1007/s40801-022-00298-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2022] [Indexed: 11/14/2022] Open
Abstract
Objective Polypharmacy increases the risk of adverse drug events and drug–drug interactions, and contributes to falls, hospital admissions, morbidity and mortality. Veterans with post-traumatic stress disorder often have psychological and physical comorbidities, increasing the likelihood of general and psychotropic polypharmacy. This study investigates the prevalence of general and psychotropic polypharmacy in inpatient veterans with post-traumatic stress disorder, and illustrates potential risks associated with polypharmacy in this population. Methods Medical records of 219 veterans admitted to a mental health facility for post-traumatic stress disorder management were retrospectively reviewed. Medication lists on admission were extracted and coded according to Anatomical Therapeutic Chemical Classification classes. The prevalence of general (five or more total medications), psychotropic (two or more N-code medications), and sedative (two or more medications with sedating effects) polypharmacy and Drug Burden Index were calculated. Class combinations were reported, and associations between demographic characteristics and polypharmacy were determined. Results Mean age was 62.5 (± 14.6) years. In addition to post-traumatic stress disorder, 90.9% had a diagnosis of at least one other psychiatric condition, and 96.8% had a diagnosis of at least one non-psychiatric medical condition. The prevalence of general polypharmacy was 76.7%, psychotropic polypharmacy was 79.9% and sedative polypharmacy was 75.3%. Drug Burden Index scores ranged from 0 to 8.2, with 66.2% of participants scoring ≥ 1. Conclusions This cohort of inpatient veterans with post-traumatic stress disorder had a high prevalence of general, psychotropic and sedative polypharmacy, and were at high risk for drug-related adverse events. This highlights the importance of increasing awareness of polypharmacy and potentially inappropriate drug combinations, and the need for improved medication review by prescribers. Supplementary Information The online version contains supplementary material available at 10.1007/s40801-022-00298-3.
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Affiliation(s)
- Rebecca Mellor
- Gallipoli Medical Research Foundation, Greenslopes Private Hospital, 121 Newdegate Street, Greenslopes, QLD, 4120, Australia.
| | - Andrew Khoo
- Toowong Private Hospital, Toowong, QLD, Australia
| | - Elise Saunders-Dow
- Gallipoli Medical Research Foundation, Greenslopes Private Hospital, 121 Newdegate Street, Greenslopes, QLD, 4120, Australia
| | - Ella Raguz
- Gallipoli Medical Research Foundation, Greenslopes Private Hospital, 121 Newdegate Street, Greenslopes, QLD, 4120, Australia
| | - Meng-Wong Taing
- Pharmacy Australia Centre of Excellence (PACE), School of Pharmacy, The University of Queensland, Woolloongabba, QLD, Australia
| | - Leila Shafiee Hanjani
- Centre for Health Sciences Research, Faculty of Medicine, The University of Queensland, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Chris Freeman
- Pharmacy Australia Centre of Excellence (PACE), School of Pharmacy, The University of Queensland, Woolloongabba, QLD, Australia
| | - Darrell Crawford
- Gallipoli Medical Research Foundation, Greenslopes Private Hospital, 121 Newdegate Street, Greenslopes, QLD, 4120, Australia
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13
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Roth M, King L, Richardson D. Depression and Anxiety as Mediators of PTSD Symptom Clusters and Pain in Treatment-Seeking Canadian Forces Members and Veterans. Mil Med 2021; 188:e1150-e1155. [PMID: 34966945 DOI: 10.1093/milmed/usab532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/28/2021] [Accepted: 12/14/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Chronic pain (CP) commonly presents alongside psychiatric conditions such as depression, PTSD, and generalized anxiety. The current study sought to better understand this complex relationship by determining whether anxiety and depression symptom severity mediated the relationship between DSM-5 PTSD symptom clusters and pain symptoms in a sample of 663 Canadian Armed Forces (CAF) personnel and veterans seeking treatment for mental health conditions. MATERIALS AND METHODS Generalized anxiety disorder, depression, and PTSD symptom severity were measured using self-report scales provided as part of a standard intake protocol. Pain symptoms were measured using the Bodily Pain subscale of the SF-36 (SF-36 BPS). Linear regressions were used to explore the relationship between PTSD symptom clusters, depression, anxiety, and pain. Bootstrapped resampling analyses were employed to test mediation effects. RESULTS The average SF-36 BPS score in this sample was 36.6, nearly 1.5 SDs below the population health status, enforcing the salience of pain symptoms as a concern for veterans and CAF seeking treatment for military-related psychiatric conditions. The effects of PTSD symptom clusters avoidance, negative mood and cognitions, and arousal on pain were fully mediated by anxiety and depression severity. However, the effect of intrusion on pain was not mediated by depression and only partly mediated by anxiety. CONCLUSION Findings emphasize the importance of including anxiety and depression in models of PTSD and pain, particularly in samples where psychiatric comorbidity is high. Clinically, results highlight the need for improved treatment regimens that address pain symptoms alongside common psychiatric comorbidities.
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Affiliation(s)
- Maya Roth
- St. Joseph's Operational Stress Injury Clinic, St. Joseph's Health Care London, London, ON N6C 5J1, Canada
| | - Lisa King
- St. Joseph's Operational Stress Injury Clinic, St. Joseph's Health Care London, London, ON N6C 5J1, Canada
| | - Don Richardson
- St. Joseph's Operational Stress Injury Clinic, St. Joseph's Health Care London, London, ON N6C 5J1, Canada
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14
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Jadhakhan F, Evans D, Falla D. Role of post-trauma stress symptoms in the development of chronic musculoskeletal pain and disability: a protocol for a systematic review. BMJ Open 2021; 11:e058386. [PMID: 34853117 PMCID: PMC8638464 DOI: 10.1136/bmjopen-2021-058386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Ferozkhan Jadhakhan
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK
| | - David Evans
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK
| | - Deborah Falla
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK
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15
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Reed DE, Cobos B, Lehinger EA, Nabity PS, Vail KE, McGeary DD. Pain-related disability, PTSD symptoms, and mood among a comorbid chronic pain and PTSD sample prior to and during the COVID-19 pandemic. J Health Psychol 2021; 27:1515-1532. [PMID: 34689654 DOI: 10.1177/13591053211051821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
There is a knowledge gap when treating comorbid chronic pain and posttraumatic stress disorder (PTSD) during the COVID-19 pandemic. Addressing this gap, 169 individuals (57.4% female), aged 39.8 years were recruited based on levels of pain-related disability and PTSD symptoms. Participants were assessed prior to, and during, the COVID-19 pandemic. Improvements in pain-related disability were marginally attenuated for the comorbid group, compared to the chronic pain group. Results show that some condition-specific symptoms may not have been affected by the COVID-19 pandemic. Cautious interpretation is warranted due to only two time points and the lack of a diverse sample.
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Affiliation(s)
- David E Reed
- University of Texas Health Science Center at San Antonio, USA.,VA Puget Sound Health Care System, USA.,University of Washington, USA
| | - Briana Cobos
- University of Texas Health Science Center at San Antonio, USA.,University of Texas at San Antonio, USA
| | - Elizabeth A Lehinger
- University of Texas Health Science Center at San Antonio, USA.,University of Washington, USA
| | - Paul S Nabity
- University of Texas Health Science Center at San Antonio, USA
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16
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Zimmer Z, Fraser K, Korinek K, Akbulut-Yuksel M, Young YM, Toan TK. War across the life course: examining the impact of exposure to conflict on a comprehensive inventory of health measures in an aging Vietnamese population. Int J Epidemiol 2021; 50:866-879. [PMID: 33395485 DOI: 10.1093/ije/dyaa247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 11/06/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The majority of evidence indicates that exposure to war and other traumatic events continue to have negative impacts on health across the life course. However, existing research on health effects of war exposure primarily concentrates on short-term impacts among veterans in high-income countries sent elsewhere to battle. Yet, most wars situate in lower- and middle-income countries, where many are now or will soon be entering old age. Consequently, the current burden of exposure to war has ignored an important global population. METHODS The Vietnam Health and Aging Study (VHAS) is a longitudinal study designed to examine historical exposure to highly stressful events during the American War. Two modes of data collection, involving a sample of 2447 individuals aged 60+ years in northern Vietnam, took place between May and August 2018. Using this first wave of data, we generate indexed measures of war exposure and analyze their associations with a set of 12 health outcomes, accounting for confounding variables. RESULTS Results indicate that greater exposure to three types of war exposure (death and injury, stressful living conditions, and fearing death and/or injury) in earlier life is associated with worse health in later-life across a large number of health outcomes, such as number of diagnosed health conditions, mental distress, somatic symptoms, physical functioning, post-traumatic stress symptoms and chronic pain. CONCLUSIONS Findings support a life course theory of health and point to long-term effects of war on health that require detailed attention.
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Affiliation(s)
- Zachary Zimmer
- Global Aging and Community Initiative, Department of Family Studies and Gerontology, Mount Saint Vincent University, Halifax, Nova Scotia, Canada
| | - Kathryn Fraser
- Global Aging and Community Initiative, Department of Family Studies and Gerontology, Mount Saint Vincent University, Halifax, Nova Scotia, Canada
| | - Kim Korinek
- Department of Sociology, University of Utah, Salt Lake City, UT, USA
| | | | | | - Tran Khanh Toan
- Family Medicine Department, Hanoi Medical University, Hanoi, Vietnam
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17
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Keizer BM, Roache JD, Jones JR, Kalpinski RJ, Porcerelli JH, Krystal JH. Continuous Ketamine Infusion for Pain as an Opportunity for Psychotherapy for PTSD: A Case Series of Ketamine-Enhanced Psychotherapy for PTSD and Pain (KEP-P2). PSYCHOTHERAPY AND PSYCHOSOMATICS 2021; 89:326-329. [PMID: 32248200 DOI: 10.1159/000507095] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 03/09/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Benjamin M Keizer
- Department of Rehabilitation Medicine, Center for the Intrepid, Brooke Army Medical Center, Joint Base San Antonio, San Antonio, Texas, USA,
| | - John D Roache
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - John R Jones
- United States Air Force, Robins Air Force Base, Warner Robins, Georgia, USA
| | - Ryan J Kalpinski
- United States Air Force, Joint Base Andrews, JB Andrews, Maryland, USA
| | - John H Porcerelli
- Department of Psychology, University of Detroit Mercy, Detroit, Michigan, USA
| | - John H Krystal
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
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18
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Hong P, Song YG, Paek S. Possible effects of agent orange and posttraumatic stress disorder on hyperglycemia in Korean veterans from the US-Vietnam war. Medicine (Baltimore) 2021; 100:e26508. [PMID: 34160471 PMCID: PMC8238358 DOI: 10.1097/md.0000000000026508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 05/12/2021] [Indexed: 01/04/2023] Open
Abstract
This study was conducted to examine whether Korean veterans from the US-Vietnam War who had a diagnosis of type II diabetes mellitus (T2DM) as well as past history of exposure to agent orange (AO) are vulnerable to hyperglycemia when receiving intra-articular corticosteroid injection (IACI) for pain relief.The current study included a total of 49 patients (n = 49) who received an injection of triamcinolone 20 or 40 mg to the shoulder under sonographic guidance or did that of dexamethasone 10 mg or triamcinolone 40 mg combined with dexamethasone 20 mg to the spine under fluoroscopic guidance. Their 7-day fasting blood glucose (FBG) levels were measured and then averaged, serving as baseline levels. This is followed by measurement of FBG levels for 14 days of IACI. Respective measurements were compared with baseline levels. The patients were also evaluated for whether there are increases in FBG levels depending on insulin therapy as well as HbA1c ≥ 7% or HbA1c < 7%.Overall, there were significant increases in FBG levels by 64.7 ± 42.5 mg/dL at 1 day of IACI from baseline (P < .05). HbA1c ≥ 7% and HbA1c < 7% showed increases in FBG levels by 106.1 ± 49.0 mg/dL and 46.5 ± 3.8 mg/dL, respectively, at 1 day of IACI from baseline (P < .05). In the presence and absence of insulin therapy, there were significant increases in them by 122.6 ± 48.7 mg/dL and 48.0 ± 20.4 mg/dL, respectively, at 1 day of IACI from baseline (P < .05). But there were decreases in them to baseline levels at 2 days of IACI.Clinicians should consider the possibility of hyperglycemia when using corticosteroids for relief of musculoskeletal pain in Korean veterans from the US-Vietnam War who had a history of exposure to AO.
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Affiliation(s)
- Pa Hong
- Department of Radiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon
| | - Yun Gyu Song
- Department of Radiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon
| | - Sungwoo Paek
- Department of Rehabilitation Medicine, Konkuk University Chungju Hospital, Konkuk University School of Medicine, Chungju, Korea
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19
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Tiet QQ, Moos RH. Strong associations among PTSD, pain, and alcohol and drug use disorders in VA primary care patients. Drug Alcohol Depend 2021; 223:108699. [PMID: 33862323 DOI: 10.1016/j.drugalcdep.2021.108699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/03/2021] [Accepted: 02/22/2021] [Indexed: 01/04/2023]
Abstract
AIMS PTSD, pain, and alcohol and drug use disorders (AUD and DUDs) are prevalent, debilitating, and costly. Clinicians benefit from understanding the co-occurrence among these conditions, especially cocaine and opioid use disorders. This is the first study to examine (1) the odds of having one condition in the presence of one of the other conditions, and (2) the extent to which having PTSD, pain, or an AUD raises the odds of having a DUD in VA primary care patients. METHODS We used cross-sectional archival data from 1283 primary care patients recruited in VA primary care clinics. Pain was measured by the numeric rating scale. PTSD, AUD, and DUDs (i.e., cannabis, opioid, cocaine, and any drug use disorder) were measured by the Mini International Diagnostic Interview. We conducted logistic regression analyses to examine the odds of having one condition in the presence of other conditions. RESULTS A total of 14.9 % of patients had PTSD, 52.8 % of patients had moderate or severe pain, 12.8 % had an AUD, and 10.4 % had any DUD. Patients who had one condition (PTSD, pain, AUD, or DUD) were highly likely to have one or more of the other conditions, with or without controlling for demographic variables. CONCLUSIONS VA Patients who had PTSD, moderate or severe pain, or an AUD were highly likely to have an opioid or cocaine use disorder, and therefore should be screened for DUDs in VA primary care.
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Affiliation(s)
- Quyen Q Tiet
- California School of Professional Psychology at Alliant International University, Emeryville, CA, United States; VA Palo Alto Health Care System, Menlo Park, CA, USA.
| | - Rudolf H Moos
- Stanford University School of Medicine, Stanford, CA, USA
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20
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Gasperi M, Afari N, Goldberg J, Suri P, Panizzon MS. Pain and Trauma: The Role of Criterion A Trauma and Stressful Life Events in the Pain and PTSD Relationship. THE JOURNAL OF PAIN 2021; 22:1506-1517. [PMID: 34029685 PMCID: PMC8578317 DOI: 10.1016/j.jpain.2021.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 04/23/2021] [Accepted: 04/29/2021] [Indexed: 12/31/2022]
Abstract
Chronic pain and post-traumatic stress disorder (PTSD) frequently co-occur, and research suggests that these 2 conditions exacerbate one another producing greater impact on normal functioning in combination than separately. The influence of traumatic experiences on both pain and PTSD has been shown, but the nature of this interplay remains unclear. Although Criterion A trauma is required for the diagnosis of PTSD, whether the association between PTSD and chronic pain is dependent on Criterion A is underexplored. In this observational cohort study, we examined the association between pain and PTSD-like symptoms in the context of Criterion A trauma in 5,791 men from the Vietnam Era Twin Registry. Correlations and mixed-effects regression models were used to evaluate the relationship between PTSD Checklist-Civilian Version symptoms and multiple indicators of pain from the Short Form McGill Pain Questionnaire across trauma history and chronic pain conditions. 53.21% of the participants experienced trauma consistent with DSM-IV Criterion A for PTSD. The associations between pain indicators and PTSD-like symptoms was stronger for individuals with a history of trauma but remained robust for individuals without trauma history. Small but significant interactions between past trauma and pain indicators and PTSD-like symptoms were observed. Findings were similar in a subsample of participants with history of chronic pain conditions. The relationship between PTSD-like symptoms and indicators of pain were largely independent of trauma consistent with Criterion A, highlighting the need to better understand and address stressful life events in chronic pain patients and pain concerns in individuals reporting trauma. PERSPECTIVE: This article demonstrates that the relationship between PTSD-like symptoms and indicators of pain is largely independent of trauma consistent with Criterion A. This finding highlights the need to better understand and address stressful life events in chronic pain patients and pain concerns in individuals reporting trauma.
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Affiliation(s)
- Marianna Gasperi
- VA Center of Excellence for Stress and Mental Health, San Diego, California; Research Service, VA San Diego Healthcare System, San Diego, California; Department of Psychiatry, University of California, San Diego, La Jolla, California.
| | - Niloofar Afari
- VA Center of Excellence for Stress and Mental Health, San Diego, California; Research Service, VA San Diego Healthcare System, San Diego, California; Department of Psychiatry, University of California, San Diego, La Jolla, California
| | - Jack Goldberg
- University of Washington, Seattle, Washington; Vietnam Era Twin Registry, Seattle, Washington; Seattle Epidemiologic Research and Information Center (ERIC), Department of Veterans Affairs Office of Research and Development, Seattle, Washington
| | - Pradeep Suri
- Seattle Epidemiologic Research and Information Center (ERIC), Department of Veterans Affairs Office of Research and Development, Seattle, Washington; Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Matthew S Panizzon
- VA Center of Excellence for Stress and Mental Health, San Diego, California; Center for Behavior Genetics of Aging, University of California, San Diego, California
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21
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Post-traumatic stress disorder due to sexual abuse and its relation to pain sensitivity among patients in methadone maintenance treatment. Psychiatry Res 2021; 298:113828. [PMID: 33652250 DOI: 10.1016/j.psychres.2021.113828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 02/21/2021] [Indexed: 11/24/2022]
Abstract
We studied whether post-traumatic stress disorder (PTSD) due to sexual abuse is related to pain indices among methadone maintenance treatment (MMT) patients. Pain threshold was determined, and suprathreshold pain levels were rated among 18 patients with PTSD and sexual abuse, and 38 patients without PTSD (20 with and 18 without sexual abuse). Patients with PTSD had higher proportion of chronic pain and high-perceived stress, and lower pain threshold, with similar supra-threshold ratings. Patients with benzodiazepine in urine had higher pain thresholds and they rated supra-threshold stimuli lower. However, the analgesic effect was not observed among PTSD patients.
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22
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Miller JV, Andre Q, Timmers I, Simons L, Rasic N, Lebel C, Noel M. Subclinical post-traumatic stress symptomology and brain structure in youth with chronic headaches. NEUROIMAGE-CLINICAL 2021; 30:102627. [PMID: 33812302 PMCID: PMC8053811 DOI: 10.1016/j.nicl.2021.102627] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 03/01/2021] [Accepted: 03/05/2021] [Indexed: 01/17/2023]
Abstract
ACEs and PTSS did not significantly differ between patients and healthy controls. Patients demonstrated greater corticolimbic connectivity compared to controls. Greater PTSS and less corticolimbic connectivity increased headache frequency. Less corticolimbic connectivity may indicate greater disease progression. Patients may be more vulnerable to the effects of PTSS compared to controls.
Background/aims Post-traumatic stress symptoms (PTSS) and chronic pain often co-occur at high rates in youth. PTSS may alter brain structure thereby contributing to headache chronicity. This study examined whether PTSS and altered limbic circuitry were associated with headache frequency in youth. Methods Thirty youth aged 10–18 years with chronic headaches and 30 age- and sex-matched controls underwent a 3T MRI scan. Volumes of the hippocampus and amygdala were obtained from T1-weighted images. Mean fractional anisotropy (FA, an index of white matter structure) axial and radial diffusivity values of the cingulum and uncinate fasciculus were extracted from diffusion-weighted images. Youth reported on their headaches daily, for one-month, and self-reported pubertal status, emotion regulation, adverse childhood experiences (ACEs) and PTSS using validated measures. Volumes of the hippocampus and amygdala and diffusivity values of the cingulum and uncinate were compared between patients and controls. Hierarchical linear regressions were used to examine the association between PTSS, subcortical volumes and/or diffusivity values and headache frequency. Results Mean FA values of the cingulum were higher in patients compared to controls (P = 0.02, Cohen’s d = 0.69). Greater PTSS (P = 0.04), smaller amygdala volumes (P = 0.01) and lower FA of the cingulum (P = 0.04) were associated with greater headache frequency, after accounting for age, puberty, pain duration, emotion regulation, and ACEs (Adjusted R2 ≥ 0.15). Headache frequency was associated with increases in radial diffusivity (P = 0.002, Adjusted R2 = 0.59), as opposed to axial diffusivity (n.s.). Conclusions PTSS, smaller amygdalar volume, and poorer cingulum structural connectivity were associated with headache frequency in youth, and may underlie headache chronicity.
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Affiliation(s)
- Jillian Vinall Miller
- Anesthesiology, Perioperative & Pain Medicine, University of Calgary, Calgary, AB, Canada; Vi Riddell Children's Pain & Rehabilitation Centre, Alberta Children's Hospital, Calgary, AB, Canada; Behaviour & The Developing Brain, Alberta Children's Hospital Research Institute, Calgary, AB, Canada.
| | - Quinn Andre
- Medicine, University of Alberta, Edmonton, AB, Canada
| | - Inge Timmers
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, United States
| | - Laura Simons
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, United States
| | - Nivez Rasic
- Anesthesiology, Perioperative & Pain Medicine, University of Calgary, Calgary, AB, Canada; Vi Riddell Children's Pain & Rehabilitation Centre, Alberta Children's Hospital, Calgary, AB, Canada; Behaviour & The Developing Brain, Alberta Children's Hospital Research Institute, Calgary, AB, Canada
| | - Catherine Lebel
- Behaviour & The Developing Brain, Alberta Children's Hospital Research Institute, Calgary, AB, Canada; Radiology, University of Calgary, Calgary, AB, Canada
| | - Melanie Noel
- Vi Riddell Children's Pain & Rehabilitation Centre, Alberta Children's Hospital, Calgary, AB, Canada; Behaviour & The Developing Brain, Alberta Children's Hospital Research Institute, Calgary, AB, Canada; Psychology, University of Calgary, Calgary, AB, Canada
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Pain, Depression, and Posttraumatic Stress Disorder Following Major Extremity Trauma Among United States Military Serving in Iraq and Afghanistan: Results From the Military Extremity Trauma and Amputation/Limb Salvage Study. J Orthop Trauma 2021; 35:e96-e102. [PMID: 33079837 DOI: 10.1097/bot.0000000000001921] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/31/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Assess the burden and co-occurrence of pain, depression, and posttraumatic stress disorder (PTSD) among service members who sustained a major limb injury, and examine whether these conditions are associated with functional outcomes. DESIGN A retrospective cohort study. SETTING Four U.S. military treatment facilities: Walter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego. PATIENTS/PARTICIPANTS Four hundred twenty-nine United States service members who sustained a major limb injury while serving in Afghanistan or Iraq met eligibility criteria upon review of their medical records. INTERVENTION Not applicable. MAIN OUTCOME MEASUREMENTS Outcomes assessed were: function using the short musculoskeletal functional assessment; PTSD using the PTSD Checklist and diagnostic and statistical manual criteria; pain using the chronic pain grade scale. RESULTS Military extremity trauma and amputation/limb salvage patients without pain, depression, or PTSD, were, on average, about one minimally clinically important difference (MCID) from age- and gender-adjusted population norms. In contrast, patients with low levels of pain and no depression or PTSD were, on average, one to 2 MCIDs from population norms. Military extremity trauma and amputation/limb salvage patients with either greater levels of pain, and who experience PTSD, depression, or both, were 4 to 6 MCIDs from population norms. Regression analyses adjusting for injury type (upper or lower limb, salvage or amputation, and unilateral or bilateral), age, time to interview, military rank, presence of a major upper limb injury, social support, presence of mild traumatic brain injury/concussion, and combat experiences showed that higher levels of pain, depression, and PTSD were associated with lower one-year functional outcomes. CONCLUSIONS Major limb trauma sustained in the military results in significant long-term pain and PTSD. Overall, the results are consistent with the hypothesis that pain, depression, and PTSD are associated with disability in this population. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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The Relationships Between Self-reported Pain Intensity, Pain Interference, and Quality of Life Among Injured U.S. Service Members With and Without Low Back Pain. J Clin Psychol Med Settings 2021; 28:746-756. [PMID: 33550539 DOI: 10.1007/s10880-020-09759-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2020] [Indexed: 10/22/2022]
Abstract
Low back pain is a prevalent military and veteran health problem and individuals injured on deployment may be at particularly high risk of pain conditions. Given that increasing numbers of active duty and veteran military personnel are seeking care in community settings, it is critical that health care providers are aware of military health issues. The current study examined the prevalence of low back pain among individuals with deployment-related injuries, compared their self-reported pain intensity and interference ratings, and assessed the relationship between low back pain, self-reported pain ratings, and quality of life. Almost half of participants had low back pain diagnoses, and individuals with low back pain reported significantly higher intensity and interference due to their pain than individuals without low back pain. Finally, the relationship between low back pain and quality of life was explained by self-reported pain indices, underscoring the importance of patient-centered metrics in pain treatment.
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25
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Chopin SM, Sheerin CM, Meyer BL. Yoga for warriors: An intervention for veterans with comorbid chronic pain and PTSD. PSYCHOLOGICAL TRAUMA : THEORY, RESEARCH, PRACTICE AND POLICY 2020; 12:888-896. [PMID: 32700935 PMCID: PMC7909482 DOI: 10.1037/tra0000649] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Comorbid chronic pain and posttraumatic stress disorder (PTSD) is common in veterans; this comorbidity is associated with increased severity and poorer prognosis when compared to each outcome alone. Yoga has been shown to be effective for chronic pain and promising for PTSD, but yoga for comorbid pain and PTSD has not been examined. This article offers empirical support for a yoga intervention for comorbid chronic pain and PTSD in a veteran population. METHOD Results are presented from a 4-year pilot yoga intervention for comorbid chronic pain and PTSD at a large, urban Veterans Affairs Medical Center. Based on the fear avoidance model of pain, the intervention used a cross-sectional, open-trial design with pre- and postmeasures. T test analyses were conducted on program completers (N = 49; out of 87 initially enrolled, 44% attrition rate), who were primarily African American (69%) and male (61%) and had a mean age of 51.41 years (SD = 11.32). RESULTS Results indicated trend-level reductions in overall PTSD symptoms, as measured by the PTSD Checklist for DSM-5 (p = .02, d = 0.38) and in symptom cluster scores of negative alterations of cognitions and mood (p = .03, d = 0.36) and arousal and reactivity (p = .03, d = 0.35). Veterans reported significant improvement in ability to participate in social activities (p < .001, d = 0.44) and significant reductions in kinesiophobia (fear of movement or physical activity; p < .001, d = 0.85). On a satisfaction measure with a range of 1 (quite dissatisfied) to 4 (extremely satisfied), the mean rating was 3.74 (SD = 0.33). CONCLUSION Yoga is a feasible and effective intervention for veterans with comorbid chronic pain and PTSD. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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26
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Fortenbaugh FC, Fonda JR, Fortier CB, Amick MM, Milberg WP, McGlinchey RE. The Impact of Common Psychiatric and Behavioral Comorbidities on Functional Disability Across Time and Individuals in Post-9/11 Veterans. J Trauma Stress 2020; 33:750-761. [PMID: 32339323 PMCID: PMC7731589 DOI: 10.1002/jts.22501] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 09/06/2019] [Accepted: 09/12/2019] [Indexed: 01/13/2023]
Abstract
Returning veterans often face multiple concurrent psychiatric and behavioral conditions that negatively impact reintegration into civilian life and are associated with functional disability. Understanding how conditions interact to negatively impact functioning is an important step toward developing holistic treatment approaches optimized for this population. This study utilized a cross-sectional and prospective longitudinal cohort design, applying regression algorithms to understand the relative contribution of common clinical issues to functional disability in U.S. veterans who served after the September 11, 2001 (9/11), terror attacks. Community-dwelling post-9/11 veterans (N = 397) completed detailed assessments, including common clinical condition diagnoses, combat experience, and demographics, which were used to predict functional disability (World Health Organization Disability Assessment Schedule); 205 participants were reassessed approximately 1-2 years after enrollment. Regression analyses showed a strong association between the predictor variables and functional disability, f 2 = 1.488. Validation analyses showed a high prediction ability of functional disability to independent samples, r = .719, and across time in the same individuals, r = .780. The strongest predictors included current posttraumatic stress disorder, depressive disorder, sleep disturbance, and pain diagnoses. These results demonstrate the importance of considering multiple common co-occurring conditions when assessing functional disability in post-9/11 veterans and suggest that certain syndromes contribute the most unique information to predicting functional disability with high confidence. As most U.S. veterans utilize private healthcare systems, these results have clinical utility for both Veterans Affairs and civilian healthcare practitioners in assessing and monitoring functional disability in post-9/11 veterans over time.
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Affiliation(s)
- Francesca C. Fortenbaugh
- Translational Research Center for TBI and Stress Disorders (TRACTS) and Geriatric Research, Education and Clinical Center (GRECC), VA Boston Healthcare System, Boston, Massachusetts, USA,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer R. Fonda
- Translational Research Center for TBI and Stress Disorders (TRACTS) and Geriatric Research, Education and Clinical Center (GRECC), VA Boston Healthcare System, Boston, Massachusetts, USA,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Catherine B. Fortier
- Translational Research Center for TBI and Stress Disorders (TRACTS) and Geriatric Research, Education and Clinical Center (GRECC), VA Boston Healthcare System, Boston, Massachusetts, USA,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Melissa M. Amick
- Translational Research Center for TBI and Stress Disorders (TRACTS) and Geriatric Research, Education and Clinical Center (GRECC), VA Boston Healthcare System, Boston, Massachusetts, USA,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - William P. Milberg
- Translational Research Center for TBI and Stress Disorders (TRACTS) and Geriatric Research, Education and Clinical Center (GRECC), VA Boston Healthcare System, Boston, Massachusetts, USA,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Regina E. McGlinchey
- Translational Research Center for TBI and Stress Disorders (TRACTS) and Geriatric Research, Education and Clinical Center (GRECC), VA Boston Healthcare System, Boston, Massachusetts, USA,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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27
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Purcell N, Becker WC, Zamora KA, McGrath SL, Hagedorn HJ, Fabian ER, McCamish N, Seal KH. Tailored to Fit: How an Implementation Framework Can Support Pragmatic Pain Care Trial Adaptation for Diverse Veterans Affairs Clinical Settings. Med Care 2020; 58 Suppl 2 9S:S80-S87. [PMID: 32826776 PMCID: PMC7444583 DOI: 10.1097/mlr.0000000000001376] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Veterans Affairs (VA) has rolled out a holistic, multicomponent Whole Health care model nationwide, yet no pragmatic trials have been conducted in real-world clinical settings to compare its effectiveness against other evidence-based approaches for chronic pain management in veterans. OBJECTIVES We describe the adaptation of the first large pragmatic randomized controlled trial of the Whole Health model for chronic pain care for diverse VA clinical settings. RESEARCH DESIGN Informed by the Promoting Action on Research Implementation in Health Systems implementation framework, we conducted qualitative semistructured interviews to obtain feedback on trial design from VA leadership, frontline clinicians, and veterans with chronic pain at 5 VA enrollment sites. Next, we convened in-person evidence-based quality improvement (EBQI) meetings with study stakeholders (including frontline clinicians and administrators) at each site to discuss study design; review interview themes; and identify site-specific barriers, facilitators, and approaches to implementation. Ethnographic observations from EBQI meetings provided additional insight into implementation strategies. SUBJECTS Seventy-four veteran and VA staff stakeholders were interviewed; 71 stakeholders participated in EBQI meetings. RESULTS At each site, unique clinical contexts and varying resources for Whole Health and pain care delivery affected plans for trial implementation. We present examples of local adaptations that emerged through the formative evaluation process to facilitate implementation and yield a more pragmatic trial design. CONCLUSIONS A systematic formative evaluation can facilitate engagement and buy-in of study stakeholders. Locally tailored pragmatic implementation strategies may improve the likelihood of successful trial execution as well as future implementation of evidence-based pain care approaches in real-world clinical settings.
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Affiliation(s)
- Natalie Purcell
- San Francisco VA Health Care System (San Francisco, CA)
- University of California, San Francisco (San Francisco, CA)
| | - William C. Becker
- VA Connecticut Healthcare System (West Haven, CT)
- Yale School of Medicine (New Haven, CT)
| | - Kara A. Zamora
- San Francisco VA Health Care System (San Francisco, CA)
- University of California, San Francisco (San Francisco, CA)
| | | | - Hildi J. Hagedorn
- Minneapolis VA Health Care System (Minneapolis, MN)
- University of Minneapolis (Minneapolis, MN)
| | - Eva R. Fabian
- San Francisco VA Health Care System (San Francisco, CA)
| | | | - Karen H. Seal
- San Francisco VA Health Care System (San Francisco, CA)
- University of California, San Francisco (San Francisco, CA)
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Emotional Awareness and Expression Therapy Achieves Greater Pain Reduction than Cognitive Behavioral Therapy in Older Adults with Chronic Musculoskeletal Pain: A Preliminary Randomized Comparison Trial. PAIN MEDICINE 2020; 21:2811-2822. [DOI: 10.1093/pm/pnaa145] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Abstract
Objective
Emotional awareness and expression therapy (EAET) emphasizes the importance of the central nervous system and emotional processing in the etiology and treatment of chronic pain. Prior trials suggest EAET can substantially reduce pain; however, only one has compared EAET with an established alternative, demonstrating some small advantages over cognitive behavioral therapy (CBT) for fibromyalgia. The current trial compared EAET with CBT in older, predominately male, ethnically diverse veterans with chronic musculoskeletal pain.
Design
Randomized comparison trial.
Setting
Outpatient clinics at the West Los Angeles VA Medical Center.
Subjects
Fifty-three veterans (mean age = 73.5 years, 92.4% male) with chronic musculoskeletal pain.
Methods
Patients were randomized to EAET or CBT, each delivered as one 90-minute individual session and eight 90-minute group sessions. Pain severity (primary outcome), pain interference, anxiety, and other secondary outcomes were assessed at baseline, post-treatment, and three-month follow-up.
Results
EAET produced significantly lower pain severity than CBT at post-treatment and follow-up; differences were large (partial η2 = 0.129 and 0.157, respectively). At post-treatment, 41.7% of EAET patients had >30% pain reduction, one-third had >50%, and 12.5% had >70%. Only one CBT patient achieved at least 30% pain reduction. Secondary outcomes demonstrated small to medium effect size advantages of EAET over CBT, although only post-treatment anxiety reached statistical significance.
Conclusions
This trial, although preliminary, supports prior research suggesting that EAET may be a treatment of choice for many patients with chronic musculoskeletal pain. Psychotherapy may achieve substantial pain reduction if pain neuroscience principles are emphasized and avoided emotions are processed.
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29
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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: 11] [Impact Index Per Article: 2.8] [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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30
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Bair MJ, Outcalt SD, Ang D, Wu J, Yu Z. Pain and Psychological Outcomes Among Iraq and Afghanistan Veterans with Chronic Pain and PTSD: ESCAPE Trial Longitudinal Results. PAIN MEDICINE 2020; 21:1369-1376. [DOI: 10.1093/pm/pnaa007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Objective
To compare pain and psychological outcomes in veterans with chronic musculoskeletal pain and comorbid post-traumatic stress disorder (PTSD) or pain alone and to determine if veterans with comorbidity respond differently to a stepped-care intervention than those with pain alone.
Design
Secondary analysis of data from the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial.
Setting
Six Veterans Health Affairs clinics.
Subjects
Iraq and Afghanistan veterans (N = 222) with chronic musculoskeletal pain.
Methods
Longitudinal analysis of veterans with chronic musculoskeletal pain and PTSD or pain alone and available baseline and nine-month trial data. Participants randomized to either usual care or a stepped-care intervention were analyzed. The pain–PTSD comorbidity group screened positive for PTSD and had a PTSD Checklist–Civilian score ≥41 at baseline.
Results
T tests demonstrated statistically significant differences and worse outcomes on pain severity, pain cognitions, and psychological outcomes in veterans with comorbid pain and PTSD compared with those with pain alone. Analysis of covariance (ANCOVA) modeling change scores from baseline to nine months indicated no statistically significant differences, controlling for PTSD, on pain severity, pain centrality, or pain self-efficacy. Significant differences emerged for pain catastrophizing (t = 3.10, P < 0.01), depression (t = 3.39, P < 0.001), and anxiety (t = 3.80, P < 0.001). The interaction between PTSD and the stepped-care intervention was not significant.
Conclusions
Veterans with the pain–PTSD comorbidity demonstrated worse pain and psychological outcomes than those with chronic pain alone. These findings indicate a more intense chronic pain experience for veterans when PTSD co-occurs with pain. PTSD did not lead to a differential response to a stepped-care intervention.
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Affiliation(s)
- Matthew J Bair
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Inc., Indianapolis, Indiana
| | - Samantha D Outcalt
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana
| | - Dennis Ang
- Division of Rheumatology, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Jingwei Wu
- Department of Biostatistics, Temple University, Philadelphia, Pennsylvania
| | - Zhangsheng Yu
- Center of Statistics Research, Research Department, School of Statistics, Shanghai Jiaotong University, Shanghai, China
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Ford JD, Grasso DJ, Jones S, Works T, Andemariam B. Interpersonal Violence Exposure and Chronic Pain in Adult Sickle Cell Patients. JOURNAL OF INTERPERSONAL VIOLENCE 2020; 35:924-942. [PMID: 29294650 DOI: 10.1177/0886260517691521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Almost half of sickle cell disease (SCD) patients develop chronic, debilitating physical pain with uncertain genesis for which they primarily receive opiate-based palliative treatment. Psychological trauma exposure, especially interpersonal victimization, has been linked to the perception of pain in several medical diseases, but has yet to be examined in SCD patients. This study examines self-reported chronicity of pain and use of prescribed opiates in 50 adult SCD patients with and without a history of interpersonal violence exposure. We conducted a retrospective chart review of 50 consecutive SCD patients seen for medical care in an adult subspecialty hematology clinic. Data collected included demographics, opiate use, pain chronicity, and measures of anxiety, depression, and interpersonal violence exposure. Sixty-eight percent of patients reported past interpersonal violence exposure. The mean number of types of interpersonal violence exposure, including physical, sexual, or emotional abuse, was 2.76 (SD = 1.63). SCD patients with a history of interpersonal violence exposure were almost five times more likely to report chronic pain and more than six times more likely to report use of opiate-based medications on a daily basis compared with SCD patients with no history of violence exposure. Depression and anxiety symptoms were associated with violence exposure, but did not account for the relationship between violence exposure and chronic pain or prescribed opiate use. Screening and assessment of exposure to interpersonal violence may be useful in addition to screening for mental health problems in the management of chronic pain with adults diagnosed with SCD. Such screening may contribute to addressing health care disparities given the preponderance of SCD patients who are of African American ethnoracial background.
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Affiliation(s)
| | | | - Sasia Jones
- University of Connecticut Health, Farmington, USA
| | - Teresa Works
- University of Connecticut Health, Farmington, USA
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32
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Carmassi C, Dell'Oste V, Bertelloni CA, Foghi C, Diadema E, Mucci F, Massimetti G, Rossi A, Dell'Osso L. Disrupted Rhythmicity and Vegetative Functions Relate to PTSD and Gender in Earthquake Survivors. Front Psychiatry 2020; 11:492006. [PMID: 33304278 PMCID: PMC7701044 DOI: 10.3389/fpsyt.2020.492006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 09/14/2020] [Indexed: 01/11/2023] Open
Abstract
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.
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Affiliation(s)
- Claudia Carmassi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Valerio Dell'Oste
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Department of Biotechnology Chemistry and Pharmacy, University of Siena, Siena, Italy
| | | | - Claudia Foghi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Elisa Diadema
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Department of Biotechnology Chemistry and Pharmacy, University of Siena, Siena, Italy
| | - Federico Mucci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Department of Biotechnology Chemistry and Pharmacy, University of Siena, Siena, Italy
| | - Gabriele Massimetti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Rossi
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
| | - Liliana Dell'Osso
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Peacock KS, Stoerkel E, Libretto S, Zhang W, Inman A, Schlicher M, Cowsar JD, Eddie D, Walter J. A randomized trial comparing the Tennant Biomodulator to transcutaneous electrical nerve stimulation and traditional Chinese acupuncture for the treatment of chronic pain in military service members. Mil Med Res 2019; 6:37. [PMID: 31791416 PMCID: PMC6886190 DOI: 10.1186/s40779-019-0227-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/13/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The present investigation tested the efficacy of the Tennant Biomodulator, a novel pain management intervention that uses biofeedback-modulated electrical stimulation, to reduce chronic pain and its psychosocial sequelae in a sample of current and former military service members. The Tennant Biomodulator used on its most basic setting was compared to two commonly used, non-pharmacological pain treatments-traditional Chinese acupuncture and transcutaneous electrical nerve stimulation (TENS)-in a comparative efficacy, randomized, open-label trial. METHODS Participants included 100 active duty and retired service men and women with chronic pain undergoing treatment at the Brooke Army Medical Center in Texas, USA, randomly assigned to receive six, weekly sessions of either Tennant Biomodulator treatment, traditional Chinese acupuncture, or TENS, in addition to usual care. Recruitment was conducted between May 2010 to September 2013. Outcome measures were collected at intake, before and after each treatment session, and at a 1-month follow-up. Intent-to-treat analyses were used throughout, with mixed models used to investigate main effects of group, time, and group × time interactions with consideration given to quadratic effects. Outcomes measured included ratings of chronic pain, pain-related functional disability, and symptoms of post-traumatic stress disorder (PTSD) and depression. RESULTS On average, regardless of their treatment group, participants exhibited a 16% reduction in pain measured by the Brooke Army Medical Center's Clinic Pain Log [F(1, 335) = 55.7, P < 0.0001] and an 11% reduction in pain-related disability measured by the Million Visual Analog Scale [MVAS: F(1, 84) = 28.3, P < 0.0001] from baseline to the end of treatment, but no one treatment performed better than the other, and the reductions in pain and pain-related disability were largely lost by 1-month follow-up. Symptoms of PTSD and depression did not change significantly as a function of time or group. CONCLUSIONS Findings build on previous work suggesting that traditional Chinese acupuncture and TENS can reduce pain and its functional sequelae without risks associated with pharmacological pain management. The Tennant Biomodulator used on its most basic setting performs as well as these other interventions. Based on the present findings, large, randomized controlled trials on the Tennant Biomodulator are indicated. Future work should test this device using its full range of settings for pain-related psychological health. TRIAL REGISTRATION Clincialtrials.gov (NCT01752010); registered December 14, 2012.
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Affiliation(s)
- Kimberly S Peacock
- University of Texas Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Erika Stoerkel
- TLI Foundation, 1750 Tysons Boulevard, McLean, Virginia, 22102, USA
| | - Salvatore Libretto
- Henry M. Jackson Foundation, 6720A Rockledge Drive, Bethesda, MD, 20817, USA
| | - Weimin Zhang
- BD Life Sciences, 1 Becton Drive, Franklin Lakes, NJ, 07417, USA
| | - Alice Inman
- Brooke Army Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX, 78234, USA
| | - Michael Schlicher
- Madigan Army Medical Center, 9040A Jackson Ave, Joint Base Lewis-McChord, WA, 98431, USA
| | - John D Cowsar
- MedPost Urgent Care Center, 513 Cibolo Valley Drive, Cibolo, TX, 78108, USA
| | - David Eddie
- Massachusetts General Hospital, Harvard Medical School, 151 Merrimac St. 6th Floor, Boston, MA, 02114, USA.
| | - Joan Walter
- H&S Ventures, Samueli Integrative Health Program, 1800 Diagonal Road, Suite 617, Alexandria, VA, 22314, USA
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Boden MT, Hoggatt KJ. Substance Use Disorders Among Veterans in a Nationally Representative Sample: Prevalence and Associated Functioning and Treatment Utilization. J Stud Alcohol Drugs 2019. [PMID: 30573015 DOI: 10.15288/jsad.2018.79.853] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Several epidemiological studies have reported that veterans and nonveterans have comparable substance use disorder (SUD) prevalence and SUD treatment rates for SUD and treatments of several types. No studies have compared functioning among veterans with SUD to veterans without SUD or to nonveterans. METHOD We investigated the prevalence of past-year and lifetime SUD (based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), overall and by substance, and estimated the association with physical and mental health functioning and treatment utilization and need among veterans and nonveterans in a nationally representative sample. RESULTS Predicted prevalence of any past-year SUD, with and without tobacco use disorder (TUD), among veterans was 32.9% and 17.1%, and prevalence of any lifetime SUD, with and without TUD, was 52.5 and 38.7%, respectively. Veterans had higher prevalence of past-year and lifetime SUD for some substances (e.g., tobacco, alcohol) but not others (e.g., cannabis, opioid). Lower physical and mental health functioning was found among veterans, relative to nonveterans, and participants with SUD, relative to those without SUD, and veterans with SUD reported the lowest functioning across all domains. More veterans than nonveterans received any SUD treatment and SUD treatment in specific domains (e.g., self-help). About 70% of veterans with past-year SUD did not receive treatment, but only 5.4% reported needing and not receiving treatment. CONCLUSIONS Relative to nonveterans, veterans have higher prevalence of past-year TUD and lifetime alcohol use disorder or TUD and lower physical or mental health functioning. A minority of veterans receive SUD treatment, and few report unmet need for treatment.
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Affiliation(s)
- Matthew Tyler Boden
- Center for Innovation to Implementation, Veterans Affairs (VA) Palo Alto Health Care System, Menlo Park, California
| | - Katherine J Hoggatt
- Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California.,Department of Epidemiology, University of California, Los Angeles, Fielding School of Public Health, Los Angeles, California
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Donovan LM, Malte CA, Spece LJ, Griffith MF, Feemster LC, Zeliadt SB, Au DH, Hawkins EJ. Center Predictors of Long-Term Benzodiazepine Use in Chronic Obstructive Pulmonary Disease and Post-traumatic Stress Disorder. Ann Am Thorac Soc 2019; 16:1151-1157. [PMID: 31113231 PMCID: PMC6812159 DOI: 10.1513/annalsats.201901-048oc] [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: 01/21/2019] [Accepted: 05/15/2019] [Indexed: 02/04/2023] Open
Abstract
Rationale: Symptoms of insomnia and anxiety are common among patients with chronic obstructive pulmonary disease (COPD), especially among patients with comorbid mental health disorders such as post-traumatic stress disorder (PTSD). Benzodiazepines provide temporary relief of these symptoms, but guidelines discourage routine use of benzodiazepines because of the serious risks posed by these medications. A more thorough understanding of guideline-discordant benzodiazepine use will be critical to reduce potentially inappropriate prescribing and its associated risks.Objectives: Examine the national prevalence, variability, and center correlates of long-term benzodiazepine prescriptions for patients with COPD and comorbid PTSD.Methods: We identified patients with COPD and PTSD between 2010 and 2012 who received care within the Department of Veterans Affairs. We used a mixed-effects logistic regression model to assess center predictors of long-term benzodiazepine prescriptions (≥90 d), while accounting for patient characteristics.Results: Of 43,979 patients diagnosed with COPD and PTSD at 129 centers, 24.4% were prescribed benzodiazepines long term, with use varying from 9.5% to 49.4% by medical center. Patients with long-term prescriptions were more likely to be white (90.1% vs. 80.7%) and have other mental health comorbidities, including generalized anxiety disorder (31.3% vs. 16.5%). Accounting for patient mix and characteristics, long-term benzodiazepine use was associated with lower patient-reported access to mental health care (odds ratio, 0.54; 95% confidence interval, 0.37-0.80).Conclusions: Long-term benzodiazepine prescribing is common among patients at high risk for complications, although this practice varies substantially from center to center. Poor access to mental health care is a potential driver of this guideline inconsistent use.
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Affiliation(s)
- Lucas M. Donovan
- Center for Veteran-Centered and Value-Driven Care, Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine
| | - Carol A. Malte
- Center for Veteran-Centered and Value-Driven Care, Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Laura J. Spece
- Center for Veteran-Centered and Value-Driven Care, Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine
| | - Matthew F. Griffith
- Center for Veteran-Centered and Value-Driven Care, Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine
| | - Laura C. Feemster
- Center for Veteran-Centered and Value-Driven Care, Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine
| | - Steven B. Zeliadt
- Center for Veteran-Centered and Value-Driven Care, Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Services and
| | - David H. Au
- Center for Veteran-Centered and Value-Driven Care, Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine
| | - Eric J. Hawkins
- Center for Veteran-Centered and Value-Driven Care, Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
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Wisløff‐Aase K, Ræder J, Månum G, Løvstad M, Schanke A, Dyb G, Ekeberg Ø, Stanghelle JK. Chronic pain among the hospitalized patients after the 22 July 2011 terror attacks in Oslo and at Utøya Island. Acta Anaesthesiol Scand 2019; 63:913-922. [PMID: 30968401 DOI: 10.1111/aas.13373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 01/16/2019] [Accepted: 03/13/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND On 22 July 2011, 48 people were hospitalized due to physical injuries from gun shots or explosion, following 2 terror attacks in the Oslo area, Norway. In this study, we have investigated the occurrence of chronic pain, the severity and consequences of chronic pain in these patients, 3 to 4 years after the incidents. METHODS Totally 43 eligible terror trauma patients were invited to participate in the study, 30 patients were included. They underwent a consultation with a psychologist and a physician; containing psychological assessment, neuropsychological screening, a standardized clinical interview, medical examination, and a pain protocol. RESULTS In 18 (60%) the injury was severe, as defined by New Injury Severity Score > 15. Twenty-four patients (80%) reported injury-related chronic pain after the trauma, in 22 with consequences on daily life. Analgesics were used by 20 patients, including 5 in need of opioids. Ten patients had unmet needs of further specialist pain care. In 12 patients, the average pain score last week was above three on a 0-10 Numeric Rating Scale. In these patients, clinical signs of neuropathic pain were evident in 10, as tested by the Douleur Neuropathique score. There were significant correlations (P < 0.05) between severity of chronic pain and presence of post-traumatic stress symptoms, reduced quality of life, reduced psychosocial and physical function; but no correlation with pre-injury patient characteristics or the degree of physical injury. CONCLUSION Chronic pain was frequent and significant, irrespective of injury severity, in these patients who obtained their physical injuries under extreme psychological conditions.
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Affiliation(s)
- Kristin Wisløff‐Aase
- Department of Anaesthesiology Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine, Faculty of Medicine University of Oslo Oslo Norway
| | - Johan Ræder
- Department of Anaesthesiology Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine, Faculty of Medicine University of Oslo Oslo Norway
| | - Grethe Månum
- Institute of Clinical Medicine, Faculty of Medicine University of Oslo Oslo Norway
- Sunnaas Rehabilitation Hospital Nesodden Norway
| | - Marianne Løvstad
- Sunnaas Rehabilitation Hospital Nesodden Norway
- Department of Psychology University of Oslo Oslo Norway
| | - Anne‐Kristine Schanke
- Sunnaas Rehabilitation Hospital Nesodden Norway
- Department of Psychology University of Oslo Oslo Norway
| | - Grete Dyb
- Institute of Clinical Medicine, Faculty of Medicine University of Oslo Oslo Norway
- Norwegian Center for Violence and Traumatic Stress Studies Oslo Norway
| | - Øivind Ekeberg
- Division of Mental Health and Addiction Oslo University Hospital Oslo Norway
- Department of Behavioral Sciences in Medicine, Faculty of Medicine University of Oslo Oslo Norway
| | - Johan Kvalvik Stanghelle
- Institute of Clinical Medicine, Faculty of Medicine University of Oslo Oslo Norway
- Sunnaas Rehabilitation Hospital Nesodden Norway
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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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The Impact of Psychological Interventions on Posttraumatic Stress Disorder and Pain Symptoms: A Systematic Review and Meta-Analysis. Clin J Pain 2019; 35:703-712. [PMID: 31145146 DOI: 10.1097/ajp.0000000000000730] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Esterman M, Fortenbaugh FC, Pierce ME, Fonda JR, DeGutis J, Milberg W, McGlinchey R. Trauma-related psychiatric and behavioral conditions are uniquely associated with sustained attention dysfunction. Neuropsychology 2019; 33:711-724. [PMID: 31144830 DOI: 10.1037/neu0000525] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE It is increasingly recognized that trauma victims, particularly Veterans, have co-occurring psychological and physical conditions that impact cognition, especially the domains of sustained attention and executive functioning. Although previous work has generally attempted to isolate the unique cognitive effects of common combat-related comorbidities, less work has been done to examine how these conditions co-occur, and whether unique cognitive signatures accompany certain clinical combinations. METHOD To address this gap, we examined how several deployment-related conditions were associated with performance on a well-validated measure of sustained attention (i.e., gradual onset continuous performance task [gradCPT]) and a battery of standard neuropsychological measures in 123 Veterans from the Translational Research Center for TBI and Stress Disorders. Initially, a Principal component analysis was conducted to investigate how comorbid conditions grouped together. RESULTS Several sustained attention measures from the gradCPT were differentially associated with four unique combinations of trauma-related pathology. Specifically, a somatic component representing the combination of current pain, sleep disturbance, and mild traumatic brain injury was associated with a higher rate of failures of attentional engagement. On the other hand, a comorbid posttraumatic stress disorder (PTSD) and mood disorder component (moodPTSD), as well as a substance use disorder component, were associated with higher rates of inhibitory control failures. Increased attentional instability was associated with moodPTSD as well as an anxiety disorder component. In contrast, the cognitive effects of deployment-related trauma were not observed on standard neuropsychological measures. CONCLUSION These findings suggest that unique combinations of trauma-related pathology have dissociable effects on sustained attentional control. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
| | | | | | | | - Joseph DeGutis
- Translational Research Center for TBI and Stress Disorders
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40
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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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Gultekin L, Kusunoki Y, Sinko L, Cannon L, Abramoski K, Khan AG, Seng J. The Eco-Social Trauma Intervention Model. Public Health Nurs 2019; 36:709-715. [PMID: 31099045 DOI: 10.1111/phn.12619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/06/2019] [Accepted: 04/05/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We describe a transdisciplinary theory of change for interventions to promote trauma recovery that utilizes an eco-social approach to enhance health status and well-being following trauma exposures. This four-level theory of change could be applied to other population health problems, as well. METHODS This theory-development process included reviewing existing literature, identifying assumptions, defining core concepts, stating propositions, depicting concepts and propositions for clarity, and illustrating with case examples grounded in our focus on trauma. RESULTS The resulting Eco-Social Trauma Intervention Model offers a framework for interventions that address the impact of trauma on the individual level through self-regulation, interpersonal level through relationships, community/organizational level through safety, and societal level through identities. Application of this model to intervention development for those affected by trauma is intended to promote resilience, recovery, posttraumatic growth, and positive adaptations to traumatic stress for populations, going beyond the current Western paradigm of treating individuals for psychopathology. CONCLUSIONS The Eco-Social Trauma Intervention Model offers an adaptable transdisciplinary framework for developing and researching scalable trauma interventions for individuals, communities, and populations.
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Affiliation(s)
- Laura Gultekin
- University of Michigan School of Nursing, Ann Arbor, Michigan
| | | | - Laura Sinko
- University of Michigan School of Nursing, Ann Arbor, Michigan
| | - Lindsay Cannon
- University of Michigan School of Nursing, Ann Arbor, Michigan
| | | | - Angubeen G Khan
- Department of Community Health Sciences, University of California Los Angeles, Los Angeles, California
| | - Julia Seng
- University of Michigan School of Nursing, Ann Arbor, Michigan
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Herbert MS, Malaktaris AL, Dochat C, Thomas ML, Wetherell JL, Afari N. Acceptance and Commitment Therapy for Chronic Pain: Does Post-traumatic Stress Disorder Influence Treatment Outcomes? PAIN MEDICINE 2019; 20:1728-1736. [DOI: 10.1093/pm/pny272] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AbstractObjectiveThe aim of this study was to determine whether post-traumatic stress disorder (PTSD) moderates treatment outcomes in Acceptance and Commitment Therapy for chronic pain.DesignLongitudinal.SettingVeterans Affairs San Diego Healthcare System.SubjectsA total of 126 veterans with chronic pain participating in an Acceptance and Commitment Therapy intervention for chronic pain. A structured clinical interview was used at baseline to designate PTSD-positive (N = 43) and -negative groups (N = 83).MethodsLinear mixed-effects models to determine whether PTSD moderated change in pain interference, pain severity, pain acceptance, depressive symptoms, or pain-related anxiety at post-treatment and six-month follow-up.ResultsParticipants with co-occurring PTSD reported greater pain interference, pain severity, depressive symptoms, and pain-related anxiety at baseline. PTSD status did not moderate treatment effects post-treatment. Rather, there were significant improvements on all study measures across groups (P < 0.001). PTSD status moderated change in depressive symptoms at six-month follow-up (P < 0.05). Specifically, participants with chronic pain alone demonstrated improvement in depressive symptoms compared with pretreatment levels, whereas participants with PTSD regressed to pretreatment levels.ConclusionsPTSD status did not significantly affect treatment outcomes, with the exception of depressive symptoms at six-month follow-up. Overall, Acceptance and Commitment Therapy for chronic pain appears helpful for improving outcomes among veterans with co-occurring PTSD; however, veterans with co-occurring PTSD may experience fewer long-term gains compared with those with chronic pain alone.
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Affiliation(s)
- Matthew S Herbert
- Center of Excellence for Stress and Mental Health (CESAMH), San Diego, California
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, California
| | - Anne L Malaktaris
- Center of Excellence for Stress and Mental Health (CESAMH), San Diego, California
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, California
| | - Cara Dochat
- San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California, USA
| | - Michael L Thomas
- Center of Excellence for Stress and Mental Health (CESAMH), San Diego, California
- Department of Psychiatry, University of California, San Diego, California
| | - Julie Loebach Wetherell
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, California
| | - Niloofar Afari
- Center of Excellence for Stress and Mental Health (CESAMH), San Diego, California
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, California
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Balba NM, Elliott JE, Weymann KB, Opel RA, Duke JW, Oken BS, Morasco BJ, Heinricher MM, Lim MM. Increased Sleep Disturbances and Pain in Veterans With Comorbid Traumatic Brain Injury and Posttraumatic Stress Disorder. J Clin Sleep Med 2018; 14:1865-1878. [PMID: 30373686 DOI: 10.5664/jcsm.7482] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 07/23/2018] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVES Veterans are at an increased risk for traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD), both of which are associated with sleep disturbances and increased pain. Furthermore, sleep disturbances and pain are reciprocally related such that each can exacerbate the other. Although both TBI and PTSD are independently linked to sleep disturbances and pain, it remains unclear whether Veterans with comorbid TBI+PTSD show worse sleep disturbances and pain compared to those with only TBI or PTSD. We hypothesized that sleep and pain would be worse in Veterans with comorbid TBI+PTSD compared to Veterans with only TBI or PTSD. METHODS Veterans (n = 639) from the VA Portland Health Care System completed overnight polysomnography and self-report questionnaires. Primary outcome variables were self-reported sleep disturbances and current pain intensity. Participants were categorized into four trauma-exposure groups: (1) neither: without TBI or PTSD (n = 383); (2) TBI: only TBI (n = 67); (3) PTSD: only PTSD (n = 126); and (4) TBI+PTSD: TBI and PTSD (n = 63). RESULTS The PTSD and TBI+PTSD groups reported worse sleep compared to the TBI and neither groups. The TBI+PTSD group reported the greatest pain intensity compared to the other groups. CONCLUSIONS These data suggest sleep and pain are worst in Veterans with TBI and PTSD, and that sleep is similarly impaired in Veterans with PTSD despite not having as much pain. Thus, although this is a complex relationship, these data suggest PTSD may be driving sleep disturbances, and the added effect of TBI in the comorbid group may be driving pain in this population.
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Affiliation(s)
- Nadir M Balba
- VA Portland Health Care System, Portland, Oregon.,Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, Oregon
| | - Jonathan E Elliott
- VA Portland Health Care System, Portland, Oregon.,Department of Neurology, Oregon Health and Science University, Portland, Oregon
| | - Kris B Weymann
- VA Portland Health Care System, Portland, Oregon.,School of Nursing, Oregon Health and Science University, Portland, Oregon
| | - Ryan A Opel
- VA Portland Health Care System, Portland, Oregon
| | - Joseph W Duke
- Department of Biological Sciences, Northern Arizona University, Flagstaff, Arizona
| | - Barry S Oken
- Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, Oregon.,Department of Neurology, Oregon Health and Science University, Portland, Oregon
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon.,Department of Psychiatry, Oregon Health and Sciences University, Portland, Oregon
| | - Mary M Heinricher
- VA Portland Health Care System, Portland, Oregon.,Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, Oregon.,Department of Neurological Surgery; Oregon Health and Science University, Portland, Oregon
| | - Miranda M Lim
- VA Portland Health Care System, Portland, Oregon.,Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, Oregon.,Department of Neurology, Oregon Health and Science University, Portland, Oregon.,Department of Medicine, Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon.,Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, Oregon
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Elman I, Upadhyay J, Langleben DD, Albanese M, Becerra L, Borsook D. Reward and aversion processing in patients with post-traumatic stress disorder: functional neuroimaging with visual and thermal stimuli. Transl Psychiatry 2018; 8:240. [PMID: 30389908 PMCID: PMC6214971 DOI: 10.1038/s41398-018-0292-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/27/2018] [Accepted: 09/26/2018] [Indexed: 12/12/2022] Open
Abstract
In patients with post-traumatic stress disorder (PTSD), a decrease in the brain reward function was reported in behavioral- and in neuroimaging studies. While pathophysiological mechanisms underlying this response are unclear, there are several lines of evidence suggesting over-recruitment of the brain reward regions by aversive stimuli rendering them unavailable to respond to reward-related content. The purpose of this study was to juxtapose brain responses to functional neuroimaging probes that reliably produce rewarding and aversive experiences in PTSD subjects and in healthy controls. The stimuli used were pleasant, aversive and neutral images selected from the International Affective Picture System (IAPS) along with pain-inducing heat applied to the dorsum of the left hand; all were administered during 3 T functional magnetic resonance imaging. Analyses of IAPS responses for the pleasant images revealed significantly decreased subjective ratings and brain activations in PTSD subjects that included striatum and medial prefrontal-, parietal- and temporal cortices. For the aversive images, decreased activations were observed in the amygdala and in the thalamus. PTSD and healthy subjects provided similar subjective ratings of thermal sensory thresholds and each of the temperatures. When 46 °C (hot) and 42 °C (neutral) temperatures were contrasted, voxelwise between-group comparison revealed greater activations in the striatum, amygdala, hippocampus and medial prefrontal cortex in the PTSD subjects. These latter findings were for the most part mirrored by the 44 vs. 42 °C contrast. Our data suggest different brain alterations patterns in PTSD, namely relatively diminished corticolimbic response to pleasant and aversive psychosocial stimuli in the face of exaggerated response to heat-related pain. The present findings support the hypothesis that brain sensitization to pain in PTSD may interfere with the processing of psychosocial stimuli whether they are of rewarding or aversive valence.
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Affiliation(s)
- Igor Elman
- Department of Psychiatry, Cooper Medical School, Rowan University, Glassboro, NJ, USA.
| | - Jaymin Upadhyay
- 000000041936754Xgrid.38142.3cCenter for Pain and the Brain, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Daniel D. Langleben
- 0000 0004 1936 8972grid.25879.31Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Mark Albanese
- 000000041936754Xgrid.38142.3cCambridge Health Alliance, Harvard Medical School, Boston, MA USA
| | - Lino Becerra
- 000000041936754Xgrid.38142.3cCenter for Pain and the Brain, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - David Borsook
- 000000041936754Xgrid.38142.3cCenter for Pain and the Brain, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
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Akhtar E, Ballew AT, Orr WN, Mayorga A, Khan TW. The Prevalence of Post-Traumatic Stress Disorder Symptoms in Chronic Pain Patients in a Tertiary Care Setting: A Cross-Sectional Study. PSYCHOSOMATICS 2018; 60:255-262. [PMID: 30143327 DOI: 10.1016/j.psym.2018.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 07/20/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND There is limited research regarding the prevalence of post-traumatic stress disorder (PTSD) in civilian multidisciplinary pain clinics. Controlled studies have only examined specific patient populations, such as those with motor vehicle accidents, war veterans, work-related injuries, back pain, and headache. OBJECTIVE The purpose of this study was to estimate the prevalence of PTSD symptoms in patients with chronic pain at a large multidisciplinary pain clinic. METHODS Three hundred consecutive new or newly referred patients with a self-reported history of chronic pain were recruited to complete an in-person screen for PTSD symptoms, which included the Brief Trauma Questionnaire and the PTSD Symptom-Scale Self-Report. Two hundred and sixty-five were eligible for the study. RESULTS Seventy-four (28%) screened positive for PTSD symptoms, a value higher than the lifetime prevalence of PTSD in the general population (6.8%). Those who screened positive for PTSD symptoms were significantly younger (p = 0.007) and had higher levels of pain intensity (p = 0.0005) compared to those who screened negative for PTSD symptoms. CONCLUSIONS The prevalence of PTSD symptoms in our chronic pain population (28%) exceeded the prevalence of PTSD in the general population (7%). Patients with chronic pain who screened positive for PTSD reported higher pain severity and were younger. This emphasizes the need for PTSD screening in the chronic pain population, as early identification and treatment may be effective in reducing the mounting health care costs and disease burden of comorbid chronic pain and PTSD.
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Affiliation(s)
- Eeman Akhtar
- Department of Psychiatry and Behavioral Sciences, University of Kansas Medical Center, Kansas City, KS
| | - Angela T Ballew
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS.
| | - Walter N Orr
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Angela Mayorga
- Department of Psychiatry and Behavioral Sciences, University of Kansas Medical Center, Kansas City, KS
| | - Talal W Khan
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
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Gender differences in psychiatric and medical comorbidity with post-traumatic stress disorder. Compr Psychiatry 2018; 84:75-81. [PMID: 29723769 DOI: 10.1016/j.comppsych.2018.04.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 04/13/2018] [Accepted: 04/18/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) is associated with significant personal and societal burden. The present study examines the gender-specific differences in this burden in terms of the co-occurrence of psychiatric disorders and medical conditions with PTSD in the general population of France. METHODS The study is based on a cross-sectional general population survey of 21,879 adults. Trained interviewers used a computer-assisted telephone interviewing system to administer the Composite International Diagnostic Interview-Short Form to screen for psychiatric disorders and medical conditions in the previous 12 months. RESULTS One third of those with moderately severe PTSD (35.3%) and half of those with severe PTSD (54.2%) suffered from comorbid depression. The prevalence of anxiety disorders and substance use disorders was also greater among severe cases of PTSD. Chronic back or neck problems, frequent or severe headaches, arthritis or rheumatism and hypertension were highly prevalent among adults with PTSD. Adjusting for gender, age, education, employment and marital status, moderately severe and severe PTSD diagnoses were associated with significantly greater odds of comorbid psychiatric disorders and medical conditions. With few exceptions, the pattern of gender differences in psychiatric and medical morbidity among those with moderate or severe PTSD were similar to differences observed among those without PTSD. CONCLUSIONS The findings highlight the burden of co-occurring psychiatric and medical conditions among PTSD sufferers in France and suggest the need for careful consideration of comorbidity in the assessment and service planning for PTSD.
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Green KT, Wilson SM, Dennis PA, Runnals JJ, Williams RA, Bastian LA, Beckham JC, Dedert EA, Kudler HS, Straits-Tröster K, Gierisch JM, Calhoun PS. Cigarette Smoking and Musculoskeletal Pain Severity Among Male and Female Afghanistan/Iraq Era Veterans. PAIN MEDICINE 2018; 18:1795-1804. [PMID: 28340108 DOI: 10.1093/pm/pnw339] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Objective Cigarette smoking and musculoskeletal pain are prevalent among Department of Veterans Affairs (VA) health care system users. These conditions frequently co-occur; however, there is limited empirical information specific to Afghanistan/Iraq era veterans. The present study sought to examine gender differences in the association between cigarette smoking and moderate to severe musculoskeletal pain in US veterans with Afghanistan/Iraq era service. Methods A random sample of 5,000 veterans with service after November 11, 2001, participated in a survey assessing health care needs and barriers to care. One thousand ninety veterans completed the survey assessing post-traumatic stress disorder (PTSD) symptoms, depressive symptoms, and current pain severity. Multivariate logistic regression was used to examine the association between gender, cigarette smoking status, and current moderate to severe musculoskeletal pain. Results Findings indicated a significant gender by smoking interaction on moderate/severe musculoskeletal pain, adjusting for age, self-reported race/ethnicity and weight status, combat exposure, probable PTSD, depressive symptoms, service-connected injury during deployment, and VA health care service utilization. Deconstruction of the interaction indicated that female veteran smokers, relative to female nonsmokers, had increased odds of endorsing moderate to severe musculoskeletal pain (odds ratio [OR] = 2.73, 95% confidence interval [CI] = 1.16-6.41), whereas this difference was nonsignificant for male veterans (OR = 1.03, 95% CI = 0.69-1.56). Conclusions Survey data from Operation Enduring Freedom/Operation Iraqi Freedom veterans suggest an association between current smoking, gender, and moderate to severe musculoskeletal pain. The stronger relationship between smoking and pain in women supports the need for interventional and longitudinal research that can inform gender-based risk factors for pain in veteran cigarette smokers.
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Affiliation(s)
- Kimberly T Green
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Sarah M Wilson
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center (MIRECC), Durham, NC, USA.,Durham VA Medical Center, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Paul A Dennis
- Durham VA Medical Center, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Jennifer J Runnals
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center (MIRECC), Durham, NC, USA.,Durham VA Medical Center, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Rebecca A Williams
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Lori A Bastian
- Department of Internal Medicine, Yale University, New Haven, CT, USA.,Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven Campus, West Haven, CT, USA
| | - Jean C Beckham
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center (MIRECC), Durham, NC, USA.,Durham VA Medical Center, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Eric A Dedert
- Durham VA Medical Center, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Harold S Kudler
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center (MIRECC), Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Kristy Straits-Tröster
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center (MIRECC), Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA.,Phoenix VA Healthcare System, 650 E. Indian School Road, Phoenix, AZ, USA8
| | - Jennifer M Gierisch
- Center for Health Services Research in Primary Care, Durham VA Medical Center, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Patrick S Calhoun
- VA Mid-Atlantic Region Mental Illness Research, Education and Clinical Center (MIRECC), Durham, NC, USA.,Durham VA Medical Center, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA.,Center for Health Services Research in Primary Care, Durham VA Medical Center, NC, USA
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Berghoff CR, McDermott MJ, Dixon-Gordon KL. Psychological flexibility moderates the relation between PTSD symptoms and daily pain interference. PERSONALITY AND INDIVIDUAL DIFFERENCES 2018. [DOI: 10.1016/j.paid.2017.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Fishbain DA, Pulikal A, Lewis JE, Gao J. Chronic Pain Types Differ in Their Reported Prevalence of Post -Traumatic Stress Disorder (PTSD) and There Is Consistent Evidence That Chronic Pain Is Associated with PTSD: An Evidence-Based Structured Systematic Review. PAIN MEDICINE 2018; 18:711-735. [PMID: 27188666 DOI: 10.1093/pm/pnw065] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Objectives The hypotheses of this systematic review were the following: 1) Prevalence of post-traumatic stress disorder (PTSD) will differ between various types of chronic pain (CP), and 2) there will be consistent evidence that CP is associated with PTSD. Methods Of 477 studies, 40 fulfilled the inclusion/exclusion criteria of this review and were grouped according to the type of CP. The reported prevalence of PTSD for each grouping was determined by aggregating all the patients in all the studies in that group. Additionally all patients in all groupings were combined. Percentage of studies that had found an association between CP and PTSD was determined. The consistency of the evidence represented by the percentage of studies finding an association was rated according to the Agency for Health Care Policy and Research guidelines. Results Grouping PTSD prevalence differed ranging from a low of 0.69% for chronic low back pain to a high of 50.1% in veterans. Prevalence in the general population with CP was 9.8%. Of 19 studies, 16 had found an association between CP and PTSD (84.2%) generating an A consistency rating (consistent multiple studies). Three of the groupings had an A or B (generally consistent) rating. The veterans grouping received a C (finding inconsistent) rating. Conclusion The results of this systematic review confirmed the hypotheses of this review.
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Affiliation(s)
- David A Fishbain
- Department of Psychiatry, Miller School of Medicine at the University of Miami, Florida, USA.,Neurological Surgery, Miller School of Medicine at the University of Miami, Florida, USA,Anesthesiology, Miller School of Medicine at the University of Miami, Florida, USA.,Department of Psychiatry, Miami VA Medical Center, Miami, Florida, USA.,State Farm Insurance Bloomington, Illinois, USA
| | - Aditya Pulikal
- Department of Psychiatry, Miller School of Medicine at the University of Miami, Florida, USA
| | - John E Lewis
- Department of Psychiatry, Miller School of Medicine at the University of Miami, Florida, USA
| | - Jinrun Gao
- State Farm Insurance Bloomington, Illinois, USA
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Abstract
Eye movement desensitisation and reprocessing (EMDR) is a relatively recent therapeutic approach to the treatment of traumatic memories in the wake of psychological trauma such as those found in post-traumatic stress disorder (PTSD). It is based on the theory that bilateral stimulation, mostly in the form of eye movements, allows the processing of traumatic memories. While the patient focuses on specific images, negative sensations and associated cognitions, bilateral stimulation is applied to desensitise the individual to these memories and more positive sensations and cognitions are introduced. Although there is still uncertainty about the theoretical concepts underlying EMDR and the role of bilateral stimulation, it is an effective and proven treatment for PTSD and traumatic memories. It should form part of treatment approaches offered to individuals with PTSD.
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