Post-Traumatic Stress Disorder Symptoms Contribute to Worse Pain and Health Outcomes in Veterans With PTSD Compared to Those Without: A Systematic Review With Meta-Analysis

Co-occurring Chronic Pain and PTSD Among US Military Veterans: Prevalence, Correlates, and Functioning

BACKGROUND

The prevalence of co-occurring chronic pain and posttraumatic stress disorder (PTSD) has yet to be established in a nationally representative sample of US veterans, and little is known about the individual contributing roles of these disorders to the psychiatric and functional burden of this comorbidity.

OBJECTIVE

To determine the prevalence of chronic pain, PTSD, and co-occurring chronic pain and PTSD, and psychiatric comorbidities and psychosocial functioning in these groups.

DESIGN

Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of US veterans.

PARTICIPANTS

Veterans (n=4069) were classified into four groups: control (i.e., no PTSD or chronic pain), chronic pain only, PTSD only, and co-occurring chronic pain and PTSD.

MAIN MEASURES

A probable PTSD diagnosis was established using the PTSD Checklist for DSM-5, and a chronic pain diagnosis using a self-report item that queried health care professional diagnoses. Psychiatric and functional status were assessed using the Patient Health Questionnaire-4, Alcohol Use Disorders Identification Test, Screen of Drug Use, Suicide Behaviors Questionnaire-Revised, Short Form Health Survey-8, Brief Inventory of Psychosocial Functioning, and Medical Outcomes Study Cognitive Functioning Scale.

KEY RESULTS

A total of 3.8% of veterans reported both probable PTSD and a diagnosis of chronic pain. Relative to veterans with chronic pain alone, those with co-occurring chronic pain and probable PTSD were more likely to screen positive for psychiatric disorders (odds ratios [ORs]=2.59-9.88) and scored lower on measures of psychosocial functioning (Cohen's ds=0.38-1.43). Relative to veterans with probable PTSD only, those with co-occurring chronic pain and probable PTSD were more likely to have attempted suicide (OR=4.79; 95%CI, 1.81-12.69).

CONCLUSIONS

Results underscore the importance of whole health care that considers a broad range of health and functional domains in the assessment and treatment of co-occurring chronic pain and PTSD in veterans.

Chronic Musculoskeletal Pain and Central Sensitization-Related Symptoms in Chilean Victims of Political Violence During the 1973 to 1990 Dictatorship

People who suffer political violence (PV) are at risk of developing mental illness, chronic noncommunicable diseases, chronic pain, and decreased life expectancy. However, these indicators have been studied primarily in war veterans and refugees. The objective of this study was to estimate the prevalence of chronic musculoskeletal pain (CMP) and central sensitization-related symptoms (CSRS) in Chilean victims of PV during the 1973 to 1990 dictatorship. A cross-sectional observational multicenter study was conducted. Three hundred twenty-five people from six centers of a Ministry of Health of Chile program participated. The presence of CMP was determined by a history of pain ≥3 months, and CSRS was determined using the central sensitization inventory. About 69.23% of the sample had CMP (76.85% of females and 56.56% of males). About 60% of people with CMP showed a high level of CSRS severity (66.67% females and 44.93% males). Females presented significantly higher proportions of CMP (p < .001), and there was an association between CSRS severity and being female (p = .004). Chilean victims of PV during the 1973 to 1990 dictatorship presented a high prevalence of CMP and high-level CSRS severity. Both conditions affected females more than males. Future studies are needed to further delve into these variables' behavior and their influence on the quality of life in this population.

Examining the role of social vulnerability, neighborhood characteristics, and geospatial patterns of firearm-related injuries and clinical outcomes in Milwaukee county

BACKGROUND

Previous work has shown socioenvironmental factors can influence firearm injury. Milwaukee County, Wisconsin is a diverse midwestern county with historic disinvestment in marginalized communities yielding stark segregation along racial and ethnic lines. It is also one of the many U.S. counties burdened by surging firearm injuries. The differences among communities within Milwaukee County provides a unique opportunity to explore the intersection of socioenvironmental factors that may affect clinical outcomes and geospatial patterns of firearm injury.

METHODS

The trauma registry from the regional adult level 1 trauma center was queried for patients who sustained a firearm-related injury from 2015 to 2022 (N = 2402). The Social Vulnerability Index (SVI) ranking was derived using patient residence addresses to evaluate its association with traumatic injury clinical outcomes (i.e., in-hospital mortality, length of hospital stay, ICU or ventilator treatment, or injury severity score) and risk screening results for alcohol use disorder (AUD), posttraumatic stress disorder (PTSD), and depression. We evaluated hotspots of firearm injury density over time for patient residences and injury locations and distances between locations. A spatially lagged regression model tested the association between firearm injury density and SVI domains, alcohol outlet types, and park coverage.

RESULTS

Most firearm injury patients were younger, male, racial or ethnic minorities from disadvantaged neighborhoods (SVI total; M = 0.86, SD = 0.15). SVI was not associated with any clinical outcomes. Of those screened, 12.9% screened positive for AUD and 44.5% screened at risk for PTSD, depression, or both. Hotspot analysis indicated consistent concentrations of firearm injury density. There were no differences in clinical outcomes between those injured inside or outside the home. Census tracts with lower socioeconomic status, greater off-premises and lower on-premises alcohol outlet density were associated with greater firearm injury density.

CONCLUSIONS

In Milwaukee County, firearm injury patients are injured in and often return to the same disadvantaged neighborhoods that may hamper recovery. Results replicate and expand previous work and implicate specific socioenvironmental factors for intervention and prevention of firearm injury.

Gender differences in PTSD severity and pain outcomes: Baseline results from the LAMP trial

BACKGROUND

Post-traumatic stress disorder (PTSD) and chronic pain are highly prevalent comorbid conditions. Veterans dually burdened by PTSD and chronic pain experience more severe outcomes compared to either disorder alone. Few studies have enrolled enough women Veterans to test gender differences in pain outcomes [catastrophizing, intensity, interference] by the severity of PTSD symptoms.

AIM

Examine gender differences in the association between PTSD symptoms and pain outcomes among Veterans enrolled in a chronic pain clinical trial.

METHODS

Participants were 421 men and 386 women Veterans with chronic pain who provided complete data on PTSD symptoms and pain outcomes. We used hierarchical linear regression models to examine gender differences in pain outcomes by PTSD symptoms.

RESULTS

Adjusted multivariable models indicated that PTSD symptoms were associated with higher levels of pain catastrophizing (0.57, 95% CI [0.51, 0.63]), pain intensity (0.30, 95% CI [0.24, 0.37]), and pain interference (0.46, 95% CI [0.39, 0.52]). No evidence suggesting gender differences in this association were found in either the crude or adjusted models (all interaction p-values<0.05).

CONCLUSION

These findings may reflect the underlying mutual maintenance of these conditions whereby the sensation of pain could trigger PTSD symptoms, particularly if the trauma and pain are associated with the same event. Clinical implications and opportunities testing relevant treatments that may benefit both chronic pain and PTSD are discussed.

Pain Intensity, Pain-Related Anxiety, and Hazardous Drinking Among Individuals With PTSD

OBJECTIVE

Evidence suggests that pain intensity may be indirectly linked to hazardous drinking and PTSD symptom severity via pain-related anxiety. The goal of this analysis was to test the hypotheses in a population with PTSD symptoms that pain intensity would be positively and indirectly associated with hazardous drinking, alcohol dependence, alcohol-related problems, and PTSD symptom severity via pain-related anxiety.

METHODS

Heavy drinkers with probable PTSD were recruited via Qualtrics panels (N = 371, 53% Female, Mage = 39.68, SD = 10.86). Linear regression and conditional process models were conducted to examine indirect associations between pain intensity and primary outcomes via pain-related anxiety.

RESULTS

Pain intensity was found to be indirectly associated with hazardous drinking, alcohol dependence, alcohol-related problems, and PTSD symptom severity via greater pain-related anxiety.

CONCLUSION

These initial findings suggest that pain-related anxiety may play an important role in relations between the experience of pain and hazardous patterns of alcohol consumption among individuals with probable PTSD. Future research is needed to determine the temporal nature of these associations and to examine the potential utility of treatments that address pain-related anxiety in the context of comorbid pain, PTSD, and hazardous drinking.

Veterans with chronic pain: Examining gender differences in pain type, overlap, and the impact of post-traumatic stress disorder

BACKGROUND

Women are more likely to experience multiple overlapping pain conditions (MOPCs) relative to men. Post-traumatic stress disorder can negatively impact the severity and trajectory of chronic pain and its treatment. Specific associations between gender, post-traumatic stress disorder (PTSD), and MOPCs require further examination.

METHODS

A cohort of all Veterans in 2021 who met criteria for one or more of 12 chronic pain types was created using national Veterans Health Administration administrative data. MOPCs were defined as the number of pain types for which each patient met criteria. Multivariable logistic regression models estimated gender differences in frequency for each of the 12 pain subtypes, after controlling for demographics and comorbidities. Negative binomial regression was used to estimate gender differences in the count of MOPCs and to explore moderation effects between gender and PTSD.

RESULTS

The cohort included 1,936,859 Veterans with chronic pain in 2021, which included 12.5% women. Among those with chronic pain, women Veterans had higher rates of MOPCs (mean = 2.3) relative to men (mean = 1.9): aIRR = 1.31, 95% CI: 1.30-1.32. PTSD also served as an independent risk factor for MOPCs in adjusted analysis (aIRR = 1.23, 95% CI: 1.23-1.24). The interaction term between gender and PTSD was not significant (p = 0.87). Independent of PTSD, depressive disorders also served as a strong risk factor for MOPCs (aIRR = 1.37, 95% CI: 1.36-1.37).

CONCLUSIONS

Individuals with MOPCs and PTSD may have complex treatment needs. They may benefit from highly coordinated trauma-sensitive care and integrated interventions that simultaneously address pain and PTSD.

SIGNIFICANCE

Women were significantly more likely than men to experience MOPCs. PTSD was also significantly, independently, associated with MOPCs. Patients, particularly women, may benefit from tailored interventions that address both trauma and MOPCs.

Considering the psychological experience of amputation and rehabilitation for military veterans: a systematic review and metasynthesis of qualitative research

PURPOSE

Research highlights the differences and unique experiences of military veterans experiencing amputation compared to civilians. This review aimed to synthesise qualitative research exploring the experience of amputation and rehabilitation among existing or previous members of the military.

METHODS

A systematic search of six databases (PsycINFO, AMED, MEDLINE, CINAHL, Web of Science and Scopus) was undertaken in March 2022. The results of 17 papers reporting 12 studies published between 2009 and 2022 were synthesised using a meta-ethnographic approach to generate new interpretations reflecting the experiences of members of the military who have experienced limb loss.

RESULTS

Three themes were developed from the data: (1) Making the physical and psychological transition to life after amputation; (2) The role of the military culture in rehabilitation; and (3) The impact of relationships and the gaze of others during rehabilitation and beyond.

CONCLUSIONS

Military veterans with limb loss experience difficulties in navigating civilian healthcare systems and gaining appropriate support away from the military. Rehabilitation professionals, with psychological training or mentoring, involved in the care of military veterans following amputation could offer psychological support during the transition to civilian life and targeted therapies to veterans experiencing high levels of pain, and facilitate peer support programmes.

The mediating role of posttraumatic stress disorder symptoms in pain cognitions among Veterans with chronic pain

Symptoms of posttraumatic stress disorder (PTSD) are highly prevalent among Veterans with chronic pain. Considerable research has examined the intersection of chronic pain and PTSD symptoms. However, it remains unclear whether changes in PTSD may potentially serve a mechanistic role in improving unhelpful pain cognitions for individuals with chronic pain. The present research contributes to the foundational knowledge by addressing this question. Baseline data from a randomized controlled trial targeting pain-related disability for Veterans (n = 103; mean age 43.66; SD = 10.17) with musculoskeletal pain and depression and/or PTSD symptoms were used. Cross-sectional mediation analyses showed that PTSD symptoms mediated the relationship between pain severity and pain catastrophizing, and between pain severity and pain acceptance. After controlling for depression, the mediation involving pain catastrophizing remained significant, while the mediation for pain acceptance did not. Although limitations exist, results point to several treatment recommendations, including ensuring that depressive affect, PTSD-specific symptoms, and attention to both body and mind are included in treatment. Results also provide preliminary evidence for examining these associations longitudinally to improve our understanding of this population and corresponding treatment recommendations.

Treating a common comorbidity: Pain outcomes following a 3-week cognitive processing therapy-based intensive treatment for posttraumatic stress disorder address

Posttraumatic stress disorder (PTSD) commonly co-occurs with pain and has been implicated in the maintenance of chronic pain. However, limited research has examined whether intervening for PTSD can hinder or optimize treatment outcomes for co-occurring pain and PTSD. In the present study, we examined changes in pain, PTSD, and depressive symptoms among 125 veterans completing a 3-week cognitive processing therapy (CPT)-based intensive treatment program (ITP) for PTSD. We also explored whether pretreatment pain interference predicted changes in PTSD and depressive symptom severity and whether larger changes in pain interference over the course of treatment were associated with larger changes in PTSD and depressive symptom severity. Linear mixed models revealed that participants' pain interference decreased throughout treatment, d = 0.15, p = .039. Higher levels of pretreatment pain interference were associated with higher PTSD, p = .001, and depressive symptom severity, p = .014, over time. Larger reductions in pain interference corresponded to more improvement in PTSD symptoms, β = -.03; p < .001, but not depressive symptoms. These findings indicate that ITPs for PTSD can reduce pain interferences, albeit to a small degree, and that reductions in pain interference can contribute to reductions in PTSD symptom severity. Future studies should examine which treatment components contribute to larger changes in symptom severity for veterans with co-occurring pain and PTSD.

The Exploration of the GWOT Combat Amputee's Experience With Longitudinal Care: A Qualitative Study

INTRODUCTION

Contemporary advances in combat medicine have allowed greater numbers of wounded service members to survive their injuries. An estimated 1,705 combat veterans sustained major lower or upper extremity amputations between 2001 and 2017 during the Global War on Terror. This study intends to answer the following question utilizing a qualitative study design: What were the common and abnormal experiences of the Global War on Terror combat amputees relative to their mechanism of injury, perception of injury, and systems of care utilized during their recovery and rehabilitation process?.

METHODS

During the months of December 2022 and January 2023, individual semi-structured interviews were conducted with U.S. Marines that served in the Global War on Terror (total n = 10). Deductive and inductive approaches were employed to identify codes, themes, and meta-themes in the data.

RESULTS

All participants deployed to Afghanistan between the years 2010 and 2014 and were assigned to the following military occupational specialties: Explosive Ordnance Disposal technicians (total n = 2); combat engineers (total n = 2); and infantrymen (total n = 6). Analysis of data collected from interviews highlighted these key observations: (1) Themes in the combat amputee experience include support, systems of care, and mindset and (2) the themes synergistically contribute to the meta-themes mental health and pain and vice versa. As all participants were subjected to a blast mechanism of injury, it is difficult to determine if this played a role in deviating rehabilitation and recovery processes. Perception of injury and how well participants adapted to their new lifestyle, meaning how optimistic they were, appeared to play a significant role in recovery. Participants had mixed feelings about the care they had received but generally spoke favorably of military hospitals and were frustrated with the Veteran Affairs, and there was no clear consensus on their relationship with civilian health care, though most participants chose to seek most of their care through the Veteran Affairs.

CONCLUSION

Based on the research question, this study found an intricate relationship between mental health, pain, and the experiences of the participants regarding their care and rehabilitation. However, the nature of qualitative research makes it impossible to determine generalizations that can be used to create meaningful change to address improving combat amputee veteran care. Further research into long-term health outcomes based on hypotheses not evaluated in existing literature would further improve the ability of health care providers to care for this unique patient population.

Acupuncture Therapy for Military Veterans Suffering from Posttraumatic Stress Disorder and Related Symptoms: A Scoping Review of Clinical Studies

Military personnel in combat face a high risk of developing posttraumatic stress disorder (PTSD). In this study, a protocol-based scoping review was conducted to identify the current status of research on the efficacy of acupuncture for treating combat-related PTSD in military personnel. A literature search was conducted across 14 databases in November 2022, and data from the included studies were collected and descriptively analyzed. A total of eight studies were included. Participants were assessed for core PTSD symptoms using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5 and the Clinician-Administered PTSD Scale, as well as related symptoms, such as sleep issues. Although the efficacy of acupuncture has been substantiated in numerous studies, certain metrics did not exhibit improvement. Auricular acupuncture was the most commonly used treatment (50%) followed by manual acupuncture (25%) and a combination of both (25%). Shenmen and Kidney points were frequently targeted at auricular acupoints. The treatment period varied between 5 days and 2 months. While adverse events were reported in two of the fifty-five patients in the intervention group and in four of the sixty-four patients in the control group in the randomized controlled trial studies, no fatal adverse events were reported.

Management of Chronic Pain and PTSD in Veterans With tDCS+Prolonged Exposure: A Pilot Study

INTRODUCTION

Chronic pain and posttraumatic stress disorder (PTSD) are prevalent comorbid conditions, particularly in Veterans; however, there are few integrated treatments for chronic pain and PTSD. Instead, interventions are typically implemented separately and may involve addictive opioids. Although there are highly effective, non-pharmacological treatments for PTSD, they are plagued by high dropout, which may be exacerbated by comorbid pain, as these PTSD treatments typically require increased activity. Importantly, a noninvasive pain treatment, tDCS (transcranial direct current stimulation) shows indications of effectiveness and may be integrated with psychological treatments, even when delivered via telehealth. This study examines the feasibility and initial efficacy of integrating home telehealth tDCS with prolonged exposure (PE), an evidence-based PTSD treatment.

MATERIALS AND METHODS

Thirty-nine Veterans were contacted, 31 consented to evaluation, 21 were enrolled, and 16 completed treatment and provided pre- and post-treatment data at one of two Veterans Affairs Medical Centers. Transcranial direct current stimulation sessions corresponded with PE exposure assignments, as there is theoretical reason to believe that tDCS may potentiate extinction learning featured in PE.

RESULTS

Patients evinced significant improvement in both pain interference and PTSD symptoms and a trend toward improvement in depression symptoms. However, a significant change in pain intensity was not observed, likely because of the small sample size.

DISCUSSION

The findings provide initial support for the feasibility of an entirely home-based, integrated treatment for comorbid PTSD and pain.

Measures of trauma exposure and trauma response: A scoping review

BACKGROUND

In contrast to the vast clinical, theoretical, and empirical literature on the impact of trauma, relatively few studies have reviewed the trauma measures that researchers and clinicians can choose to use in their work. This scoping review aimed to catalog all trauma measures (trauma exposure and its subjective responses) that have been published in the peer-reviewed literature, developed for use with adult populations.

METHOD

Through a systematic search of the literature and the screening of 19,631 abstracts, a total of 363 unique trauma measures were identified.

RESULT

Most of these measures were developed for assessment purposes rather than for clinical screening or diagnostic purposes. Most of these measures are patient-self-report measures that assess trauma exposure in the patients' lifetime, or subsequent symptoms, particularly cognitive impairments.

DISCUSSION

Complications in the trauma literature are highlighted, including the use of very similar abbreviations of measures, substantial discrepancies regarding the definition of trauma, and the general assumption that a potentially traumatic event inevitably leads to traumatic distress rather than a path of resilience.

The Impact of Comorbid Chronic Pain on Pharmacotherapy for Veterans with Post-Traumatic Stress Disorder

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.

Biomarkers of Neurodegeneration in Post-Traumatic Stress Disorder: An Integrative Review

Post-Traumatic Stress Disorder (PTSD) is a chronic psychiatric disorder that occurs following exposure to traumatic events. Recent evidence suggests that PTSD may be a risk factor for the development of subsequent neurodegenerative disorders, including Alzheimer's dementia and Parkinson's disease. Identification of biomarkers known to be associated with neurodegeneration in patients with PTSD would shed light on the pathophysiological mechanisms linking these disorders and would also help in the development of preventive strategies for neurodegenerative disorders in PTSD. With this background, the PubMed and Scopus databases were searched for studies designed to identify biomarkers that could be associated with an increased risk of neurodegenerative disorders in patients with PTSD. Out of a total of 342 citations retrieved, 29 studies were identified for inclusion in the review. The results of these studies suggest that biomarkers such as cerebral cortical thinning, disrupted white matter integrity, specific genetic polymorphisms, immune-inflammatory alterations, vitamin D deficiency, metabolic syndrome, and objectively documented parasomnias are significantly associated with PTSD and may predict an increased risk of subsequent neurodegenerative disorders. The biological mechanisms underlying these changes, and the interactions between them, are also explored. Though requiring replication, these findings highlight a number of biological pathways that plausibly link PTSD with neurodegenerative disorders and suggest potentially valuable avenues for prevention and early intervention.

Initial assessment of medical post-traumatic stress among patients with chronic esophageal diseases

BACKGROUND

Diagnosis and management of chronic esophageal disease requires the use of potentially traumatic medical procedures, performed with or without sedation. Medical trauma and post-traumatic stress (PTS) are emerging as important considerations in patients with digestive illness. To date, no study assesses medical PTS from procedures in patients with esophageal disease.

METHODS

Adult patients with achalasia, eosinophilic esophagitis, gastroesophageal reflux disease, or functional esophageal disease at a university-based gastroenterology clinic completed: Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5), Gastroesophageal Disease Questionnaire, Brief Esophageal Dysphagia Questionnaire, Northwestern Esophageal Quality of Life scale (HRQoL), NIH-PROMIS Depression scale, and a study-specific questionnaire about esophageal procedures (endoscopy with sedation; functional lumen imaging probe (FLIP) with sedation; high-resolution manometry (HRM); wireless pH testing; or 24-h pH-impedance testing).

KEY RESULTS

Half of 149 participants reported at least one traumatic procedure, with HRM most often cited. Only 2.7% met the cutoff for PTS on PCL-5. This increased to 7.1% for patients with a traumatic procedure combined with experiencing intense fear. Rates of moderate-severe PTS ranged from 7.4%-12% for all patients and 14%-29% for those with a traumatic procedure with fear. Medical PTS was associated with poorer HRQoL, and increased esophageal symptoms, depression, and hypervigilance and symptom anxiety.

CONCLUSIONS & INFERENCES

Preliminary evidence suggests medical PTS affects few patients with esophageal disease. However traumatic procedures, most often associated with HRM, significantly increase PTS symptoms. The potential impacts of medical PTS on esophageal patient assessment and outcomes are considerable and warrants further study.

Can heart rate variability be a bio-index of hope? A pilot study

Background

Hope can affect the thinking habits, emotional regulations, and behaviors of individuals. Hope is considered as a positive trait by clinicians, who often assess the level of hope in psychological evaluations. Previous measurements of hope were largely based on self-reported questionnaires leading to the problem of subjectivity. Heart Rate Variability (HRV) is a bio index that is an objective, quick, cost effective, and non-invasive measurement. HRV has been used in the evaluation of physical health and some psychiatric conditions. However, it has not been tested for its potential to be a bio-index of the level of hope.

Method

This pilot cross-sectional observational study aimed to examine the relationships between HRV and the level of hope among adult Chinese people in Hong Kong. Convenience sampling was used and 97 healthy participants were recruited. Their level of hope was measured by the Dispositional Hope Scale-Chinese (DHS-C), and their HRV was quantified by emWave Pro Plus, a reliable sensor of HRV. Spearman's correlation coefficient analysis was performed on the HRV measurements and DHS-C.

Results

The DHS-C's overall mean score was 45.49. The mean scores of the subscale DHS-C (Agency) was 22.46, and the mean scores of DHS-C (Pathway) was 23.03. It was also revealed that there were significant, weak, and negative correlations between the level of hope and four out of ten HRV metrics. One HRV metric was found to have a significant, weak, and positive correlation with the level of hope.

Conclusion

This study provided initial evidence to support the use of HRV as a bio-index of hope. Implications of the current study and recommendations for future research directions are discussed.

Headache comorbidity in refugees and migrants with post-traumatic stress disorder

BACKGROUND

Headache is often comorbid with post-traumatic stress disorder yet overlooked in health assessments of refugees.

OBJECTIVES

To describe prevalence of severe headache among refugees with post-traumatic stress disorder and compare severity of post-traumatic stress disorder symptoms and treatment outcomes among those with and without severe headache.

METHODS

This follow-up study used data from the Danish Database on Refugees with Trauma. Participants were recruited from 2009 to 2015 at a specialized psychiatric clinic. Prevalence of severe headache was computed by age, sex, and history of head injury or torture. Severe headache was defined as maximum headache scores on the Hopkins Symptom Checklist, Symptom Checklist-90 or the Visual Analogue Scale. Groups with and without severe headache were described according to validated questionnaires before and after 12-18 months of multidisciplinary treatment for post-traumatic stress disorder. Regression analyses were used to analyze associations between headache at start of treatment and symptom burden post-treatment, controlled for pre-treatment scores and possible confounders.

RESULTS

Among 403 female and 489 male participants, nearly all (97.5%) complained of headaches. Severe headache prevalence was 31.4% to 50.0% (depending on which questionnaire was used) and was significantly more common among females and those aged 30-49 years. There was no clear relationship between headache and head injury or torture. Participants with severe headache had heavier symptom burdens compared to those without severe headache. Post-treatment, headache prevalence by age and sex did not change significantly. Those without severe headache showed a tendency toward improvement in outcome measures; this was not seen among those with severe headache. Pre-treatment headache scores were correlated with all outcome measures. Regression analyses controlled for pre-treatment scores of the outcome variables showed associations between pre-treatment headache scores (Hopkins Symptom Checklist or Symptom Checklist-90) and post-treatment scores for intrusion, numbing, hyperarousal, anxiety, disability, and quality of life (all p < 0.02).

CONCLUSION

Headache is a prevalent comorbid condition among refugees with post-traumatic stress disorder. Measures of pre-treatment headache severity appear to predict post-traumatic stress disorder treatment outcomes. Severe headache adversely affects post-traumatic stress disorder prognosis. Assessment and treatment options should be studied further.

Treatment of Comorbid Disorders, Syndromes, and Symptoms of Posttraumatic Stress Disorder Related to Childhood Maltreatment with STAIR-NT

Abstract. Background: Early interpersonal traumatic events, such as childhood maltreatment, increase the risk of developing complex posttraumatic stress symptoms. The biphasic treatment program STAIR-NT (Skills Training for Affective and Interpersonal Regulation with Narrative Therapy), developed specifically for this patient group, combines interventions to improve emotion regulation and interpersonal skills with narrative therapy. Objective: Many affected patients with PTSD after childhood maltreatment also suffer from various comorbid mental disorders and symptoms that can affect and impede the course and outcome of treatment with STAIR-NT. Method: Based on experience from a current treatment study, we provide recommendations for integrating treatment of comorbid mental symptoms into STAIR-NT. Results / Conclusion: Training affective and interpersonal regulation skills in the first treatment phase offers various interventions to efficiently adapt transdiagnostic mechanisms such as emotion dysregulation. In cases of severe comorbid mental disorders or symptoms, adding disorder-specific interventions to STAIR-NT may be indicated.

Yoga Plus Mantram Repetition to Reduce Chronic Pain in Veterans With Post-Traumatic Stress Disorder: A Feasibility Trial

Background

Veterans with post-traumatic stress disorder (PTSD) are more likely to report chronic pain than veterans without PTSD. Yoga has been shown to reduce both chronic pain and PTSD symptoms in clinical trials. The goal of our study was to assess the feasibility and acceptability of conducting a randomized controlled trial (RCT) that combined yoga and mantram repetition (Yoga + MR) into one program for military veterans with both chronic pain and PTSD.

Methods

In this feasibility RCT, 27 veterans were randomized to either Yoga + MR or a relaxation intervention. Due to the COVID-19 pandemic, in-person recruitment, assessments, and intervention attendance were re-evaluated. Although remote delivery of aspects of the study were utilized, interventions were delivered in-person. Feasibility benchmarks met included full recruitment in 12 months or less, 75%+ retention at initial follow-up assessment, 50%+ attendance rate, and 75%+ of participants satisfied with the interventions.

Results

The sample was racially and ethnically diverse, and 15% of participants were women. Participant recruitment lasted approximately 11 months. Out of 32 participants initially randomized, two participants asked to be dropped from the study and three did not meet PTSD symptom criteria. For the remaining 27 participants, retention rates were 85% at 12 weeks and 81% at 18 weeks. Participants attended 66% of in-person yoga and 55% of in-person relaxation sessions. Satisfaction was high, with 100% of yoga participants and 75%/88% of relaxation participants agreeing or strongly agreeing they were satisfied with the intervention/instructors. After 12 weeks (end of intervention), Yoga + MR participants reported reduced back-pain related disability (primary outcome), reduced alcohol use, reduced fatigue, and increased quality of life, while relaxation group participants reported reductions in pain severity, PTSD symptoms, and fatigue.

Conclusions

Amidst many research challenges during the pandemic, recruitment, retention, and efficacy results from this feasibility trial support advancement to a larger RCT to study Yoga + MR for chronic pain and PTSD.

Acupuncture for military veterans with posttraumatic stress disorder and related symptoms after combat exposure: Protocol for a scoping review of clinical studies

Posttraumatic stress disorder is caused by traumatic events such as death, serious injury, and sexual violence. Military personnel and veterans are at high risk for posttraumatic stress disorder. Conventional posttraumatic stress disorder treatments have certain limitations. Complementary and integrative medicine treatments, especially acupuncture, are potential novel first-line treatments that may overcome these limitations. We aim to investigate the current status of the available clinical evidence related to acupuncture treatment for posttraumatic stress disorder in war veterans. We will follow the scoping review process as previously described. The study question is as follows: "Which types of clinical research designs, study types, study durations, adverse events, and clinical outcomes have been reported regarding acupuncture therapy for posttraumatic stress disorder in military veterans?" We will perform a comprehensive search of Medline, Excerpta Medica dataBASE, Cochrane Central Register of Controlled Trials, Web of Science, Scopus databases, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, and PsycArticles databases, as well as Chinese, Korean, and Japanese databases, from inception to June 2022. Data from the included studies will be collected and descriptively analyzed in relation to our research question. The extracted data will be collated, synthesized, and summarized according to the analytical framework of a scoping review. The protocol of this study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews to ensure the clarity and completeness of our reporting in all phases of this scoping review (Protocol registration: https://osf.io/t723f/). The findings of this scoping review will provide fundamental data that will help researchers identify appropriate research questions and design further studies on the use of acupuncture for PTSD management in military veterans. These results will be helpful for developing disaster site-specific research protocols for future clinical trials on this topic.

Chronic post-traumatic pain: rheumatological and orthopedic aspects

Trauma causes a complex local and systemic reaction of the macroorganism, the consequences of which can be various functional, neurological and psychoemotional disorders. One of the most painful complications of injuries of the musculoskeletal system is chronic post-traumatic pain (CPTP), which occurs, depending on the severity of the damage, in 10–50% of cases. The pathogenesis of this syndrome is multifactorial and includes the development of chronic inflammation, degenerative changes (fibrosis, angiogenesis, heterotopic ossification), pathology of the muscular and nervous systems, neuroplastic changes leading to the development of central sensitization, as well as depression, anxiety and catastrophization. Risk factors for CPTP should be considered the severity of injury, comorbid diseases and conditions (in particular, obesity), stress and serious trauma-related experiences (within the framework of post-traumatic stress disorder), the development of post-traumatic osteoarthritis and chronic tendopathy, genetic predisposition, deficiencies in treatment and rehabilitation in the early period after injury. To date, there is no clear system of prevention and treatment of CPTP. Considering the pathogenesis of this suffering, adequate anesthesia after injury, active anti–inflammatory therapy (including local injections of glucocorticoids), the use of hyaluronic acid, slow-acting symptomatic agents and autologous cellular preparations – platelet-riched plasma, mesenchymal stem cells, etc. are of fundamental importance. However, therapeutic and surgical methods of CPTP control require further study

Pain Catastrophizing Mediates the Relationship Between Pain Intensity and Sleep Disturbances in U.S. Veterans With Chronic Pain

INTRODUCTION

Veterans with chronic pain frequently report comorbid disruptions in sleep and psychological dysfunction. The purpose of this study was to investigate whether psychological function variables mediate the sleep-pain relationship. Knowledge regarding such contributing factors can inform the development and optimization of treatments for sleep disturbances and pain.

MATERIALS AND METHODS

In an IRB-approved, registered clinical trial, we collected objective sleep data from U.S. military Veterans with chronic pain (N = 184, ages 23-81) using wrist actigraphy for 7 days and self-reported survey data assessing sleep quality, pain intensity, and psychological function (depression, anxiety, post-traumatic stress disorder, and pain catastrophizing). We investigated the associations between objectively measured and self-reported sleep quality and self-reported pain intensity. In addition, using parallel mediation analyses, we examined whether psychological function variables mediated these associations.

RESULTS

Actigraphy showed suboptimal sleep duration (less than 7 hours) and sleep fragmentation for most participants. Self-reported poor sleep quality and pain intensity were significantly correlated. Pain catastrophizing was found to mediate the association between self-reported sleep quality and pain intensity.

CONCLUSIONS

Sleep disturbances in this sample of Veterans with chronic pain included insufficient sleep, fragmented sleep, and perceived poor sleep quality. Analyses suggest that poor perceived sleep quality and pain intensity are mediated via pain catastrophizing. The finding highlights the potential importance of pain catastrophizing in Veterans with chronic pain. Future longitudinal research is needed to determine the extent to which treatments that reduce pain catastrophizing might also improve both sleep and pain outcomes.

Whole Health Use and Interest Across Veterans With Co-Occurring Chronic Pain and PTSD: An Examination of the 18 VA Medical Center Flagship Sites

Objective

Veterans Healthcare Administration (VHA) conducted a large demonstration project of a holistic Whole Health approach to care in 18 medical centers, which included making complementary and integrative health (CIH) therapies more widely available. This evaluation examines patterns of service use among Veterans with chronic pain, comparing those with and without PTSD.

Methods

We assessed the use of Whole Health services in a cohort of Veterans with co-occurring chronic pain and PTSD (n = 1698; 28.9%), comparing them to Veterans with chronic musculoskeletal pain only (n = 4170; 71.1%). Data was gathered from VA electronic medical records and survey self-report. Whole Health services were divided into Core Whole Health services (e.g., Whole Health coaching) and CIH services (e.g., yoga). Logistic regression was used to determine whether Veterans with co-occurring chronic pain and PTSD utilized more Whole Health services compared to Veterans with chronic pain but without PTSD.

Results

A total of 40.1% of Veterans with chronic pain and PTSD utilized Core Whole Health services and 53.2% utilized CIH therapies, compared to 28.3% and 40.0%, respectively, for Veterans with only chronic pain. Adjusting for demographics and additional comorbidities, Veterans with comorbid chronic pain and PTSD were 1.24 ( 95% CI: 1.12, 1.35, P ≤ .001) times more likely than Veterans with chronic pain only to use Core Whole Health services, and 1.23 ( 95% CI: 1.14, 1.31, P ≤ .001) times more likely to use CIH therapies. Survey results also showed high interest levels in Core Whole Health services and CIH therapies among Veterans who were not already using these services.

Conclusion

Early implementation efforts in VHA led to high rates of use of Core Whole Health and CIH therapy use among Veterans with co-occurring chronic pain and PTSD. Future assessments should examine how well these additional services are meeting the needs of Veterans in both groups.

Associations between symptoms of posttraumatic stress disorder, pain, and alcohol use disorder among OEF/OIF/OND veterans

BACKGROUND

Alcohol use disorder (AUD) is prevalent among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) veterans. Pain and posttraumatic stress disorder (PTSD) are highly comorbid and increase risk of AUD. Prior studies linking pain or PTSD to AUD have not explored interactions between pain and PTSD symptoms.

METHODS

OEF/OIF/OND veterans (N = 1230) were recruited from social media websites for a cross-sectional study of health behavior. Pain was assessed using the Pain Outcomes Questionnaire. PTSD symptoms and PTSD symptom clusters were assessed using the Posttraumatic Stress Disorder Checklist for DSM-5. AUD symptoms were assessed with the AUD Identification Test. Linear regression models were used to test for main and interaction effects in the full sample and separately by sex.

RESULTS

Both pain and PTSD symptoms were associated with increased AUD symptomology, though the relationship between pain and AUD was heighted at relatively low PTSD symptoms. With respect to PTSD symptom clusters, re-experiencing and negative cognitions and mood were associated with increased AUD symptomology. Interactions between pain and re-experiencing as well as pain and avoidance were revealed. Results for men mirrored the full sample, while an interaction between pain and negative cognitions and mood was associated with AUD in women.

CONCLUSIONS

Results highlight associations between AUD, PTSD symptoms, and pain among veterans. While the relationship between pain and AUD appeared stronger in the context of low PTSD symptoms, both pain and PTSD symptoms were associated with increased AUD. Clinicians treating veterans with AUD should address the range of potential comorbidities.

Pain-related disability, PTSD symptoms, and mood among a comorbid chronic pain and PTSD sample prior to and during the COVID-19 pandemic

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.

Angiotensin II type 1 receptor blockade attenuates posttraumatic stress disorder-related chronic pain by inhibiting glial activation in the spinal cord

Clinically, posttraumatic stress disorder (PTSD) and chronic pain are highly comorbid conditions, but the underlying mechanisms of and therapeutic strategies against PTSD-related pain remain unclear. Our previous studies suggested that dysregulation of neuroinflammation contributes to the development of stress-induced hyperalgesia. Recent studies reported that angiotensin II was a 'stress-related hormone', and could induce glial activation by stimulating the type 1 receptor (AT1R). In the present study, we aimed to investigate whether AT1R blockade could attenuate mechanical allodynia induced by PTSD-like stress. Adult male rats were exposed to single prolonged stress (SPS) to establish a model of PTSD-pain comorbidity. Our results showed that SPS exposure increased the levels of angiotensin II in the hippocampus, prefrontal cortex (PFC) and spinal cord; intraperitoneal injection of losartan attenuated SPS-induced mechanical allodynia, and suppressed SPS-induced glial activation (both microglia and astrocytes) and proinflammatory cytokine expression in the PFC and spinal cord, but not in the hippocampus. We further showed that intrathecal injection of losartan also exerted anti-hyperalgesic effect and suppressed SPS-induced glial activation and proinflammatory cytokine expression in the spinal cord. These results indicated that AT1R blockade by losartan attenuated mechanical allodynia induced by PTSD-like stress, and this may be attributed to the suppression of glial activation and proinflammatory cytokine expression in the spinal cord. Although further research is warranted to verify our findings in female rodents and to assess pharmacological effects of AT1R blockade in PFC and hippocampus, our study suggested the therapeutic potential of targeting AT1R in the treatment of PTSD-related chronic pain.

Complex PTSD and borderline personality disorder

BACKGROUND

This article builds on a previous review (Ford and Courtois, Borderline Personal Disord Emot Dysregul 1:9, 2014) which concluded that complex posttraumatic stress disorder (cPTSD) could not be conceptualized as a sub-type of either PTSD or BPD. Recent research is reviewed that extends and clarifies the still nascent understanding of the relationship between cPTSD and BPD.

MAIN BODY

The circumscribed formulation of adult cPTSD that has been developed, validated, and included in the 11th Edition of the International Classification of Diseases has spurred research aimed at differentiating cPTSD and BPD both descriptively and empirically. A newly validated Developmental Trauma Disorder (DTD) syndrome for children and adolescents provides a basis for systematic research on the developmental course and origins of adult cPTSD and BPD. This review summarizes recent empirical findings regarding BPD, PTSD, and cPTSD in terms of: (1) prevalence and comorbidity; (2) clinical phenomenology; (3) traumatic antecedents; (4) psychobiology; (5) emotion dysregulation; (6) dissociation; and (7) empirically supported approaches to clinical assessment and psychotherapeutic treatment.

CONCLUSION

The evidence suggests that PTSD, cPTSD, and BPD are potentially comorbid but distinct syndromes. A hypothesis is advanced to stimulate scientific research and clinical innovation defining and differentiating the disorders, positing that they may represent a continuum paralleling the classic conceptualization of the stress response, with dissociation potentially involved in each disorder.

Authenticity as a Resilience Factor Against CV-19 Threat Among Those With Chronic Pain and Posttraumatic Stress Disorder

OBJECTIVE

The novel coronavirus (2019; CV-19) is linked to increases in emotional distress and may be particularly problematic for those with pre-existing mental and physical conditions, such as chronic pain and posttraumatic stress disorder (PTSD). However, little empirical research has been published on resilience factors in these individuals. The present study aims to examine authenticity as a resilience factor among those with chronic pain and/or PTSD.

METHODS

Prior to the national response to the pandemic (January 10-24, 2020), participants were screened for pain-related disability (Oswestry Disability Index; ODI) and PTSD symptoms (Posttraumatic Checklist for DSM-5; PCL-5), and on the basis of those responses were categorized into one of four groups: healthy, chronic pain only, PTSD only, or comorbid chronic pain and PTSD. During the CV-19 pandemic (May 5-May 13, 2020), participants responded again to the ODI and PCL-5, in addition to the Wood Authenticity Scale, Brief Pain Inventory, and items related to the CV-19 pandemic.

RESULTS

A total of 110 participants (54.55% women), aged 42.19 (SD = 13.16), completed the survey during the pandemic. The comorbid group endorsed higher levels of CV-19 Threat and Impact compared to all other groups. Authenticity moderated this relationship relevant to CV-19 Threat among those in the chronic pain only group, and not in any other group.

CONCLUSION

The comorbid group endorsed higher levels of CV-19 Threat and Impact compared to all other groups. Importantly, greater authenticity was associated with less CV-19 Threat in the chronic pain only group, and not in any other group. The present study also highlights the importance of engaging authentically for those with chronic pain during the pandemic.

Acceptability and feasibility of using actigraphy to assess habitual physical activity and sleep parameters in men and women living in rural communities in conflict-affected Eastern Democratic Republic of Congo

BACKGROUND

The goals of this study were to (1) determine the feasibility and acceptability of using actigraphy to objectively measure sleep quality and habitual physical activity in rural Democratic Republic of Congo (DRC) and (2) examine the relationship between sleep parameters, self-report symptoms, daytime physical activity, and physical function, including the ability to work.

METHOD

Thirty individuals were asked to wear a wrist-worn accelerometer for 5 nights and 4 days. Nighttime sleep parameters derived were average and intra-individual variability (IIV) in total sleep time (TST), sleep onset latency (SOL), sleep efficiency (SE), and wake after sleep onset (WASO). Daytime habitual physical data derived were average and peak activity and daytime napping.

RESULTS

Ninety-three percent (n = 28) of participants completed the study. All participants who wore the device marked sleep and wake cycles and periods of non-wear using the marker. Trauma-related symptoms were not associated with mean or IIV in TST, SE, SOL, or WASO (p > 0.01). Those with higher levels of bodily pain slept longer (β = 0.633, p = 0.003, adjusted R ² = 0.279), were more likely to report that their physical health limited their physical activities (β = 0.71, p < 0.001, adjusted R ² = 0.679) and had greater difficulty doing daily work (β = 0.84, p = 0.001, adjusted R ² = 0.665).

CONCLUSION

The use of actigraphy to collect objective measures of activity and sleep quality in rural post-conflict settings is feasible and acceptable. Our preliminary findings suggest that bodily pain and not trauma-related symptoms have a significant impact on sleep and functional outcomes in men and women survivors of prolonged conflict in the DRC.