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Benedict TM, Nitz AJ, Gambrel MK, Louw A. Pain neuroscience education improves post-traumatic stress disorder, disability, and pain self-efficacy in veterans and service members with chronic low back pain: Preliminary results from a randomized controlled trial with 12-month follow-up. MILITARY PSYCHOLOGY 2024; 36:376-392. [PMID: 38913769 PMCID: PMC11197901 DOI: 10.1080/08995605.2023.2188046] [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: 04/14/2022] [Accepted: 02/28/2023] [Indexed: 03/17/2023]
Abstract
Post-traumatic stress disorder (PTSD) and chronic low back pain (CLBP) are frequently co-morbid. Some research suggests that PTSD and CLBP may share common neurobiological mechanisms related to stress. Traditional biomedical education may be ineffective for PTSD and CLBP, especially when co-morbid. The purpose of this study is to determine if pain neuroscience education (PNE) is more effective than traditional education in reducing PTSD, disability, pain, and maladaptive beliefs in patients with CLBP. Participants with CLBP and possible PTSD/PTSD-symptoms were recruited for this study. Participants were randomly allocated to a PNE group or a traditional education group. The intervention included 30 minutes of education followed by a standardized exercise program once a week for 4-weeks with a 4 and 8-week follow-up and healthcare utilization assessed at 12-months. Forty-eight participants consented for this research study with 39 allocated to treatment (PNE n = 18, traditional n = 21). PNE participants were more likely to achieve a clinically meaningful reduction in PTSD symptoms and disability at short-term follow-up. At 12-months, the PNE group utilized healthcare with 76% lower costs. In participants with CLBP, PNE may reduce hypervigilance toward pain and improve PTSD symptoms. Participants who received PNE were more confident body-tissues were safe to exercise. These beliefs about pain could contribute to a decrease in perceived disability and healthcare consumption for CLBP.
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Affiliation(s)
- Timothy M. Benedict
- Baylor University – Keller Army Community Hospital, Division 1 Sports Physical Therapy Fellowship, United States Military Academy, West Point, New York
| | - Arthur J. Nitz
- Department of Rehabilitation Sciences, University of Kentucky, Lexington, Kentucky
| | - Michael K. Gambrel
- Department of Physical Therapy, Veterans Affairs Medical Center, Lexington, Kentucky
| | - Adriaan Louw
- Director of Pain Science, Evidence in Motion, Story City, Iowa
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McGrew SJ, Thai JM, Woller SJ, Smit T, Rogers AH, Vujanovic AA, Zvolensky MJ. Posttraumatic Stress and Opioid Use and Pain among Individuals with Probable Posttraumatic Stress Disorder and Self-Reported Chronic Pain: The Role of Health Literacy. Subst Use Misuse 2024:1-8. [PMID: 38914534 DOI: 10.1080/10826084.2024.2369164] [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: 06/26/2024]
Abstract
BACKGROUND Chronic pain and opioid misuse are a prevalent comorbidity with deleterious health outcomes. Growing work indicates that posttraumatic stress disorder (PTSD) can increase the risk for chronic pain and opioid misuse and dependence. However, there is little understanding of social determinants of health (SDoH) that may account for interrelations of PTSD with chronic pain and opioid misuse and dependence. Health literacy is one relevant SDoH construct, reflecting the ability to gather, process, and comprehend health-related information required to engage in a healthcare setting. OBJECTIVE The purpose of the present cross-sectional study was to examine the indirect effect of health literacy in the association between PTSD and opioid misuse, opioid dependence, pain intensity, and pain disability. METHOD The sample included 142 adults (Mage = 35.2, SD = 9.9; 67.4% female; 70.1% White/Caucasian) with self-reported chronic pain and probable PTSD who were using opioid medication. RESULTS Results demonstrated that PTSD symptom severity had a small indirect effect on opioid misuse and opioid dependence via health literacy; no indirect effects were evident for pain intensity and disability. CONCLUSION The present investigation provides evidence that health literacy may serve as an important explanatory factor in associations between PTSD symptom severity and opioid misuse and dependence among adults with co-occurring probable PTSD and chronic pain.
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Affiliation(s)
- Shelby J McGrew
- Department of Psychological & Brain Sciences, Texas A&M University, College Station, TX, USA
| | - Jessica M Thai
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Savannah J Woller
- Department of Psychological & Brain Sciences, Texas A&M University, College Station, TX, USA
| | - Tanya Smit
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Andrew H Rogers
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Seattle Children's Hospital, Seattle Children's Research Institute, Seattle, WA, USA
| | - Anka A Vujanovic
- Department of Psychological & Brain Sciences, Texas A&M University, College Station, TX, USA
| | - Michael J Zvolensky
- Department of Psychology, University of Houston, Houston, TX, USA
- Department of Behavioral Science, The University of Texas Maryland Anderson Cancer Center, Houston, TX, USA
- HEALTH Institute, University of Houston, Houston, TX, USA
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Hadlandsmyth K, Driscoll MA, Johnson NL, Mares JG, Mengeling MA, Thomas EBK, Norman SB, Lund BC. Veterans with chronic pain: Examining gender differences in pain type, overlap, and the impact of post-traumatic stress disorder. Eur J Pain 2024. [PMID: 38450917 DOI: 10.1002/ejp.2258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 02/08/2024] [Accepted: 02/26/2024] [Indexed: 03/08/2024]
Abstract
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.
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Affiliation(s)
- Katherine Hadlandsmyth
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Mary A Driscoll
- Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nicole L Johnson
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Jasmine G Mares
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
| | - Michelle A Mengeling
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, 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, Iowa City, Iowa, USA
- Department of Psychological and Brain Sciences, University of Iowa College of Liberal Arts and Sciences, Iowa City, Iowa, USA
| | - Sonya B Norman
- National Center for PTSD, White River Junction, Vermont, USA
- University of California San Diego School of Medicine, La Jolla, California, USA
| | - Brian C Lund
- VA Office of Rural Health (ORH), Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa, USA
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Rodgers-Melnick SN, Srinivasan R, Rivard RL, Adan F, Dusek JA. Immediate Effects of Integrative Health and Medicine Modalities Among Outpatients With Moderate-To-Severe Symptoms. GLOBAL ADVANCES IN INTEGRATIVE MEDICINE AND HEALTH 2024; 13:27536130241254070. [PMID: 38737216 PMCID: PMC11088302 DOI: 10.1177/27536130241254070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/22/2024] [Accepted: 04/19/2024] [Indexed: 05/14/2024]
Abstract
Background Patients seeking integrative health and medicine (IHM) modalities often present with multiple physical and psychological concerns. Research supports IHM's effectiveness for addressing symptoms over longer time periods. However, few studies have evaluated immediate outpatient effects. Objective This study describes pre-encounter patient-reported outcome (PRO) clusters and examines the immediate clinical effectiveness of IHM modalities on pain, stress, and anxiety among outpatients with moderate-to-severe symptoms. Methods A retrospective review was conducted of encounters among adults presenting to outpatient acupuncture, chiropractic, massage, integrative medicine consultation, or osteopathic manipulation treatment between January 2019 and July 2020. Encounters were included if patients reported pre-encounter pain, stress, or anxiety ≥4 on a numeric rating scale (NRS). Outcome analyses included random effects for patient and provider using a mixed model. Results Across 7335 clinical encounters among 2530 unique patients (mean age: 49.14 years; 81.0% female; 75.9% White; 15.8% Black/African American), the most common pre-encounter PRO clusters were pain, stress, and anxiety ≥4 (32.4%); pain ≥4 only (31.3%); and stress and anxiety ≥4 (15.6%). Clinically meaningful single-encounter mean [95% CI] changes were observed across all modalities in pain (-2.50 [-2.83, -2.17]), stress (-3.22 [-3.62, -2.82]), and anxiety (-3.05 [-3.37, -2.73]). Conclusion Patients presenting to outpatient IHM with moderate-to-severe symptoms most often presented with pain, stress, and anxiety ≥4 on the NRS. Multiple IHM modalities yielded clinically meaningful (≥2 unit) immediate reductions in these symptoms. Future research measuring immediate and longitudinal effectiveness is needed to optimize the triage and coordination of IHM modalities to meet patients' needs.
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Affiliation(s)
- Samuel N. Rodgers-Melnick
- Connor Whole Health, University Hospitals of Cleveland, Cleveland, OH, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Roshini Srinivasan
- Connor Whole Health, University Hospitals of Cleveland, Cleveland, OH, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Rachael L. Rivard
- Connor Whole Health, University Hospitals of Cleveland, Cleveland, OH, USA
- Center for Evaluation and Survey Research, HealthPartners Institute, Minneapolis, MN, USA
| | - Francoise Adan
- Connor Whole Health, University Hospitals of Cleveland, Cleveland, OH, USA
- Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jeffery A. Dusek
- Department of Medicine, University of California – Irvine, Irvine, CA, USA
- Susan Samueli Integrative Health Institute, University of California – Irvine, Irvine, CA, USA
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Kerr PL, Gregg JM. The Roles of Endogenous Opioids in Placebo and Nocebo Effects: From Pain to Performance to Prozac. ADVANCES IN NEUROBIOLOGY 2024; 35:183-220. [PMID: 38874724 DOI: 10.1007/978-3-031-45493-6_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
Placebo and nocebo effects have been well documented for nearly two centuries. However, research has only relatively recently begun to explicate the neurobiological underpinnings of these phenomena. Similarly, research on the broader social implications of placebo/nocebo effects, especially within healthcare delivery settings, is in a nascent stage. Biological and psychosocial outcomes of placebo/nocebo effects are of equal relevance. A common pathway for such outcomes is the endogenous opioid system. This chapter describes the history of placebo/nocebo in medicine; delineates the current state of the literature related to placebo/nocebo in relation to pain modulation; summarizes research findings related to human performance in sports and exercise; discusses the implications of placebo/nocebo effects among diverse patient populations; and describes placebo/nocebo influences in research related to psychopharmacology, including the relevance of endogenous opioids to new lines of research on antidepressant pharmacotherapies.
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Affiliation(s)
- Patrick L Kerr
- West Virginia University School of Medicine-Charleston, Charleston, WV, USA.
| | - John M Gregg
- Department of Surgery, VTCSOM, Blacksburg, VA, USA
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Espejo EP, Sheridan TM, Pino CA, Phillips CR. Mental Health Predictors of Response to Standard Medical Intervention at a Military Pain Specialty Clinic. Mil Med 2023; 188:149-156. [PMID: 37948258 DOI: 10.1093/milmed/usad060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/03/2023] [Accepted: 02/15/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Chronic pain among active duty service members can negatively impact operational readiness and contributes to significant health care costs within military treatment facilities. Response to standard medical intervention (SMI) for chronic pain is highly variable. The objective of the current study was to examine whether mental health indicators predict individual variation in response to SMI for chronic pain in a military pain specialty clinic. METHODS This is a retrospective observational study of data previously collected at the Pain Medicine Center at Naval Medical Center San Diego (NMCSD) approved by the NMCSD Institutional Review Board. We included 286 ADSMs who completed the Pain Assessment Screening Tool and Outcomes Registry (PASTOR) at two assessment points (mean = 118.45 days apart, SD = 37.22) as part of standard care. Hierarchical linear regression analyses were conducted to examine whether pretreatment mental health measures predict changes in the pain impact score (PIS)-a composite measure of pain intensity, pain interference, and physical functioning-over the course of treatment. RESULTS After controlling for pretreatment PIS, pretreatment PTSD symptoms, fatigue, and anger were all significant predictors of posttreatment PIS: Higher PTSD symptoms, higher fatigue, and lower anger predicted poorer response to treatment (all Ps < .05). CONCLUSION Higher pretreatment PTSD and fatigue symptoms may portend poorer response to SMI for chronic pain. Poor response to treatment may also be predicted by lower pretreatment anger. Further investigation is warranted to identify the best strategies for treating chronic pain in military treatment facilities when these conditions are identified during initial evaluation.
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Affiliation(s)
- Emmanuel P Espejo
- Pain Medicine Center, Department of Anesthesiology, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Tara M Sheridan
- Pain Medicine Center, Department of Anesthesiology, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Carlos A Pino
- Pain Medicine Center, Department of Anesthesiology, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Christopher R Phillips
- Pain Medicine Center, Department of Anesthesiology, Naval Medical Center San Diego, San Diego, CA 92134, USA
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Manuel J, Rudolph L, Beissner F, Neubert TA, Dusch M, Karst M. Traumatic Events, Posttraumatic Stress Disorder, and Central Sensitization in Chronic Pain Patients of a German University Outpatient Pain Clinic. Psychosom Med 2023; 85:351-357. [PMID: 36825929 PMCID: PMC10171308 DOI: 10.1097/psy.0000000000001181] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 11/02/2022] [Indexed: 02/25/2023]
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) and traumatic life events are often coupled to chronic pain, possibly linked by central sensitization. We wanted to assess the prevalence of traumatic events and PTSD in chronic pain patients of a German university hospital outpatient pain clinic. Moreover, we evaluated the extent of indicators and co-occurring traits of central sensitization in comorbid patients. METHODS We retrospectively divided 914 chronic pain patients into four groups depending on their trauma severity: no trauma, accidental trauma, interpersonal trauma, and PTSD. We collected electronic pain drawings focusing on pain area and widespreadness, as well as information about pain intensity, sleep impairment, disability, stress, anxiety, depression, and somatization. Differences between groups were calculated using Kruskal-Wallis with post-hoc Mann-Whitney tests. RESULTS Of 914 patients, 231 (25%) had no trauma, 210 (23%) had accidental traumas, 283 (31%) had interpersonal traumas, 99 (11%) had PTSD, and 91 (10%) could not be classified. We observed statistically significant differences between groups in pain area and widespreadness, as well as maximal pain, sleep impairment, disability, stress, anxiety, depression, and somatization. The severity of symptoms increased with trauma severity. CONCLUSIONS Traumatic life events and PTSD are frequent in chronic pain patients. The increased pain area and widespreadness, as well as the increased negative impact on co-occurring traits of sensory sensitivity (anxiety, depression, somatization), are compatible with central sensitization in comorbid patients. Therefore, a heightened awareness of the comorbidity between traumatic experiences and chronic pain is recommended.
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Baicalein exerts anxiolytic and antinociceptive effects in a mouse model of posttraumatic stress disorder: Involvement of the serotonergic system and spinal delta-opioid receptors. Prog Neuropsychopharmacol Biol Psychiatry 2023; 122:110689. [PMID: 36462602 DOI: 10.1016/j.pnpbp.2022.110689] [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] [Received: 08/22/2022] [Revised: 11/26/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022]
Abstract
Post-traumatic stress disorder (PTSD) is a serious mental disease featured by a stress dysfunction that occurs after an individual has faced intense mental stress, often accompanied by anxiety and chronic pain. Currently, the mainstream drug for PTSD is serotonin reuptake inhibitors (SSRIs), however, their pain management for patients is limited. Baicalein, a Chinese traditional herbal medicine, has shown promising results in treating anxiety, depression, and pain. In this study, we found that baicalein may alleviate single prolonged stress (SPS)-induced PTSD-like behaviors in mice without altering baseline nociceptive sensitivity or activity. Meanwhile, baicalein increased the noradrenaline (NE) and serotonin (5-HT) content and decreased the ratio of 5-hydroxyindoleacetic acid (5-HIAA)/5-HT by inhibiting the activity of monoamine oxidase A (MAO-A) in SPS-induce mice. The anxiolytic and antinociceptive effects induced by baicalein were totally abolished by 5-HT depleting agents. Moreover, the anxiolytic effects of baicalein could be abolished by the 5-HT1A receptor antagonist WAY-100635, and the analgesic effects could be abolished by delta-opioid receptor antagonists in the spinal. Taken together, our study provides compelling evidence that baicalein reversed anxiety-like behaviors and neuropathic pain in PTSD through serotonergic system and spinal delta-opioid receptors.
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Westergaard ML, Jensen RH, Carlsson J. Headache comorbidity in refugees and migrants with post-traumatic stress disorder. Cephalalgia 2023; 43:3331024221147502. [PMID: 36786299 DOI: 10.1177/03331024221147502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
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.
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Affiliation(s)
| | - Rigmor Højland Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Glostrup, Denmark
| | - Jessica Carlsson
- Competence Center for Transcultural Psychiatry, Mental Health Center Ballerup.,Mental Health Services in the Capital Region of Denmark, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Parental post-traumatic stress disorder and increased risk of chronic pain conditions and major psychiatric disorders in their offspring. Gen Hosp Psychiatry 2022; 79:152-157. [PMID: 36379154 DOI: 10.1016/j.genhosppsych.2022.10.008] [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] [Received: 06/13/2022] [Revised: 09/15/2022] [Accepted: 10/13/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Previous research suggests that individuals with post-traumatic stress disorder (PTSD) have higher risk of chronic pain symptoms. It remains unknown whether risk of chronic pain symptoms occurs in the offspring of parents with PTSD. This study aimed to explore the risk of chronic pain conditions and depression in the offspring of parents with PTSD. METHODS Between 1996 and 2011, we included subjects whose parents had PTSD and controls with parents without PTSD or any major psychiatric disorders (MPDs) from the Taiwan National Health Research Database. The controls (1:10) were matched for age, sex, time of birth, income, and residence. Poisson regression was applied to estimate the risk of chronic pain conditions and MPDs between case and control cohorts during the study period. The chronic pain conditions assessed were migraine, tension headache, fibromyalgia, peripheral neuropathy, dorsopathies, dysmenorrhea, irritable bowel syndrome (IBS), and dyspepsia. RESULTS We included 1139 cases and 11,390 matched controls. After adjusting for demographics and family history of psychiatric comorbidities, offspring of parents with PTSD had higher risk for depressive disorder [reported as odds ratio (OR) with 95% confidence interval (CI): 2.59, 1.71-3.92] than controls. For chronic pain conditions, offspring of parents with PTSD had higher risk for migraine (2.01, 1.01-3.98) and IBS (1.55, 1.02-2.34) than controls. CONCLUSIONS Healthcare workers should be aware that offspring of parents with PTSD have a higher risk of chronic pain conditions and depressive disorder. Further intervention to mitigate the risk is warranted.
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Korem N, Duek O, Ben-Zion Z, Kaczkurkin AN, Lissek S, Orederu T, Schiller D, Harpaz-Rotem I, Levy I. Emotional numbing in PTSD is associated with lower amygdala reactivity to pain. Neuropsychopharmacology 2022; 47:1913-1921. [PMID: 35945274 PMCID: PMC9485255 DOI: 10.1038/s41386-022-01405-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/01/2022] [Accepted: 07/15/2022] [Indexed: 11/09/2022]
Abstract
Posttraumatic stress disorder (PTSD) is associated with altered pain perception, namely increased pain threshold and higher pain response. While pain consists of physiological and affective components, affective components are often overlooked. Similar patterns of increased threshold-high response in PTSD were shown in response to emotional stimuli, i.e., emotional numbing. As both emotional numbing and pain processing are modulated by the amygdala, we aimed to examine whether individuals diagnosed with PTSD show lower amygdala activation to pain compared with combat controls, and whether the amygdala responses to pain correlates with emotional numbing. To do so, two independent samples of veterans (original study: 44 total (20 PTSD); conceptual replication study: 40 total (20 PTSD)) underwent threat conditioning, where a conditioned stimulus (CS+; visual stimulus) was paired with an unconditioned stimulus (US; electric-shock). We contrasted the amygdala activity to the CS + US pairing with the CS+ presented alone and correlated it with emotional numbing severity. In both samples, the PTSD group showed a robust reduction in amygdala reactivity to shock compared to the Combat Controls group. Furthermore, amygdala activation was negatively correlated with emotional numbing severity. These patterns were unique to the amygdala, and did not appear in comparison to a control region, the insula, a pivotal region for the processing of pain. To conclude, amygdala response to pain is lower in individuals with PTSD, and is associated with emotional numbing symptoms. Lower amygdala reactivity to mild pain may contribute to the "all-or-none" reaction to stressful situations often observed in PTSD.
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Affiliation(s)
- Nachshon Korem
- Yale University School of Medicine, Department of Psychiatry, New Haven, CT, 06511, USA.
- U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, 06516, USA.
- Yale University School of Medicine, Departments of Comparative Medicine and Neuroscience, New Haven, CT, 06511, USA.
| | - Or Duek
- Yale University School of Medicine, Department of Psychiatry, New Haven, CT, 06511, USA
- U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, 06516, USA
| | - Ziv Ben-Zion
- Yale University School of Medicine, Department of Psychiatry, New Haven, CT, 06511, USA
- U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, 06516, USA
| | | | - Shmuel Lissek
- Department of Psychology, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Temidayo Orederu
- The Nash Family Department of Neuroscience, Department of Psychiatry, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Daniela Schiller
- The Nash Family Department of Neuroscience, Department of Psychiatry, and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Ilan Harpaz-Rotem
- Yale University School of Medicine, Department of Psychiatry, New Haven, CT, 06511, USA
- U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, 06516, USA
- Yale University Department of Psychology, New Haven, CT, 06511, USA
- Wu Tsai Institute, Yale University New Haven, New Haven, CT, 06510, USA
| | - Ifat Levy
- U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, CT, 06516, USA
- Yale University School of Medicine, Departments of Comparative Medicine and Neuroscience, New Haven, CT, 06511, USA
- Yale University Department of Psychology, New Haven, CT, 06511, USA
- Wu Tsai Institute, Yale University New Haven, New Haven, CT, 06510, USA
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Webb EK, Ward RT, Mathew AS, Price M, Weis CN, Trevino CM, deRoon-Cassini TA, Larson CL. The role of pain and socioenvironmental factors on posttraumatic stress disorder symptoms in traumatically injured adults: A 1-year prospective study. J Trauma Stress 2022; 35:1142-1153. [PMID: 35238074 PMCID: PMC9357124 DOI: 10.1002/jts.22815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 01/11/2022] [Accepted: 01/11/2022] [Indexed: 01/29/2023]
Abstract
Approximately 20% of individuals who experience a traumatic injury will subsequently develop posttraumatic stress disorder (PTSD). Physical pain following traumatic injury has received increasing attention as both a distinct, functionally debilitating disorder and a comorbid symptom related to PTSD. Studies have demonstrated that both clinician-assessed injury severity and patient pain ratings can be important predictors of nonremitting PTSD; however, few have examined pain and PTSD alongside socioenvironmental factors. We postulated that both area- and individual-level socioeconomic circumstances and lifetime trauma history would be uniquely associated with PTSD symptoms and interact with the pain-PTSD association. To test these effects, pain and PTSD symptoms were assessed at four visits across a 1-year period in a sample of 219 traumatically injured participants recruited from a Level 1 trauma center. We used a hierarchal linear modeling approach to evaluate whether (a) patient-reported pain ratings were a better predictor of PTSD than clinician-assessed injury severity scores and (b) socioenvironmental factors, specifically neighborhood socioeconomic disadvantage, individual income, and lifetime trauma history, influenced the pain-PTSD association. Results demonstrated associations between patient-reported pain ratings, but not clinician-assessed injury severity scores, and PTSD symptoms, R2( fvm ) = .65. There was a significant interaction between neighborhood socioeconomic disadvantage and pain such that higher disadvantage decreased the strength of the pain-PTSD association but only among White participants, R2( fvm ) = .69. Future directions include testing this question in a larger, more diverse sample of trauma survivors (e.g., geographically diverse) and examining factors that may alleviate both pain and PTSD symptoms.
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Affiliation(s)
- E. Kate Webb
- Department of Psychology, University of Wisconsin–Milwaukee, Milwaukee, Wisconsin, USA
| | - Richard T. Ward
- Department of Psychology, University of Wisconsin–Milwaukee, Milwaukee, Wisconsin, USA
| | - Abel S. Mathew
- Department of Psychology, University of Wisconsin–Milwaukee, Milwaukee, Wisconsin, USA
| | - Matthew Price
- Department of Psychology, University of Vermont, Burlington, Vermont, USA
| | - Carissa N. Weis
- Department of Psychology, University of Vermont, Burlington, Vermont, USA
| | - Colleen M. Trevino
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Terri A. deRoon-Cassini
- Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Christine L. Larson
- Department of Psychology, University of Wisconsin–Milwaukee, Milwaukee, Wisconsin, USA
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13
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Bedford CE, Nakamura Y, Marchand WR, Garland EL. Heightened autonomic reactivity to negative affective stimuli among active duty soldiers with PTSD and opioid-treated chronic pain. Psychiatry Res 2022; 309:114394. [PMID: 35066311 PMCID: PMC8928316 DOI: 10.1016/j.psychres.2022.114394] [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] [Received: 04/21/2021] [Revised: 01/08/2022] [Accepted: 01/12/2022] [Indexed: 11/24/2022]
Abstract
Within military populations, chronic pain conditions and posttraumatic stress disorder (PTSD) frequently co-occur, however, little research has examined the psychophysiological correlates of this comorbidity among active-duty soldiers. The current study examined physiological reactivity to negative affective stimuli among 30 active duty soldiers with chronic pain conditions treated with long-term opioid therapy. Participants completed a diagnostic interview and self-report measures. Then, their heart rate and skin temperature were recorded during an affective picture-viewing task. Soldiers with PTSD exhibited greater increases in the ratio of low-to-high frequency heart rate variability (LF/HF HRV) while viewing negative affective images than soldiers without PTSD. PTSD symptom severity was positively associated with LF/HF HRV reactivity and negatively associated with skin temperature reactivity. Additionally, opioid craving was associated with LF/HF HRV and skin temperature reactivity among soldiers with PTSD. Taken together, the results of the present study provide evidence for heightened sympathetic nervous system reactivity among soldiers with comorbid chronic pain and PTSD, underscoring the importance of intervening on potential risk factors for these conditions.
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Affiliation(s)
- Carter E. Bedford
- Florida State University, Department of Psychology, 1107 W. Call St., Tallahassee, FL 32306 USA
| | - Yoshio Nakamura
- University of Utah, Department of Anesthesiology, Pain Research Center, Salt Lake City, UT 84112, USA,University of Utah, Center on Mindfulness and Integrative Health Intervention Development, 395 1500 E, Salt Lake City, UT 84112, USA
| | - William R. Marchand
- Salt Lake Veterans Administration Medical Center, Salt Lake City, UT 84112, USA,University of Utah, Department of Psychiatry, 501 Chipeta Way, Salt Lake City, UT 84108
| | - Eric L. Garland
- Salt Lake Veterans Administration Medical Center, Salt Lake City, UT 84112, USA,University of Utah, College of Social Work, 395 1500 E, Salt Lake City, UT 84112, USA,University of Utah, Center on Mindfulness and Integrative Health Intervention Development, 395 1500 E, Salt Lake City, UT 84112, USA
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14
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Campbell KA. The neurobiology of childhood trauma, from early physical pain onwards: as relevant as ever in today's fractured world. Eur J Psychotraumatol 2022; 13:2131969. [PMID: 36276555 PMCID: PMC9586666 DOI: 10.1080/20008066.2022.2131969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: The situation in the world today, encompassing multiple armed conflicts, notably in Ukraine, the Coronavirus pandemic and the effects of climate change, increases the likelihood of childhood exposure to physical injury and pain. Other effects of these worldwide hardships include poverty, malnutrition and starvation, also bringing with them other forms of trauma, including emotional harm, neglect and deliberate maltreatment. Objective: To review the neurobiology of the systems in the developing brain that are most affected by physical and emotional trauma and neglect. Method: The review begins with those that mature first, such as the somatosensory system, progressing to structures that have a more protracted development, including those involved in cognition and emotional regulation. Explored next are developing stress response systems, especially the hypothalamic-pituitary-adrenal axis and its central regulator, corticotropin-releasing hormone. Also examined are reward and anti-reward systems and genetic versus environmental influences. The behavioural consequences of interpersonal childhood trauma, focusing on self-harm and suicide, are also surveyed briefly. Finally, pointers to effective treatment are proffered. Results: The low-threshold nature of circuitry in the developing brain and lack of inhibitory connections therein result in heightened excitability, making the consequences of both physical and emotional trauma more intense. Sensitive and critical periods in the development of structures such as the amygdala render the nervous system more vulnerable to insults occurring at those points, increasing the likelihood of psychiatric disorders, culminating in self-harm and even suicide. Conclusion: In view of the greater excitability of the developing nervous system, and its vulnerability to physical and psychological injuries, the review ends with an exhortation to consider the long-term consequences of childhood trauma, often underestimated or missed altogether when faced with adults suffering mental health problems.
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15
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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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16
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Wojciechowski T. The relevance of post-traumatic stress disorder as a moderator of the relationship between experience of violent or sexual assault and opioid use in adulthood. CRIMINAL BEHAVIOUR AND MENTAL HEALTH : CBMH 2021; 31:410-420. [PMID: 34755403 DOI: 10.1002/cbm.2222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/17/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Past research has indicated that individuals suffering from post-traumatic stress disorder (PTSD) may demonstrate increased sensitivity to stress exposure following onset of the disorder. Thus, having PTSD may amplify the effects of subsequent stressors. This has been found to be relevant in some forms of substance use but relationships between PTSD, new stress and opioid use specifically has not been examined. AIMS To explore interactions between PTSD, new victimisation and opioid use and test the hypothesis that PTSD will moderate any victimisation-opioid use relationship. METHODS The pathways to desistance data were used in analyses. A series of logistic regression models were used to test both direct effects of victimisation and PTSD on opioid use and interactions between them. RESULTS The sample was comprised of a male majority (male N = 1,170; female N = 184). Results indicated that neither PTSD nor victimisation were significant predictors of opioid use. PTSD was found to moderate the relationship between victimisation and opioid use in the hypothesised manner. CONCLUSIONS There may be clinical implications of these results relating to both inpatient and outpatient treatment. Regular trauma screening, additional victims' services and trauma-informed care may help to reduce the risk of opioid use among individuals suffering from PTSD.
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Affiliation(s)
- Thomas Wojciechowski
- School of Criminal Justice, Michigan State University, East Lansing, Michigan, USA
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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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Do somatic symptoms relate to PTSD and gender after earthquake exposure? A cross-sectional study on young adult survivors in Italy. CNS Spectr 2021; 26:268-274. [PMID: 32248878 DOI: 10.1017/s1092852920000097] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Increasing evidence confirms a strict relationship between mental disorders and physical health. Particularly, stressful life events and post-traumatic stress disorder (PTSD) have been closely correlated with various physical disorders and somatic symptoms, such as chronic pain, gastrointestinal disorders, and headaches. The aim of this study was to investigate the emergence of somatic symptoms in a sample of young adult survivors 21 months after exposure to the L'Aquila 2009 earthquake, with particular attention to PTSD and gender impact. METHODS Four hundred and fifty high-school senior students (253 male and 197 female) exposed to the 2009 L'Aquila earthquake, 21 months earlier, were enrolled and evaluated by the Trauma and Loss Spectrum Self-Report (TALS-SR), for symptomatological PTSD, and the Mood Spectrum Self-Report-Lifetime Version (MOODS-SR) "rhythmicity and vegetative functions" domain, for somatic symptoms. RESULTS Significantly higher rates of endorsement of the MOODS-SR somatic symptoms emerged in survivors with PTSD compared to those without. Females reported higher rates of endorsement of at least one MOODS-SR somatic symptom compared to males; however, a Decision Tree model and a two-way analysis of variance model confirmed a significant effect of PTSD only. A multivariate logistical regression showed a significant association between the presence of at least one MOOD-SR somatic symptom and re-experiencing and maladaptive coping TALS-SR domains. CONCLUSION This study corroborates a relevant impact of symptomatological PTSD, across both the genders, on somatic symptoms occurring in young adults after months from exposure to a massive earthquake.
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Abstract
BACKGROUND Childhood trauma has been linked to neuropathic pain in noncancer populations, but its relationship with cancer treatment-related neuropathic pain is unknown. OBJECTIVE This secondary data analysis of a prospective, longitudinal, observational study aimed to explore the relationship of childhood trauma experience with pain severity, pain interference, and neuropathic symptom severity (NSS) 12 months after surgery in women receiving treatment for stage 0 to III breast cancer. METHODS Women (N = 44) recruited from a comprehensive cancer center self-reported childhood trauma experience, pain severity, pain interference, NSS, co-occurring symptoms, and pain beliefs via questionnaires. Descriptive statistics were used to describe childhood trauma experience. Linear regression was used to model childhood trauma and other predictors on pain variables 12 months after surgery. RESULTS Childhood trauma predicted pain severity and pain interference 12 months after surgery (P < .05), as did baseline pain severities and helplessness-pain catastrophizing. Age predicted only NSS. Together, the best models predicted 31.6% to 40.9% of the variance in pain severities at 12 months (P < .001). CONCLUSIONS Childhood trauma exposure was a significant predictor of pain 12 months after breast cancer surgery and adjuvant treatment. Younger and helplessness-pain catastrophizing women are also at risk. Research is needed to identify preventive neuropathic pain interventions for high-risk women. IMPLICATIONS FOR PRACTICE Women receiving breast cancer treatment should proactively be assessed for childhood trauma history, possibly by using discreet previsit questionnaires. Childhood trauma survivors may be at high risk for poor pain outcomes and may benefit from tailored pain interventions.
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20
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Benedict TM, Keenan PG, Nitz AJ, Moeller-Bertram T. 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. Mil Med 2021; 185:e1481-e1491. [PMID: 32248229 DOI: 10.1093/milmed/usaa052] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 03/03/2020] [Accepted: 03/05/2020] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Post-traumatic stress disorder (PTSD) and chronic pain are frequently co-morbid conditions in the U.S. veteran population. Although several theories about the cause of increased pain prevalence in individuals with PTSD have been presented, no synthesis of primary data informing the impact of co-morbid PTSD and pain has been completed. The purpose of this study was to systematically review the literature and quantify disability, function, and pain-related beliefs and outcomes in veterans with PTSD compared to veterans without PTSD. MATERIALS AND METHODS A systematic search of three electronic databases was conducted. Inclusion criteria required pain-related comparison of veterans with PTSD to those without PTSD. Primary outcome measures and standardized mean differences (SMDs) were assessed for pain, function, disability, pain beliefs, and healthcare utilization using a random effects model. RESULTS 20 original research studies met inclusion criteria and were assessed for quality and outcomes of interest. The majority of studies were cross-sectional. Veterans with PTSD and pain demonstrated higher pain (SMD = 0.58, 95% CI 0.28-0.89), disability (SMD = 0.52, 95%CI 0.33-0.71), depression (SMD = 1.40, 95%CI 1.2-1.6), catastrophizing beliefs (SMD = 0.95, 95% CI 0.69-1.2), sleep disturbance (SMD = 0.80, 95% CI 0.57-1.02), and healthcare utilization; they had lower function (SMD = 0.41, 95% CI 0.25-0.56) and pain self-efficacy (SMD = 0.77, 95% CI 0.55-0.99) compared to veterans without PTSD. CONCLUSION In veterans with chronic pain, PTSD symptomology has a large effect for many negative health-related outcomes. This review supports the need for clinicians to screen and understand the effects of PTSD symptoms on patients with pain. Clinicians should recognize that veterans with PTSD and pain likely have elevated pain catastrophizing beliefs and decreased self-efficacy that should be targeted for intervention.
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Affiliation(s)
- Timothy M Benedict
- Department of Rehabilitation Sciences, University of Kentucky, 900 S. Limestone Ave Lexington, Lexington, KY 40536-0200
| | - Patrick G Keenan
- Office of the Chief, Specialist Corps, 3630 Stanley Road, Fort Sam Houston, San Antonio, TX 78234
| | - Arthur J Nitz
- Department of Rehabilitation Sciences, University of Kentucky, 900 S. Limestone Ave Lexington, Lexington, KY 40536-0200
| | - Tobias Moeller-Bertram
- Department of Medicine at UC Riverside, Desert Clinic Pain Institute, 36101 Bob Hope Drive, Rancho Mirage, CA 92270
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21
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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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22
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Morgan L, Aldington D. Comorbid chronic pain and post-traumatic stress disorder in UK veterans: a lot of theory but not enough evidence. Br J Pain 2020; 14:256-262. [PMID: 33194190 PMCID: PMC7605058 DOI: 10.1177/2049463719878753] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Chronic pain and post-traumatic stress disorder (PTSD) are strongly correlated in military veteran populations. The aim of this article is to review what is known about the comorbidity of the two conditions. METHODS A literature search was carried out to establish evidence for current explanatory models of why the two conditions frequently co-occur, the most appropriate treatments and current UK service provision for veterans and to identify gaps in research. RESULTS Chronic pain and PTSD share a number of features, yet the mechanisms behind their comorbidity are not well understood, and while each condition alone has extensive literature, there is limited evidence to support specific care and treatment for the two conditions simultaneously. In addition, there is currently no UK data for veterans with comorbid chronic pain and PTSD so it is not possible to gauge the numbers affected or to predict the numbers who will be affected in the future, and there appear to be no co-located services within the United Kingdom for the management of the two conditions simultaneously in this population. CONCLUSION This review highlights a paucity of evidence in all areas of comorbid chronic pain and PTSD. Further work needs to consider fully the nature of the event that led to the development of the two conditions and examine further the possible mechanisms involved, and clinics need to establish routine and systematic evaluations of how any interventions work in practice.
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Affiliation(s)
- Louise Morgan
- Centre for Veterans’ Health, King
Edward VII’s Hospital, London, UK
| | - Dominic Aldington
- Department of Anaesthesia, Royal
Hampshire County Hospital, Hampshire Hospitals NHS Foundation Trust,
Winchester, UK
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23
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Scioli ER, Smith BN, Whitworth JW, Spiro A, Esterman M, Dutra S, Bogdan KM, Eld A, Rasmusson AM. Moderated mediation for exercise maintenance in pain and posttraumatic stress disorder: A randomized trial. Health Psychol 2020; 39:826-840. [PMID: 32833484 PMCID: PMC8559731 DOI: 10.1037/hea0000876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study utilizes the Science of Behavior Change (SOBC) experimental medicine approach to evaluate the effects of a 3-month, individually prescribed progressive exercise training program on neurobiological, cognitive and motivational mechanisms by which our exercise-training paradigm may foster exercise maintenance. We will investigate hypothesized relationships between exercise-training associated augmentation of neuropeptide Y (NPY) system function and improvements in self-regulation and reward sensitivity-cognitive control and motivational processes posited to promote self-efficacy and intrinsic motivation, which have been shown to predict exercise maintenance. This study will recruit Veterans with chronic low back pain and posttraumatic stress disorder (PTSD). Procedures include a baseline, acute cardiopulmonary exercise challenge assessment that will inform the exercise prescription for a 12-week progressive exercise training program comprised of three 45-minute aerobic exercise sessions per week-all of which will be supervised by an exercise physiologist. Additionally, a week-7 and week-14 exercise challenge assessment will track changes in NPY system function and the variables of interest. We hypothesize that increases in the capacity to release NPY in response to acute exercise testing will be associated with improvements in self-regulation and reward sensitivity, which will in turn be associated with self-efficacy and intrinsic motivation to maintain regular exercise. Ninety participants will be randomized either to the "active exercise training condition" or to the "wait list symptom monitoring condition". The study aims to demonstrate the feasibility of procedures and elucidate mechanisms relevant to developing individually prescribed, motivationally based exercise regimens to reduce negative consequences of PTSD and low back pain over the long-term. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
- Erica R Scioli
- Women's Health Sciences Division, National Center for PTSD, Research Service, VA Boston Healthcare System
| | - Brian N Smith
- Women's Health Sciences Division, National Center for PTSD, Research Service, VA Boston Healthcare System
| | | | - Avron Spiro
- Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC) VA Boston Healthcare System
| | | | - Sunny Dutra
- Clinical Psychology Department, William James College
| | - Kristina M Bogdan
- Women's Health Sciences Division, National Center for PTSD, Research Service, VA Boston Healthcare System
| | - Alex Eld
- Affiliate of Women's Health Sciences Division, National Center for PTSD, Research Service, VA Boston Healthcare System
| | - Ann M Rasmusson
- Women's Health Sciences Division, National Center for PTSD, Research Service, VA Boston Healthcare System
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How are pain and traumatic stress symptoms related in acute whiplash-associated disorders? An investigation of the role of pain-related fear in a daily diary study. Pain 2020; 160:1954-1966. [PMID: 30985618 DOI: 10.1097/j.pain.0000000000001581] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Comorbidity of pain and posttraumatic stress disorder is well recognized, but the reason for this association is unclear. This study investigated the direction of the relationship between pain and traumatic stress and the role that pain-related fear plays, for patients with acute whiplash-associated disorder. Participants (n = 99) used an electronic diary to record hourly ratings of pain, traumatic stress, and fear of pain (FOP) symptoms over a day. Relationships between pain, traumatic stress, and pain-related fear symptoms were investigated through multilevel models including variables lagged by 1 hour. Traumatic stress was associated with previous pain, even after controlling for previous traumatic stress and current pain; current pain was not associated with previous traumatic stress. The relationship between traumatic stress and previous pain became negligible after controlling for FOP, except for traumatic stress symptoms of hyperarousal that were driven directly by pain. Overall, these results support a pain primacy model, and suggest that pain-related fear is important in the maintenance and development of comorbid pain and traumatic stress symptoms. They also confirm that traumatic stress symptoms of hyperarousal are central in this relationship. Differences between this study and others that reported mutual maintenance can be understood in terms of different stages of whiplash-associated disorder and different intervals between repeated measurements. Traumatic stress may affect pain over longer time intervals than measured in this study. Future research could explore how relationships between traumatic stress symptoms, pain, and FOP change over time, and whether previous experiences of traumatic stress influence these relationships.
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25
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Yuan Y, Zhen L, Li Z, Xu W, Leng H, Xu W, Zheng V, Luria V, Pan J, Tao Y, Zhang H, Cao S, Xu Y. trans-Resveratrol ameliorates anxiety-like behaviors and neuropathic pain in mouse model of post-traumatic stress disorder. J Psychopharmacol 2020; 34:726-736. [PMID: 32308103 DOI: 10.1177/0269881120914221] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND trans-Resveratrol has been extensively investigated for its anti-inflammatory, antioxidant, and anti-psychiatric properties. However, whether it could rescue posttraumatic stress disorder-like stress-induced pain abnormality is unknown. AIM The present study examined the effects of trans-resveratrol on anxiety-like behavior and neuropathic pain induced by single-prolonged stress, which is a classical animal model for mimicking posttraumatic stress disorder. METHODS The single-prolonged stress-induced anxiety-like behavior and pain response were detected by the novelty suppressed feeding, marble burying, locomotor activity, von Frey, and acetone-induced cold allodynia tests in mice. The serum corticosterone levels and glucocorticoid receptor, protein kinase A, phosphorylated cAMP response element binding protein, and brain-derived neurotrophic factor expression were detected by enzyme-linked immunosorbent assay and immunoblot analyses. RESULTS trans-Resveratrol reversed single-prolonged stress-induced increased latency to feed and the number of marbles buried in the novelty suppressed feeding and marble burying tests, but did not significantly influence locomotion distance in the locomotor activity test. trans-Resveratrol also reversed single-prolonged stress-induced cold and mechanical allodynia. Moreover, single-prolonged stress induced abnormality in the limbic hypothalamus-pituitary-adrenal axis was reversed by trans-resveratrol, as evidenced by the fact that trans-resveratrol reversed the differential expression of glucocorticoid receptor in the anxiety- and pain-related regions. In addition, trans-resveratrol increased protein kinase A, phosphorylated cAMP response element binding protein, and brain-derived neurotrophic factor levels, which were decreased in mice subjected to single-prolonged stress. CONCLUSIONS These results provide compelling evidence that trans-resveratrol protects neurons against posttraumatic stress disorder-like stress insults through regulation of limbic hypothalamus-pituitary-adrenal axis function and activation of downstream neuroprotective molecules such as protein kinase A, phosphorylated cAMP response element binding protein, and brain-derived neurotrophic factor expression.
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Affiliation(s)
- Yirong Yuan
- Department of Neurosurgery, The People's Hospital of Yichun City, Yichun, China
| | - Linlin Zhen
- Department of Breast and Thyroid Surgery, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Zhi Li
- Department of Breast and Thyroid Surgery, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huai'an, China.,Department of Pharmaceutical Sciences, The State University of New York, Buffalo, USA
| | - Wenhua Xu
- Department of Orthopedics, The People's Hospital of Yichun City, Yichun, China
| | - Huilin Leng
- Department of Neurology, The People's Hospital of Yichun City, Yichun, China
| | - Wen Xu
- Brain Institute, Wenzhou Medical University, Wenzhou, China
| | - Victor Zheng
- Department of Pharmaceutical Sciences, The State University of New York, Buffalo, USA
| | - Victor Luria
- Department of System Biology, Harvard University Medical School, Boston, USA
| | - Jianchun Pan
- Brain Institute, Wenzhou Medical University, Wenzhou, China
| | - Yuanxiang Tao
- Department of Anesthesiology, The State University of New Jersey, Newark, USA
| | - Hanting Zhang
- Department of Behavioral Medicine and Psychiatry and Physiology, Pharmacology and Neuroscience, West Virginia University Health Sciences Center, Morgantown, USA
| | - Shengsheng Cao
- Department of Orthopedics, The People's Hospital of Yichun City, Yichun, China.,These authors jointly directed this work
| | - Ying Xu
- Department of Pharmaceutical Sciences, The State University of New York, Buffalo, USA.,These authors jointly directed this work
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Assessment and Treatment of Sleep in Mild Traumatic Brain Injury. Concussion 2020. [DOI: 10.1016/b978-0-323-65384-8.00007-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Liao C, de Molliens MP, Schneebeli ST, Brewer M, Song G, Chatenet D, Braas KM, May V, Li J. Targeting the PAC1 Receptor for Neurological and Metabolic Disorders. Curr Top Med Chem 2019; 19:1399-1417. [PMID: 31284862 PMCID: PMC6761004 DOI: 10.2174/1568026619666190709092647] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 12/23/2018] [Accepted: 12/26/2018] [Indexed: 12/16/2022]
Abstract
The pituitary adenylate cyclase-activating polypeptide (PACAP)-selective PAC1 receptor (PAC1R, ADCYAP1R1) is a member of the vasoactive intestinal peptide (VIP)/secretin/glucagon family of G protein-coupled receptors (GPCRs). PAC1R has been shown to play crucial roles in the central and peripheral nervous systems. The activation of PAC1R initiates diverse downstream signal transduction pathways, including adenylyl cyclase, phospholipase C, MEK/ERK, and Akt pathways that regulate a number of physiological systems to maintain functional homeostasis. Accordingly, at times of tissue injury or insult, PACAP/PAC1R activation of these pathways can be trophic to blunt or delay apoptotic events and enhance cell survival. Enhancing PAC1R signaling under these conditions has the potential to mitigate cellular damages associated with cerebrovascular trauma (including stroke), neurodegeneration (such as Parkinson's and Alzheimer's disease), or peripheral organ insults. Conversely, maladaptive PACAP/PAC1R signaling has been implicated in a number of disorders, including stressrelated psychopathologies (i.e., depression, posttraumatic stress disorder, and related abnormalities), chronic pain and migraine, and metabolic diseases; abrogating PAC1R signaling under these pathological conditions represent opportunities for therapeutic intervention. Given the diverse PAC1R-mediated biological activities, the receptor has emerged as a relevant pharmaceutical target. In this review, we first describe the current knowledge regarding the molecular structure, dynamics, and function of PAC1R. Then, we discuss the roles of PACAP and PAC1R in the activation of a variety of signaling cascades related to the physiology and diseases of the nervous system. Lastly, we examine current drug design and development of peptides and small molecules targeting PAC1R based on a number of structure- activity relationship studies and key pharmacophore elements. At present, the rational design of PAC1R-selective peptide or small-molecule therapeutics is largely hindered by the lack of structural information regarding PAC1R activation mechanisms, the PACAP-PAC1R interface, and the core segments involved in receptor activation. Understanding the molecular basis governing the PACAP interactions with its different cognate receptors will undoubtedly provide a basis for the development and/or refinement of receptor-selective therapeutics.
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Affiliation(s)
- Chenyi Liao
- Department of Chemistry, University of Vermont, Burlington, VT 05405, United States
| | | | - Severin T Schneebeli
- Department of Chemistry, University of Vermont, Burlington, VT 05405, United States
| | - Matthias Brewer
- Department of Chemistry, University of Vermont, Burlington, VT 05405, United States
| | - Gaojie Song
- Shanghai Key Laboratory of Regulatory Biology, Institute of Biomedical Sciences and School of Life Sciences, East China Normal University, Shanghai, 200241, China
| | - David Chatenet
- INRS - Institut Armand-Frappier, 531 boul. des Prairies, Laval, QC H7V 1B7, Canada
| | - Karen M Braas
- Department of Neurological Sciences, University of Vermont, Larner College of Medicine, 149 Beaumont Avenue, Burlington, VT 05405, United States
| | - Victor May
- Department of Neurological Sciences, University of Vermont, Larner College of Medicine, 149 Beaumont Avenue, Burlington, VT 05405, United States
| | - Jianing Li
- Department of Chemistry, University of Vermont, Burlington, VT 05405, United States
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Bartel A, Jordan J, Correll D, Devane A, Samuelson KW. Somatic burden and perceived cognitive problems in trauma‐exposed adults with posttraumatic stress symptoms or pain. J Clin Psychol 2019; 76:146-160. [DOI: 10.1002/jclp.22855] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Alisa Bartel
- Department of PsychologyUniversity of Colorado Colorado SpringsColorado Springs Colorado
| | - Joshua Jordan
- Department of PsychiatryUniversity of California San FranciscoSan Francisco California
| | - Danielle Correll
- Department of PsychologyUniversity of Colorado Colorado SpringsColorado Springs Colorado
| | - Amanda Devane
- Department of PsychologyUniversity of Colorado Colorado SpringsColorado Springs Colorado
| | - Kristin W. Samuelson
- Department of PsychologyUniversity of Colorado Colorado SpringsColorado Springs Colorado
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Post-traumatic Stress Disorder Symptoms are Associated With Incident Chronic Back Pain: A Longitudinal Twin Study of Older Male Veterans. Spine (Phila Pa 1976) 2019; 44:1220-1227. [PMID: 30985567 PMCID: PMC7102423 DOI: 10.1097/brs.0000000000003053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A longitudinal cotwin control study of the Vietnam Era Twin Registry. OBJECTIVE The aim of this study was to examine the association of post-traumatic stress disorder (PTSD) symptoms with incident chronic back pain (CBP), while controlling for genetic factors and early family environment. SUMMARY OF BACKGROUND DATA It is unknown whether PTSD symptoms are associated with an increased incidence of CBP. METHODS In 2010 to 2012, a baseline survey was undertaken as part of a large-scale study of PTSD. Study participants completed the PTSD Symptom Checklist (PCL) and a self-report measure of CBP. In 2015 to 2017, a follow-up survey was sent to all 171 monozygotic (MZ) twin pairs (342 individuals) where both cotwins had no history of CBP at baseline, but only one cotwin in the pair met criteria for having current PTSD symptoms (one twin with PCL <30 and the cotwin with PCL ≥30). No other inclusion/exclusion criteria were applied. CBP at 5-year follow-up was defined as back pain of duration ≥3 months in the low back or mid/upper back. Covariates included age, race, education, income, Veterans Affairs health care use, disability compensation, smoking, body mass index, and depression. Statistical analysis estimated the cumulative incidence of CBP according to baseline PTSD symptoms. Risk ratios (RRs) and 95% confidence intervals (95% CIs) were estimated in matched-pair cotwin control analyses adjusting for familial factors. RESULTS Among 227 males completing 5-year follow-up, including 91 MZ twin pairs, the mean age was 62 years. Five-year incidence of CBP in those without and with baseline PTSD symptoms was 40% and 60%, respectively. Baseline PTSD symptoms were significantly associated with incident CBP in crude and multivariable-adjusted within-pair analyses (RR 1.6, 95% CI 1.2-2.1; P = 0.002). CONCLUSION PTSD symptoms were associated with an increased incidence of CBP, without confounding by genetic factors or early family environment. PTSD symptoms may be a modifiable risk factor for prevention of CBP. LEVEL OF EVIDENCE 3.
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Benedict TM, Nitz AJ, Abt JP, Louw A. Development of a pain neuroscience education program for post-traumatic stress disorder and pain. Physiother Theory Pract 2019; 37:473-485. [PMID: 31232667 DOI: 10.1080/09593985.2019.1633717] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Introduction: Individuals with co-morbid post-traumatic stress disorder (PTSD) and pain have higher disability, pain, and pain catastrophizing beliefs than patients without PTSD. Pain neuroscience education (PNE) may be an effective tool to help those with PTSD and pain reduce maladaptive beliefs about pain. The purpose of this paper is to report the development and evaluation of a PNE curriculum for participants with PTSD and pain. Methods: After writing an initial draft of PNE for PTSD and pain, a panel of medical experts in PNE, PTSD, and rehabilitation reviewed the booklet. After addressing recommendations from the medical panel (n = 29), individuals with (n = 13) and without (n = 20) PTSD reviewed the booklet. Results: Overall, 89% of participants recommended the PNE booklet and 90% thought it would help patients with PTSD and pain. Although patients with PTSD rated the PNE booklet more critically than other participants, a particular support group (n = 4) rated the PNE booklet significantly different (p < .05) than remaining participants with PTSD (n = 9). Individuals with PTSD and pain were able to comprehend the PNE booklet at a comparable rate to an expert medical panel and participants without PTSD after adjusting for education levels (p = .12). Conclusions: Many patients with PTSD and pain avoid painful activities because they believe they are harmful. This research demonstrates that individuals with PTSD and pain can comprehend PNE that challenges these beliefs. The PNE curriculum developed by this research may provide a logical explanation for the link between PTSD symptoms and pain and should be tested for clinical effectiveness.
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Affiliation(s)
- Timothy M Benedict
- Army Public Health Center, Aberdeen Proving Ground, MD, USA.,Department of Rehabilitation Sciences, University of Kentucky, Lexington, KY, USA
| | - Arthur J Nitz
- Army Public Health Center, Aberdeen Proving Ground, MD, USA
| | - John P Abt
- Army Public Health Center, Aberdeen Proving Ground, MD, USA
| | - Adriaan Louw
- International Spine and Pain Institute, Story City, IA, USA
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Tobacco dependence is associated with increased risk for multi-morbid clustering of posttraumatic stress disorder, depressive disorder, and pain among post-9/11 deployed veterans. Psychopharmacology (Berl) 2019; 236:1729-1739. [PMID: 30617565 DOI: 10.1007/s00213-018-5155-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 12/17/2018] [Indexed: 10/27/2022]
Abstract
RATIONALE Tobacco use is highly prevalent among individuals with posttraumatic stress disorder (PTSD), depressive disorders, and pain. Research has revealed pairwise relationships among these conditions but has not examined more complex relationships that may influence symptom severity, chronicity, and treatment outcome. OBJECTIVE To examine the clustering of current PTSD, depressive disorders, and clinically significant pain according to current tobacco use and dependence among post-9/11 deployed veterans. METHODS Logistic regression was used to examine the clustering of these conditions in relationship to current tobacco use/dependence, while adjusting for age and total combat exposure, in 343 post-9/11 deployed veterans enrolled in the Translational Research Center for TBI and Stress Disorders (TRACTS) cohort (Mage = 32.1 + 8.3 years; 38% current tobacco use; 25% low and 12% moderate/high tobacco dependence). RESULTS A three-way clustering of PTSD, depressive disorder, and pain was more likely than any single or pairwise combination of these conditions in moderate/high tobacco-dependent veterans compared to tobacco non-users (adjusted ORs = 3.50 to 4.18). This multi-morbidity cluster also was associated with increased PTSD severity. CONCLUSIONS Moderate to high dependence on tobacco is associated with substantially increased clustering of PTSD, depression, and clinically significant pain in veterans. Research examining synergistic interactions among these conditions, biological vulnerabilities shared among them, and the direct impact of tobacco use on the pathophysiology of PTSD, depression, and pain is needed. The results of such work may spur development of more effective integrated treatments to reduce the negative impact of these multi-morbid conditions on veterans' wellbeing and long-term health.
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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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Smith KE, Bunting AM, Golder S, Hall MT, Higgins GE, Logan TK. Prevalence and Correlates of Disability Among a Sample of Victimized Women on Probation and Parole. JOURNAL OF CORRECTIONAL HEALTH CARE 2019; 25:143-161. [PMID: 30866703 DOI: 10.1177/1078345819833387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this exploratory study was to establish the prevalence of disability as measured by self-reported Social Security Disability Insurance (SSDI) receipt among a sample of women on probation and parole who have experienced interpersonal victimization in childhood and/or adulthood. Women receiving SSDI were more likely to be older, White, to live alone, and to score lower on measures of social support compared to women not receiving SSDI. SSDI recipients were also more likely to report poorer health, chronic pain, and more frequent health care service utilization. High rates of adverse childhood experiences, rape, adult victimization, and an overall greater severity of post-traumatic stress disorder symptomatology were observed for women receiving SSDI. Groups had similar overall mental health profiles and diverged primarily on trauma variables. Findings support the need for trauma-informed care and highlight the possibility that some criminal justice system-involved women likely qualify for SSDI, yet are not receiving it.
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Affiliation(s)
- Kirsten E Smith
- 1 Kent School of Social Work, University of Louisville, Louisville, KY, USA
| | - Amanda M Bunting
- 2 Department of Sociology, University of Kentucky, Lexington, KY, USA
| | - Seana Golder
- 1 Kent School of Social Work, University of Louisville, Louisville, KY, USA
| | - Martin T Hall
- 1 Kent School of Social Work, University of Louisville, Louisville, KY, USA
| | - George E Higgins
- 3 Department of Criminal Justice, University of Louisville, Louisville, KY, USA
| | - T K Logan
- 4 Department of Behavioral Science, University of Kentucky, Lexington, KY, USA.,5 Center on Drug and Alcohol and Research, University of Kentucky, Lexington, KY, USA
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Abstract
Supplemental Digital Content is Available in the Text. Pharmacological blockade of FKBP51 can reduce established persistent pain states across sexes. It is well established that FKBP51 regulates the stress system by modulating the sensitivity of the glucocorticoid receptor to stress hormones. Recently, we have demonstrated that FKBP51 also drives long-term inflammatory pain states in male mice by modulating glucocorticoid signalling at spinal cord level. Here, we explored the potential of FKBP51 as a new pharmacological target for the treatment of persistent pain across the sexes. First, we demonstrated that FKBP51 regulates long-term pain states of different aetiologies independently of sex. Deletion of FKBP51 reduced the mechanical hypersensitivity seen in joint inflammatory and neuropathic pain states in female and male mice. Furthermore, FKBP51 deletion also reduced the hypersensitivity seen in a translational model of chemotherapy-induced pain. Interestingly, these 3 pain states were associated with changes in glucocorticoid signalling, as indicated by the increased expression, at spinal cord level, of the glucocorticoid receptor isoform associated with glucocorticoid resistance, GRβ, and increased levels of plasma corticosterone. These pain states were also accompanied by an upregulation of interleukin-6 in the spinal cord. Crucially, we were able to pharmacologically reduce the severity of the mechanical hypersensitivity seen in these 3 models of persistent pain with the unique FKBP51 ligand SAFit2. When SAFit2 was combined with a state-of-the-art vesicular phospholipid gel formulation for slow release, a single injection of SAFit2 offered pain relief for at least 7 days. We therefore propose the pharmacological blockade of FKBP51 as a new approach for the treatment of persistent pain across sexes, likely in humans as well as rodents.
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Do post-traumatic pain and post-traumatic stress symptomatology mutually maintain each other? A systematic review of cross-lagged studies. Pain 2019; 159:2159-2169. [PMID: 29994992 DOI: 10.1097/j.pain.0000000000001331] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
After traumatic exposure, individuals are at risk of developing symptoms of both pain and post-traumatic stress disorder (PTSD). Theory and research suggest a complex and potentially mutually maintaining relationship between these symptomatologies. However, findings are inconsistent and the applied methods are not always well suited for testing mutual maintenance. Cross-lagged designs can provide valuable insights into such temporal associations, but there is a need for a systematic review to assist clinicians and researchers in understanding the nature of the relationship. Thus, the aim of this systematic review was to identify, critically appraise, and synthesize results from cross-lagged studies on pain and PTSD symptomatology to assess the evidence for longitudinal reciprocity and potential mediators. Systematic searches resulted in 7 eligible studies that were deemed of acceptable quality with moderate risk of bias using the cohort study checklist from Scottish Intercollegiate Guidelines Network. Furthermore, synthesis of significant pathways in the cross-lagged models showed inconsistent evidence of both bidirectional and unidirectional interaction patterns between pain and PTSD symptomatology across time, hence not uniformly supporting the theoretical framework of mutual maintenance. In addition, the synthesis suggested that hyperarousal and intrusion symptoms may be of particular importance in these cross-lagged relationships, while there was inconclusive evidence of catastrophizing as a mediator. In conclusion, the findings suggest an entangled, but not necessarily mutually maintaining relationship between pain and PTSD symptomatology. However, major variations in findings and methodologies complicated synthesis, prompting careful interpretation and heightening the likelihood that future high-quality studies will change these conclusions.
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Ng QX, Soh AYS, Loke W, Venkatanarayanan N, Lim DY, Yeo WS. Systematic review with meta-analysis: The association between post-traumatic stress disorder and irritable bowel syndrome. J Gastroenterol Hepatol 2019; 34:68-73. [PMID: 30144372 DOI: 10.1111/jgh.14446] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/04/2018] [Accepted: 08/06/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Post-traumatic stress disorder (PTSD) is a psychiatric condition characterized by symptoms of hyperarousal and hypervigilance. Increasing research on the "gut-brain" axis (bidirectional signaling between the gut and the brain) has drawn links between PTSD and irritable bowel syndrome (IBS), an exceedingly common yet incompletely understood gastrointestinal condition. This meta-analysis thus aimed to examine the body of evidence and extent of association of PTSD with IBS. METHODS Using the keywords [early abuse OR childhood abuse OR violence OR trauma OR PTSD] AND [irritable bowel syndrome or IBS], a preliminary search on the PubMed, Medline, Embase, ScienceDirect, PsychINFO, Web of Science, and Google Scholar databases yielded 11,257 papers published in English between January 1, 1988, and May 1, 2018. Of these, only eight studies were included in the final meta-analysis. RESULTS The eight studies (four cross-sectional and four cohort) contained a total of 648,375 subjects. Most studies were from the USA and conducted on army veterans. The funnel plot revealed a roughly symmetrical distribution of studies, and Egger test was not significant for publication bias (P = 0.583). Random-effects meta-analysis found PTSD to be a significant risk factor for IBS (pooled odds ratio 2.80, 95% confidence interval: 2.06 to 3.54, P < 0.001). CONCLUSIONS Overall, PTSD is associated with an increased likelihood of IBS. This is the first meta-analysis to specifically examine the association between PTSD and IBS, and it provides insights into the probable (patho)physiology and management of IBS, supporting a holistic consideration of the psychosocial aspects of IBS and further research into effective multi-modal therapeutics.
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Affiliation(s)
- Qin Xiang Ng
- National University Hospital, National University Health System, Singapore.,MOH Holdings Pte Ltd, Singapore
| | - Alex Yu Sen Soh
- National University Hospital, National University Health System, Singapore
| | | | | | | | - Wee-Song Yeo
- National University Hospital, National University Health System, Singapore
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Alsaadi T, Kassie S, Mohamed Ali O, Mozahem K, Al Fardan S, Ahmed AM. Psychiatric Comorbidity in Neurological Disorders: Towards a Multidisciplinary Approach to Illness Management in the United Arab Emirates. Front Psychiatry 2019; 10:263. [PMID: 31073293 PMCID: PMC6495369 DOI: 10.3389/fpsyt.2019.00263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 04/08/2019] [Indexed: 01/03/2023] Open
Abstract
Aim: To determine the prevalence of mood and anxiety disorders in undiagnosed patients attending neurological services, and detect rates of referral to and attendance of psychiatric services. Methods: Depressive symptoms and anxiety were assessed in 395 adult patients with primary diagnoses of neurological disorders. The Patient Health Questionnaire nine-item depression scale (PHQ-9), and Generalized Anxiety Disorder seven-item scale (GAD-7) were administered. Demographic details of the patients were recorded. Referral to and attendance of psychiatric services were recorded for patients scoring within the clinical range of depression and anxiety disorders (scores > 10). Results: There was a 39% prevalence rate of depressive symptoms, 34% rate of anxiety, and 35.4% concurrent rate of both disorders in this cohort. The referral rate to psychiatric services was 33.6%, and attendance rate was 47.8%. There was significant association between severity of psychiatric symptoms and referral to psychiatric services, as well as significant association between comorbid psychiatric symptoms and attendance to psychiatric services. Conclusion: Our results indicate similar prevalence rates of comorbid psychiatric symptoms to studies carried out in the Middle East and North Africa (MENA) region and relatively high attendance and referral rates to psychiatric services. Implications: The results shed light on the clinical profile of patients in this region and support the need for integrated collaborative medical services. Moreover, findings have important implications for health care policies pertaining to resource distribution and funding.
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Affiliation(s)
- Taoufik Alsaadi
- Department of Neurology, Psychiatry, American Center for Psychiatry and Neurology, Abu Dhabi, United Arab Emirates
| | - Seada Kassie
- Department of Neurology, Psychiatry, American Center for Psychiatry and Neurology, Abu Dhabi, United Arab Emirates
| | - Ola Mohamed Ali
- Department of Neurology, Psychiatry, American Center for Psychiatry and Neurology, Abu Dhabi, United Arab Emirates
| | - Khaldoun Mozahem
- Department of Neurology, Psychiatry, American Center for Psychiatry and Neurology, Abu Dhabi, United Arab Emirates
| | - Safana Al Fardan
- Department of Education - Medical Affairs, Shaikh Khalifa Medical Center, Abu Dhabi, United Arab Emirates
| | - Ahmed M Ahmed
- Department of Neurology, Psychiatry, American Center for Psychiatry and Neurology, Abu Dhabi, United Arab Emirates
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Quadrelli S, Mountford C, Ramadan S. Systematic review of in-vivo neuro magnetic resonance spectroscopy for the assessment of posttraumatic stress disorder. Psychiatry Res Neuroimaging 2018; 282:110-125. [PMID: 30097168 DOI: 10.1016/j.pscychresns.2018.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 07/18/2018] [Accepted: 07/19/2018] [Indexed: 10/28/2022]
Abstract
Posttraumatic stress disorder (PTSD) is a trauma and stressor-related disorder that results in complex somatic, cognitive, affective and behavioural effects, after exposure to traumatic event(s). Conventional imaging (T1 and T2 weighted magnetic resonance imaging) has little to offer in the way of diagnosis of mental health conditions such as PTSD and there is currently no objective diagnostic test available. Magnetic resonance spectroscopy (MRS) allows for non-invasive measurement of metabolites and neurochemicals in the brain using a conventional MRI scanner and offers the potential to predict, diagnose and monitor PTSD. This systematic review summarises the results of 24 MRS studies, performed between 1998 and 2017, to measure neurochemical differences, occurring as a consequence of PTSD. The most consistent finding in subjects with PTSD is lower N-acetylaspartate levels in the hippocampus and anterior cingulate cortex, with and without atrophic change. More recent studies, using more advanced techniques and modern hardware, have shown evidence of glutamatergic dysfunction and differences in gamma-aminobutyric acid levels in the brain of patients with PTSD. Conflicting results have been reported in choline-containing metabolites and there is emerging evidence of glutathione being affected. Myo-inositol and creatine are unchanged in the majority of studies.
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Affiliation(s)
- Scott Quadrelli
- School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW 2308, Australia; Department of Radiology, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4024, Australia; The Translational Research Institute, Woolloongabba, QLD 4024, Australia; The University of Queensland, St Lucia, QLD 4072, Australia.
| | - Carolyn Mountford
- The Translational Research Institute, Woolloongabba, QLD 4024, Australia
| | - Saadallah Ramadan
- School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW 2308, Australia
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Alhalal E, Ford-Gilboe M, Wong C, AlBuhairan F. Factors mediating the impacts of child abuse and intimate partner violence on chronic pain: a cross-sectional study. BMC Womens Health 2018; 18:160. [PMID: 30285706 PMCID: PMC6171313 DOI: 10.1186/s12905-018-0642-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 09/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most research on the health impacts of intimate partner violence (IPV) and child abuse has been conducted in Western countries and may not be generalizable to women living in different contexts, such as Saudi Arabia. Chronic pain, a disabling health issue associated with experiences of both child abuse and IPV among women, negatively impacts women's well-being, quality of life, and level of functioning. Yet, the psychosocial mechanisms that explain how abuse relates to chronic pain are poorly understood. We developed and tested a theoretical model that explains how both IPV and child abuse are related to chronic pain. METHODS We recruited a convenience sample of 299 Saudi women, who had experienced IPV in the past 12 months, from nine primary health care centers in Saudi Arabia between June and August 2015. Women completed a structured interview comprised of self-report measures of IPV, child abuse, PTSD, depressive symptoms, chronic pain, and social support. Using Structural equation modeling (SEM), we analyzed the proposed model twice with different mental health indicators as mediators: PTSD symptoms (Model 1) and depressive symptoms (Model 2). RESULTS Both models were found to fit the data, accounting for 31.6% (Model 1) and 32.4% (Model 2) of the variance in chronic pain severity. In both models, mental health problems (PTSD and depressive symptoms) fully mediated the relationship between severity of IPV and child abuse and chronic pain severity. Perceived family support partially mediated the relationship between abuse severity and depressive symptoms. CONCLUSIONS These results underscore the significance of considering lifetime abuse, women's mental health (depressive and PTSD symptoms) and their social resources in chronic pain management and treatment.
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Affiliation(s)
- Eman Alhalal
- Nursing College, King Saud University, Riyadh, Saudi Arabia
| | - Marilyn Ford-Gilboe
- Arthur Labatt Family School of Nursing, Western University, London, ON Canada
| | - Carol Wong
- Arthur Labatt Family School of Nursing, Western University, London, ON Canada
| | - Fadia AlBuhairan
- Department of Pediatrics and Adolescent Medicine, AlDara Hospital and Medical Center, Riyadh, Saudi Arabia
- Department of Population, Family, and Reproductive Health Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD USA
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Neurotransmitter, Peptide, and Steroid Hormone Abnormalities in PTSD: Biological Endophenotypes Relevant to Treatment. Curr Psychiatry Rep 2018; 20:52. [PMID: 30019147 DOI: 10.1007/s11920-018-0908-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW This review summarizes neurotransmitter, peptide, and other neurohormone abnormalities associated with posttraumatic stress disorder (PTSD) and relevant to development of precision medicine therapeutics for PTSD. RECENT FINDINGS As the number of molecular abnormalities associated with PTSD across a variety of subpopulations continues to grow, it becomes clear that no single abnormality characterizes all individuals with PTSD. Instead, individually variable points of molecular dysfunction occur within several different stress-responsive systems that interact to produce the clinical PTSD phenotype. Future work should focus on critical interactions among the systems that influence PTSD risk, severity, chronicity, comorbidity, and response to treatment. Effort also should be directed toward development of clinical procedures by which points of molecular dysfunction within these systems can be identified in individual patients. Some molecular abnormalities are more common than others and may serve as subpopulation biological endophenotypes for targeting of currently available and novel treatments.
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41
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Kao GS, Bhandari RP, Huestis SE, Golianu B. Traumatic Stress and Pediatric Pain: Towards a Neurobiological Stress-Health Perspective. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2018; 11:249-255. [PMID: 32318154 PMCID: PMC7163901 DOI: 10.1007/s40653-017-0145-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
This theoretical review aims to present the limited findings on traumatic stress and pain in children and adolescents, highlight recent discoveries regarding neurobiological processes, and suggest an alternative stress-health perspective in the future study and conceptualization of pediatric pain and traumatic stress based on results. Current literature highlights a positive correlation between pain and trauma symptoms in youth and suggests a complex relationship that may have mutually maintaining dynamics and intertwined physiological processes. Developmentally sensitive, longitudinal, process-oriented designs assessing neurobiological alterations and stress responses should be utilized in the examination of the trauma-pain relationship. Such investigations may provide a more unified explanation of the relationship between chronic pain and traumatic stress.
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Affiliation(s)
- Grace S. Kao
- Stanford Children’s Health, Stanford University School of Medicine, Stanford, CA USA
- Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, CA USA
- Departments of Pediatrics and Anesthesiology, Perioperative and Pain Medicine, Baylor College of Medicine, Houston, TX USA
- Texas Children’s Hospital, 6621 Fannin St., #A3300, Houston, TX 77030 USA
| | - Rashmi Parekh Bhandari
- Stanford Children’s Health, Stanford University School of Medicine, Stanford, CA USA
- Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Samantha E. Huestis
- Stanford Children’s Health, Stanford University School of Medicine, Stanford, CA USA
- Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Brenda Golianu
- Stanford Children’s Health, Stanford University School of Medicine, Stanford, CA USA
- Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, CA USA
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42
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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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43
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Pacella ML, Girard JM, Wright AG, Suffoletto B, Callaway CW. The Association between Daily Posttraumatic Stress Symptoms and Pain over the First 14-days after Injury: An Experience Sampling Study. Acad Emerg Med 2018; 25:844-855. [PMID: 29513381 DOI: 10.1111/acem.13406] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 02/26/2018] [Accepted: 03/01/2018] [Indexed: 01/02/2023]
Abstract
OBJECTIVES Psychosocial factors and responses to injury modify the transition from acute to chronic pain. Specifically, posttraumatic stress disorder symptoms (PTSS; reexperiencing, avoidance, and hyperarousal symptoms) exacerbate and co-occur with chronic pain. Yet no study has prospectively considered the associations among these psychological processes and pain reports using experience sampling methods (ESM) during the acute aftermath of injury. This study applied ESM via daily text messaging to monitor and detect relationships among psychosocial factors and post-injury pain across the first 14-days after emergency department (ED) discharge. METHODS We recruited 75 adults (59% male; M age = 33) who experienced a potentially traumatic injury (i.e., involving life threat or serious injury) in the past 24-hours from the EDs of two Level 1 trauma centers. Participants received 5 questions per day via text messaging from Day-1 to Day-14 post-ED discharge; three questions measured PTSS, one question measured perceived social support, and one question measured physical pain. RESULTS Sixty-seven participants provided sufficient data for inclusion in the final analyses, and the average response rate per subject was 86%. Pain severity score decreased from a mean of 7.2 to 4.4 over 14 days and 50% of the variance in daily pain scores was within-person. In multilevel structural equation models, pain scores decreased over time, and daily fluctuations of hyperarousal (b = 0.22, 95% CI [0.08, 0.36]) were uniquely associated with daily fluctuations in reported pain level within each person. CONCLUSIONS Daily hyperarousal symptoms predict same-day pain severity over the acute post-injury recovery period. We also demonstrated feasibility to screen and identify patients at risk for pain chronicity in the acute aftermath of injury. Early interventions aimed at addressing hyperarousal (e.g. anxiolytics) could potentially aid in reducing experience of pain. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Maria L. Pacella
- Department of Emergency Medicine University of Pittsburgh Pittsburgh PA
| | | | | | - Brian Suffoletto
- Department of Emergency Medicine University of Pittsburgh Pittsburgh PA
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44
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Pain anxiety differentially mediates the association of pain intensity with function depending on level of intolerance of uncertainty. J Psychiatr Res 2018; 97:30-37. [PMID: 29175295 DOI: 10.1016/j.jpsychires.2017.11.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 10/13/2017] [Accepted: 11/10/2017] [Indexed: 01/13/2023]
Abstract
Uncertainty about symptom duration, cause, prognosis and treatment is common in patients who seek medical care, yet individual ability to manage this uncertainty varies. Intolerance of uncertainty is considered an important factor in the etiology and persistence of negative emotions- in particular, depression and anxiety. We explored the contribution of intolerance of uncertainty to anxiety due to pain and physical function in patients seeking care at an orthopedic medical practice. Participants (N = 105, mean age of 51 ± 17, 63% male) were administered PROMIS Physical Function v1.2 Upper Extremity CAT, Numerical Rating Scale (NRS), Pain Anxiety Symptoms Scale-short form (PASS-20), and the Intolerance of Uncertainty Scale-short version (IUS-12). Results showed that the mediating role of pain anxiety is contingent upon the level of intolerance of uncertainty. Specifically, a minimum level of intolerance of uncertainty is required for the development of pain anxiety and its effect on function, and as intolerance of uncertainty rises from low to medium to high levels, the effect of pain on function goes from being independent of the anxiety to being more and more carried by and through anxiety about pain. These findings support the contention that intolerance of uncertainty plays a crucial role in the relationship between pain, pain anxiety, and physical function. Intolerance of uncertainty appears to be a trans-diagnostic target for coping skills training.
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45
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Brailey K, Mills MA, Marx BP, Proctor SP, Seal KH, Spiro A, Ulloa EW, Vasterling JJ. Prospective Examination of Early Associations of Iraq War Zone Deployment, Combat Severity, and Posttraumatic Stress Disorder with New Incident Medical Diagnoses. J Trauma Stress 2018. [PMID: 29513919 DOI: 10.1002/jts.22264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
War zone deployment and posttraumatic stress disorder (PTSD) have been associated with morbidity and mortality decades later. Less is known about the associations between these variables and the early emergence of medical disorders in war zone veterans. This prospective study of 862 U.S. Army soldiers (n = 569 deployed; n = 293 nondeployed) examined: (a) associations between Iraq War deployment status (deployed vs. nondeployed) and new medical diagnoses that emerged within six months after return from Iraq among all participants; and (b) associations between combat severity and PTSD symptoms, and new postdeployment medical diagnoses that emerged within 12 months after return from Iraq within deployed participants. New medical diagnoses were abstracted from diagnostic codes associated with clinical outpatient visits recorded within the Department of Defense Standard Ambulatory Data Record database. Combat severity was measured with the Combat Experiences module of the Deployment Risk and Resilience Inventory, and postdeployment posttraumatic stress disorder symptom severity was measured using the PTSD Checklist-Civilian. Neither deployment nor combat severity was associated with new medical diagnoses. However, among deployed soldiers, more severe PTSD symptoms were associated with increased risk for a new medical disorder diagnosis; every 10-point increase in PTSD symptoms increased odds of a new diagnosis by nearly 20% (odds ratio = 1.20). Results suggest that PTSD symptoms are associated with early morbidity in Iraq War veterans.
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Affiliation(s)
- Kevin Brailey
- Psychology Service, VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Mary Alice Mills
- Psychology Service, VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Brian P Marx
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA.,National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Susan P Proctor
- Military Performance Division, U.S. Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA.,Research Service, VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Environmental Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Karen H Seal
- San Francisco VA Health Care System, San Francisco, California, USA.,Departments of Medicine and Psychiatry, University of California San Francisco, San Francisco, California, USA
| | - Avron Spiro
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA.,Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Erin W Ulloa
- Behavioral Health Service, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.,Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jennifer J Vasterling
- Psychology Service, VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
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46
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Belelli D, Brown AR, Mitchell SJ, Gunn BG, Herd MB, Phillips GD, Seifi M, Swinny JD, Lambert JJ. Endogenous neurosteroids influence synaptic GABA A receptors during postnatal development. J Neuroendocrinol 2018; 30. [PMID: 28905487 DOI: 10.1111/jne.12537] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 08/22/2017] [Accepted: 09/10/2017] [Indexed: 12/12/2022]
Abstract
GABA plays a key role in both embryonic and neonatal brain development. For example, during early neonatal nervous system maturation, synaptic transmission, mediated by GABAA receptors (GABAA Rs), undergoes a temporally specific form of synaptic plasticity to accommodate the changing requirements of maturing neural networks. Specifically, the duration of miniature inhibitory postsynaptic currents (mIPSCs), resulting from vesicular GABA activating synaptic GABAA Rs, is reduced, permitting neurones to appropriately influence the window for postsynaptic excitation. Conventionally, programmed expression changes to the subtype of synaptic GABAA R are primarily implicated in this plasticity. However, it is now evident that, in developing thalamic and cortical principal- and inter-neurones, an endogenous neurosteroid tone (eg, allopregnanolone) enhances synaptic GABAA R function. Furthermore, a cessation of steroidogenesis, as a result of a lack of substrate, or a co-factor, appears to be primarily responsible for early neonatal changes to GABAergic synaptic transmission, followed by further refinement, which results from subsequent alterations of the GABAA R subtype. The timing of this cessation of neurosteroid influence is neurone-specific, occurring by postnatal day (P)10 in the thalamus but approximately 1 week later in the cortex. Neurosteroid levels are not static and change dynamically in a variety of physiological and pathophysiological scenarios. Given that GABA plays an important role in brain development, abnormal perturbations of neonatal GABAA R-active neurosteroids may have not only a considerable immediate, but also a longer-term impact upon neural network activity. Here, we review recent evidence indicating that changes in neurosteroidogenesis substantially influence neonatal GABAergic synaptic transmission. We discuss the physiological relevance of these findings and how the interference of neurosteroid-GABAA R interaction early in life may contribute to psychiatric conditions later in life.
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Affiliation(s)
- D Belelli
- Division of Neuroscience, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - A R Brown
- Division of Neuroscience, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - S J Mitchell
- Division of Neuroscience, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - B G Gunn
- Division of Neuroscience, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - M B Herd
- Division of Neuroscience, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - G D Phillips
- Division of Neuroscience, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - M Seifi
- Institute for Biomedical & Biomolecular Sciences, School of Pharmacy & Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - J D Swinny
- Institute for Biomedical & Biomolecular Sciences, School of Pharmacy & Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - J J Lambert
- Division of Neuroscience, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
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48
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Siqveland J, Hussain A, Lindstrøm JC, Ruud T, Hauff E. Prevalence of Posttraumatic Stress Disorder in Persons with Chronic Pain: A Meta-analysis. Front Psychiatry 2017; 8:164. [PMID: 28959216 PMCID: PMC5603802 DOI: 10.3389/fpsyt.2017.00164] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 08/22/2017] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To summarize evidence for the prevalence of posttraumatic stress disorder (PTSD) among persons with chronic pain (CP). METHODS We searched databases for studies published between January 1995 and December 2016, reporting the prevalence of PTSD in persons with CP. Two reviewers independently extracted data and assessed the risk of bias. We calculated the pooled prevalence using a random-effects model and performed subgroup analyses according to pain location, the population and assessment method. RESULTS Twenty-one studies were included and the PTSD prevalence varied from 0-57%, with a pooled mean prevalence of 9.7%, 95% CI (5.2-17.1). In subgroup analysis, the PTSD prevalence was 20.5%, 95% CI (9.5-39.0) among persons with chronic widespread pain, 11.2%, 95% CI (5.7-22.8) among persons with headache, and 0.3%, 95% CI (0.0-2.4) among persons with back pain. The prevalence in clinical populations was 11.7%, 95% CI (6.0-21.5) and in non-clinical populations 5.1%, 95% CI (0.01-17.2). In studies of self-reported PTSD symptoms, PTSD prevalence was 20.4%, 95% CI (10.6-35.5), and in studies where structured clinical interviews had been used to assess PTSD its prevalence was 4.5%, 95% (CI 2.1-9.3). The risk of bias was medium for most studies and the heterogeneity was high (I2 = 98.6). CONCLUSION PTSD is overall more prevalent in clinical cohorts of persons with CP and particularly in those with widespread pain, but may not always be more prevalent in non-clinical samples of persons with CP, compared to the general population. There is a large heterogeneity in prevalence across studies. Future research should identify sources of heterogeneity and the mechanisms underlying the comorbidity of the two conditions.
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Affiliation(s)
- Johan Siqveland
- Department for Research and Development, Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Regional Resource Centre for Traumatic Stress and Suicide Prevention, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ajmal Hussain
- Department for Research and Development, Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | | | - Torleif Ruud
- Department for Research and Development, Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Edvard Hauff
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Oslo University Hospital, Oslo, Norway
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49
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Locci A, Pinna G. Neurosteroid biosynthesis down-regulation and changes in GABA A receptor subunit composition: a biomarker axis in stress-induced cognitive and emotional impairment. Br J Pharmacol 2017; 174:3226-3241. [PMID: 28456011 DOI: 10.1111/bph.13843] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 04/05/2017] [Accepted: 04/12/2017] [Indexed: 12/26/2022] Open
Abstract
By rapidly modulating neuronal excitability, neurosteroids regulate physiological processes, such as responses to stress and development. Excessive stress affects their biosynthesis and causes an imbalance in cognition and emotions. The progesterone derivative, allopregnanolone (Allo) enhances extrasynaptic and postsynaptic inhibition by directly binding at GABAA receptors, and thus, positively and allosterically modulates the function of GABA. Allo levels are decreased in stress-induced psychiatric disorders, including depression and post-traumatic stress disorder (PTSD), and elevating Allo levels may be a valid therapeutic approach to counteract behavioural dysfunction. While benzodiazepines are inefficient, selective serotonin reuptake inhibitors (SSRIs) represent the first choice treatment for depression and PTSD. Their mechanisms to improve behaviour in preclinical studies include neurosteroidogenic effects at low non-serotonergic doses. Unfortunately, half of PTSD and depressed patients are resistant to current prescribed 'high' dosage of these drugs that engage serotonergic mechanisms. Unveiling novel biomarkers to develop more efficient treatment strategies is in high demand. Stress-induced down-regulation of neurosteroid biosynthesis and changes in GABAA receptor subunit expression offer a putative biomarker axis to develop new PTSD treatments. The advantage of stimulating Allo biosynthesis relies on the variety of neurosteroidogenic receptors to be targeted, including TSPO and endocannabinoid receptors. Furthermore, stress favours a GABAA receptor subunit composition with higher sensitivity for Allo. The use of synthetic analogues of Allo is a valuable alternative. Pregnenolone or drugs that stimulate its levels increase Allo but also sulphated steroids, including pregnanolone sulphate which, by inhibiting NMDA tonic neurotransmission, provides neuroprotection and cognitive benefits. In this review, we describe current knowledge on the effects of stress on neurosteroid biosynthesis and GABAA receptor neurotransmission and summarize available pharmacological strategies that by enhancing neurosteroidogenesis are relevant for the treatment of SSRI-resistant patients. Linked Articles This article is part of a themed section on Pharmacology of Cognition: a Panacea for Neuropsychiatric Disease? To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.19/issuetoc.
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Affiliation(s)
- Andrea Locci
- The Psychiatric Institute, Department of Psychiatry, College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Graziano Pinna
- The Psychiatric Institute, Department of Psychiatry, College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
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50
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Missig G, Mei L, Vizzard MA, Braas KM, Waschek JA, Ressler KJ, Hammack SE, May V. Parabrachial Pituitary Adenylate Cyclase-Activating Polypeptide Activation of Amygdala Endosomal Extracellular Signal-Regulated Kinase Signaling Regulates the Emotional Component of Pain. Biol Psychiatry 2017; 81:671-682. [PMID: 28057459 PMCID: PMC5332340 DOI: 10.1016/j.biopsych.2016.08.025] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 07/15/2016] [Accepted: 08/16/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND Chronic pain and stress-related psychopathologies, such as depression and anxiety-associated abnormalities, are mutually reinforcing; however, the neuronal circuits and mechanisms that underlie this reinforcement are still not well understood. Pituitary adenylate cyclase-activating polypeptide (PACAP; Adcyap1) and its cognate PAC1 receptor (Adcyap1r1) are expressed in peripheral nociceptive pathways, participate in anxiety-related responses and have been have been linked to posttraumatic stress disorder and other mental health afflictions. METHODS Using immunocytochemistry, pharmacological treatments and behavioral testing techniques, we have used a rodent partial sciatic nerve chronic constriction injury model (n = 5-8 per group per experiment) to evaluate PACAP plasticity and signaling in nociceptive and stress-related behaviors. RESULTS We show that chronic neuropathic pain increases PACAP expression at multiple tiers along the spinoparabrachioamygdaloid tract. Furthermore, chronic constriction injury bilaterally augments nociceptive amygdala (in the central nucleus of the amygdala [CeA]) PACAP immunoreactivity, extracellular signal-regulated kinase phosphorylation, and c-Fos activation, in parallel with heightened anxiety-like behavior and nociceptive hypersensitivity. Acute CeA infusions with the PACAP receptor antagonist PACAP(6-38) blocked chronic constriction injury-induced behavioral responses. Additionally, pretreatments with inhibitors of mitogen-activated protein kinase enzymes or endocytosis to block endosomal PACAP receptor extracellular signal-regulated kinase signaling attenuated PACAP-induced CeA neuronal activation and nociceptive responses. CONCLUSIONS Our data suggest that chronic pain-induced PACAP neuroplasticity and signaling in spinoparabrachioamygdaloid projections have an impact on CeA stress- and nociception-associated maladaptive responses, which can be ameliorated upon receptor antagonism even during injury progression. Thus, the PACAP pathway provides for an important mechanism underlying the intersection of stress and chronic pain pathways via the amygdala.
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Affiliation(s)
- Galen Missig
- Department of Neurological Sciences, Burlington, Vermont
| | - Linda Mei
- Department of Neurological Sciences, Burlington, Vermont
| | | | - Karen M Braas
- Department of Neurological Sciences, Burlington, Vermont
| | - James A Waschek
- Department of Psychiatry and Behavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Kerry J Ressler
- Division of Depression and Anxiety, McLean Hospital-Harvard Medical School, Belmont, Massachusetts
| | - Sayamwong E Hammack
- Department of Psychological Science, University of Vermont College of Medicine, Burlington, Vermont
| | - Victor May
- Department of Neurological Sciences, Burlington, Vermont.
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