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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A systematic review of literature examining mediators and mechanisms of change in empirically supported treatments for posttraumatic stress disorder

Despite the availability of empirically supported treatments (ESTs) for posttraumatic stress disorder (PTSD), relatively little is known regarding these treatments' mechanisms of change. This systematic review moves beyond previous reviews by summarizing the findings and reviewing the methodological quality of literature that specifically examined mediators/mechanisms of change in ESTs for PTSD. Studies were included if they were written in English, empirical, peer-reviewed, claimed to study mediators/mechanisms of a recommended PTSD treatment, measured the mediator/mechanism during or before and after treatment, and included a posttreatment PTSD or global outcome (e.g., functioning). PsycINFO and PubMed were searched on October 7, 2022. Two coders screened and coded studies. Sixty-two eligible studies were identified. The most consistent mediator/mechanism was reduction in negative posttraumatic cognitions, followed by between-session extinction and decreased depression. Only 47% of studies measured the mediator/mechanism before the outcome and measured the mediator/mechanism and outcome at least three times, and 32% also used growth curve modeling to establish temporal precedence of change in the mediator/mechanism and outcome. Many of the mediators/mechanisms examined had weak or no empirical support. Results highlight the need for improved methodological rigor in treatment mediator and mechanism research. Implications for clinical care and research are discussed. PROSPERO ID: 248088.

An updated audit of the patient selection process for pain management programmes in a speciality care service before and during the COVID-19 pandemic

BACKGROUND

The provision of pain management programmes (PMPs) changed substantially in response to the COVID-19 pandemic with virtual delivery implemented in many services. Little is known about patient selection processes for virtual PMPs and how this might differ from in-person programmes. The aim of this audit was to document the patient selection process for PMPs at a speciality pain service prior to and during the pandemic.

METHODS

This retrospective audit used data from consecutive patients attending a multidisciplinary assessment to determine the suitability of a PMP. Anonymized data were extracted from assessment letters and hospital records in the months prior to the pandemic (n =168) and during the start of the pandemic once the service began delivering virtual PMPs (n =171).

RESULTS

For the standard pain management pathway, most patients were offered a PMP option within the service before and during the pandemic, although a greater proportion of patients were offered treatment during the pandemic. For the neuromodulation pathway, most patients were offered a pre-neuromodulation PMP option, and this was similar before and during the pandemic. Psychosocial complexities and unwillingness to engage in a pain management approach that does not principally focus on pain reduction were the most common reasons that patients were not offered a programme.

DISCUSSION

This audit points to a pattern of more inclusive assessment outcomes within our service over time and particularly during the pandemic. Offering a range of in-person and virtual PMPs can meet a wider range of patient need. Research is needed to understand how to best assess and match patients with the breadth of treatment delivery formats now available.

Moral injury and chronic pain in veterans

Posttraumatic stress disorder (PTSD) and chronic pain are highly prevalent and co-morbid among veterans. Moral injury (MI), which results from traumatic experiences that conflict with deeply held moral beliefs, is also associated with pain. However, relationships between different types of exposures to potentially morally injurious events (PMIEs) and pain have not yet been investigated. In the current study, we investigated these relationships between exposure to PMIEs (betrayal, witnessing, and perpetration) and different types of pain (joint pain, muscle pain, and overall pain intensity), while controlling for other relevant variables (including PTSD symptoms, combat exposure, adverse childhood experiences, age, gender, and race/ethnicity). We also examined gender differences in these associations. Participants were 11,871 veterans drawn from a nationwide, population-based survey who self-reported exposure to PMIEs, PTSD symptoms, frequency of adverse childhood experiences, combat exposure, sociodemographic information, past six-month joint pain, past six-month muscle pain, and past week overall pain intensity. Population weighted regression models demonstrated that PMIEs were not significantly associated with joint or muscle pain, but that betrayal was associated with past week overall pain intensity, even when controlling for all other variables. Models investigating men and women separately found that for women, betrayal was associated with joint pain and pain intensity, but for men, betrayal was not associated with any pain outcome. These findings suggest that it may be especially important to assess betrayal when treating patients with a history of trauma and chronic pain.

New generation psychological treatments in chronic pain

Chronic pain conditions are common and have a considerable impact on health and wellbeing. This impact can be reduced by cognitive behavioral therapy (CBT), the most commonly applied psychological approach to chronic pain. At the same time, CBT continues to develop, and now includes what is sometimes called "third wave" CBT. In this review, we examine the evidence for application of acceptance and commitment therapy (ACT), a principal example of this new wave or latest generation of treatment approaches, in people with chronic pain. We identified 25 randomized controlled trials of ACT for adults with chronic pain. Across the included trials, small to large effect sizes favoring ACT were reported for key outcomes including pain interference, disability, depression, and quality of life. Evidence from three studies provided some support for the cost effectiveness of ACT for chronic pain. Evidence also supported the mediating role of theoretically consistent processes of change (psychological flexibility) in relation to treatment outcomes. Investigation of moderators and predictors of outcomes was limited and inconsistent. In future, a greater focus on process based treatments is recommended. This should include continued identification of evidence based processes of change, and research methods more suited to understanding the experience and needs of individual people.