Predicting posttraumatic stress disorder symptoms and pain intensity following severe injury: the role of catastrophizing

Pain after combat injury in male UK military personnel deployed to Afghanistan

BACKGROUND

Chronic pain after injury poses a serious health burden. As a result of advances in medical technology, ever more military personnel survive severe combat injuries, but long-term pain outcomes are unknown. We aimed to assess rates of pain in a representative sample of UK military personnel with and without combat injuries.

METHODS

We used data from the ADVANCE cohort study (ISRCTN57285353). Individuals deployed as UK armed forces to Afghanistan were recruited to include those with physical combat injuries, and a frequency-matched uninjured comparison group. Participants completed self-reported questionnaires, including 'overall' pain intensity and self-assessment of post-traumatic stress disorder, anxiety, and depression.

RESULTS

A total of 579 participants with combat injury, including 161 with amputations, and 565 uninjured participants were included in the analysis (median 8 yr since injury/deployment). Frequency of moderate or severe pain was 18% (n=202), and was higher in the injured group (n=140, 24%) compared with the uninjured group (n=62, 11%, relative risk: 1.1, 95% confidence interval [CI]: 1.0-1.2, P<0.001), and lower in the amputation injury subgroup (n=31, 19%) compared with the non-amputation injury subgroup (n=109, 26%, relative risk: 0.9, 95% CI: 0.9-1.0, P=0.034). Presence of at least moderate pain was associated with higher rates of post-traumatic stress (RR: 3.7, 95% CI: 2.7-5.0), anxiety (RR: 3.2, 95% CI: 2.4-4.3), and depression (RR: 3.4, 95% CI: 2.7-4.5) after accounting for injury.

CONCLUSION

Combat injury, but not amputation, was associated with a higher frequency of moderate to severe pain intensity in this cohort, and pain was associated with adverse mental health outcomes.

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

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

Interpretations of ambiguous situations in combat veterans with and without post-traumatic stress disorder

Deployed combat personnel are at increased risk of post-traumatic stress disorder (PTSD). People with PTSD often judge ambiguous information as negative or threatening (interpretation bias). However, this may be adaptive during deployment. The current study aimed to investigate the extent to which interpretation bias in combat personnel is associated with PTSD symptoms, rather than with appropriate situational awareness. Combat veterans with and without PTSD and civilians without PTSD generated explanations for ambiguous situations and judged the likelihood of various possible explanations. They also made judgements about future consequences of worst-case scenarios, and their coping ability. Veterans with PTSD generated more negative explanations for ambiguous situations, judged negative interpretations as more likely and felt less able to cope with the worst-case scenario than veteran and civilian controls. Veterans with versus without PTSD judged worst-case scenarios to have more severe and insurmountable consequences, although they did not differ significantly from civilians. Veteran versus civilian controls rated their coping ability as higher; this was the only difference between control groups. In summary, group differences in interpretation bias were associated with PTSD symptoms rather than combat role. Veterans without PTSD may be particularly resilient when coping with everyday adversity.

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

OBJECTIVE

Chronic pain can worsen PTSD symptomatology and may increase the risk of the prescription of multiple central nervous system (CNS)-active medications. The objective is to determine the impact of chronic pain on the number of CNS medications, including psychiatric medications, as well as the amount of medication changes.

METHODS

Veterans Affairs (VA) administrative data were used to identify VA-served Veterans with PTSD (N = 637,428) who had chronic pain (50.3%) and did not have chronic pain (49.7%) in 2020. The outcomes included the number of changes in psychiatric medications and the number of currently prescribed CNS-active mediations during a one-year observation period.

RESULTS

The number of changes in psychiatric medications was significantly higher for those with chronic pain (mean (M) = 1.8) versus those without chronic pain (M = 1.6) (Z = 38.4, p < 0.001). The mean number of concurrent CNS-active medications were significantly higher for those with chronic pain (M = 2.7) versus those without chronic pain (M = 2.0) (Z = 179.7, p < 0.001). These differences persisted after adjustment for confounding factors using negative binomial regression.

CONCLUSIONS

Veterans with comorbid chronic pain and PTSD are at increased risk for a higher number of medication changes and for receiving CNS-active polytherapy.

The Helplessness Dimension of Pain Catastrophizing Mediates the Relation between PTSD Symptoms and Pain Rehabilitation Measures

Background

Comorbid chronic pain and post-traumatic stress disorder (PTSD) complicate the treatment of both conditions. Previous research has identified pain catastrophizing as a potentially important variable contributing to the relationship between chronic pain and PTSD. However, little is known regarding how the different dimensions of pain catastrophizing-rumination, magnification, and helplessness-uniquely contribute to the relationship between PTSD symptomatology and measures of pain outcome.

Methods

491 treatment seeking participants were admitted to a three-week interdisciplinary pain rehabilitation program between July 2016 and March 2020. The patients completed measures of pain severity, pain interference, pain catastrophizing, depressive symptoms, quality of life (QOL), and PTSD symptoms at pretreatment.

Results

Parallel mediation analyses were conducted to evaluate the mediating effect of the Pain Catastrophizing Scale subscales on the relationship between PTSD symptomatology and pain-relevant variables. The helplessness subscale accounted for significant unique variance in the relationship between PTSD symptomatology and pain severity (b = 0.010, SE = 0.002, 95% CI: 0.006, 0.014), pain interference (b = 0.004, SE = 0.002, 95% CI: 0.001, 0.008), and mental health QOL (b = -0.117, SE = 0.031, 95% CI: -0.179, -0.059), while the rumination and magnification subscales had no significant influence.

Conclusions

Pain catastrophizing is a multifaceted construct. These results suggest that the helplessness dimension of pain catastrophizing may be the primary target when treating patients with comorbid chronic pain and PTSD symptoms. This study represents the first to evaluate the influence of the individual dimensions of pain catastrophizing on the relationship between PTSD symptomatology and chronic pain outcome.

Dispositional and situational personal features and acute post-collision head and neck pain: Double mediation of pain catastrophizing and pain sensitivity

Pain variability can be partially attributed to psycho-cognitive features involved in its processing. However, accumulating research suggests that simple linear correlation between situational and dispositional factors may not be sufficiently explanatory, with some positing a role for mediating influences. In addition, acute pain processing studies generally focus on a post-operative model with less attention provided to post-traumatic injury. As such, this study aimed to investigate a more comprehensive pain processing model that included direct and indirect associations between acute pain intensity in the head and neck, pain catastrophizing (using pain catastrophizing scale (PCS)), and pain sensitivity (using the pain sensitivity questionnaire (PSQ)), among 239 patients with post-motor vehicle collision pain. The effect of personality traits (using Ten Items Personality Inventory (TIPI)) and emotional status (using Hospital Anxiety and Depression Scale (HADS) and Perceived Stress Scale (PSS)) on that model was examined as well. To this end, three Structural Equation Modeling (SEM) analyses were conducted. Overall, the data had good fit to all the models, with only PSQ found to have a direct correlation with acute pain intensity. The SEM analyses conversely revealed several mediations. Specifically, that: first, PSQ fully mediated the relationship between PCS and pain intensity; second, PCS and PSQ together fully mediated the relationship between conscientiousness (personality trait) and pain intensity; and finally, emotional status had direct and indirect links with PSQ and pain intensity. In conclusion, these models suggest that during the acute post-collision phase, pain sensitivity intermediates between emotional states and personality traits, partially via elevated pain catastrophizing thoughts.

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

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

Correlation Between Aspects of Perceived Patient Loneliness and Spinal Cord Stimulation Outcomes

OBJECTIVES

Loneliness as a whole has been characterized as a health-related risk factor and is associated with worse outcomes after cardiac procedures. Evidence suggests that chronic pain patients are particularly vulnerable to feeling lonely. We examined the relationship between different aspects of loneliness and one-year postoperative outcomes after spinal cord stimulation (SCS) for chronic pain.

MATERIALS AND METHODS

We contacted 69 patients with thoracic SCS who had participated in our prospective outcomes database with one-year follow-up to complete the validated, abbreviated UCLA Loneliness Scale (UCLA-3). We examined responses on question 9 of the Oswestry Disability Index (ODI), question 12 of the Beck Depression Inventory (BDI), and UCLA-3 due to their relevance to different aspects of loneliness. We conducted regression analyses to determine the relationship between aspects of loneliness and pain outcomes.

RESULTS

We identified that loss of interest in people, companionship, and feeling excluded were associated with pain outcomes. Loss of interest in people was associated with improvement in pain (NRS worst p = 0.021, r = 0.32, NRS least p = 0.004, r = 0.4; NRS right now p = 0.016, r = 0.33). Companionship and feeling excluded were also associated with pain. We examined the interface between depression and total loneliness and found that while both were related to each other, depression was not associated with pain outcomes.

CONCLUSIONS

This study demonstrates an association between loss of interest in people, companionship, and feeling excluded and worse postoperative pain outcomes after receiving SCS. It identifies aspects of loneliness as important factors to consider when predicting the outcomes of SCS therapy for chronic pain control.

Posttraumatic Stress in Children After Injury: The Role of Acute Pain and Opioid Medication Use

OBJECTIVES

After injury, many children experience posttraumatic stress symptoms (PTSS) that negatively impact recovery. Acute pain and PTSS share neurobiological pathways, and acute dosage of morphine has been linked to reduced PTSS in naturalistic studies. However, the complex interactions between pain, morphine and other opioid use, and PTSS have yet to be investigated in robust pediatric samples.This prospective, longitudinal study examined relationships between acute pain, opioid medications, and PTSS after pediatric injury.

METHODS

Ninety-six children aged 8 to 13 years (mean = 10.60, SD = 1.71), hospitalized for unintentional injury, completed assessments at baseline (T1) and 12 weeks (T2) later. Pain ratings and opioid administration data were obtained via chart review.

RESULTS

Structural equation modeling revealed that worst pain endorsed during hospitalization was positively associated with concurrent and later PTSS when controlling for evidence-based risk factors (ie, age, sex, prior trauma history, traumatic appraisals of injury event, heart rate). Neither opioid medications overall nor morphine specifically (milligram/kilogram/day) administered during hospitalization mediated the relationship between pain and T2 PTSS.

CONCLUSIONS

Pain during hospitalization may increase susceptibility for persistent PTSS above and beyond the influence of other empirical risk factors. Findings suggest that pain assessment may be a useful addition to pediatric PTSS screening tools and highlight the need for additional research on pharmacological secondary prevention approaches. Given that inadequate pain control and persistent PTSS each hinder recovery and long-term functioning, better understanding of interactions between acute pain and PTSS after injury is essential for improving screening, prevention, and early intervention efforts.

The Sequential Relation Between Changes in Catastrophizing and Changes in Posttraumatic Stress Disorder Symptom Severity

Catastrophizing has been discussed as a cognitive precursor to the emergence of posttraumatic stress disorder (PTSD) symptoms following the experience of stressful events. Implicit in cognitive models of PTSD is that treatment-related reductions in catastrophizing should yield reductions in PTSD symptoms. The tenability of this prediction has yet to be tested. The present study investigated the sequential relation between changes in a specific form of catastrophizing-symptom catastrophizing-and changes in PTSD symptom severity in a sample of 73 work-disabled individuals enrolled in a 10-week behavioral activation intervention. Measures of symptom catastrophizing and PTSD symptom severity were completed at pre-, mid-, and posttreatment assessment points. Cross-sectional analyses of pretreatment data revealed that symptom catastrophizing accounted for significant variance in PTSD symptom severity, β = .40, p < .001, sr = .28 (medium effect size), even when controlling for known correlates of symptom catastrophizing, such as pain and depression. Significant reductions in symptom catastrophizing and PTSD symptoms were observed during treatment, with large effect sizes, ds = 1.42 and 0.94, respectively, ps < .001. Cross-lagged analyses revealed that early change in symptom catastrophizing predicted later change in PTSD symptoms; early changes in PTSD symptom severity did not predict later change in symptom catastrophizing. These findings are consistent with the conceptual models that posit a causal relation between catastrophizing and PTSD symptom severity. The clinical implications of the findings are discussed.

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

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.

The association between cognitive coping strategies and treatment outcomes in smokers with PTSD

OBJECTIVE

Numerous researchers have suggested that certain coping styles (e.g., maladaptive cognitive coping strategies) interfere with recovery from traumatic experiences and contribute to the onset/maintenance of posttraumatic stress disorder (PTSD). Further, given that individuals with PTSD have a high rate of smoking (e.g., Mahaffey et al., 2016) and that maladaptive coping strategies in general are associated with lower smoking quit rates, it is possible that use of maladaptive cognitive coping strategies are particularly problematic for the recovery of smokers with PTSD. The present study examined whether specific cognitive coping strategies are associated with poorer outcome among smokers with PTSD following an integrated treatment for both disorders.

METHOD

Patients with chronic PTSD and nicotine dependence (N = 142) received up to 12 sessions of smoking cessation counseling combined with varenicline or integrated prolonged exposure therapy and cessation counseling combined with varenicline. We hypothesized that greater maladaptive, and lower adaptive, cognitive coping strategies at baseline would moderate degree of improvement in smoking and PTSD outcomes through to follow-up.

RESULTS

Multilevel modeling revealed that neither maladaptive nor adaptive cognitive coping strategies moderated smoking abstinence outcomes over the course of the study (ps ≥ .271). However, greater use of catastrophizing and lower use of positive reappraisal at baseline were associated with less improvement in the hyperarousal PTSD symptom cluster over the course of the study (ps ≤ .01).

CONCLUSIONS

These findings suggest that maladaptive cognitive coping strategies are not necessarily a contraindication for overall outcomes in integrated PTSD and smoking treatment, although they may influence improvement in hyperarousal symptoms. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Race-related differences in acute pain complaints among inner-city women: the role of socioeconomic status

Previous research has shown that African Americans (AA) report higher pain intensity and pain interference than other racial/ethnic groups as well as greater levels of other risk factors related to worse pain outcomes, including PTSD symptoms, pain catastrophizing, and sleep disturbance. Within a Conservation of Resources theory framework, we tested the hypothesis that socioeconomic status (SES) factors (i.e., income, education, employment, perception of income meeting basic needs) largely account for these racial/ethnic differences. Participants were 435 women [AA, 59.1%; Hispanic/Latina (HL), 25.3%; Non-Hispanic/White (NHW), 15.6%] who presented to an Emergency Department (ED) with an acute pain-related complaint. Data were extracted from psychosocial questionnaires completed at the participants' baseline interview. Structural equation modeling was used to examine whether racial/ethnic differences in pain intensity and pain interference were mediated by PTSD symptoms, pain catastrophizing, sleep quality, and sleep duration, and whether these mediation pathways were, in turn, accounted for by SES factors. Results indicated that SES factors accounted for the mediation relationships linking AA race to pain intensity via PTSD symptoms and the mediation relationships linking AA race to pain interference via PTSD symptoms, pain catastrophizing, and sleep quality. Results suggested that observed racial/ethnic differences in AA women's pain intensity, pain interference, and common risk factors for elevated pain may be largely due to racial/ethnic differences in SES. These findings highlight the role of social inequality in persistent health disparities facing inner-city, AA women.

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

Background: The mutual maintenance model proposes that post-traumatic stress disorder (PTSD) symptoms and chronic physical symptoms have a bi-directional temporal relationship. Despite widespread support for this model, there are relatively few empirical tests of the model and these have primarily examined patients with a traumatic physical injury. Objective: To extend the assessment of this model, we examined the temporal relationship between PTSD and physical symptoms for military personnel deployed to combat (i.e., facing the risk of death) who were not evacuated for traumatic injury. Methods: The current study used a prospective, longitudinal design to understand the cross-lagged relationships between PTSD and physical symptoms before, immediately after, 3 months after, and 1 year after combat deployment. Results: The cross-lagged results showed physical symptoms at every time point were consistently related to greater PTSD symptoms at the subsequent time point. PTSD symptoms were related to subsequent physical symptoms, but only at one time-point with immediate post-deployment PTSD symptoms related to physical symptoms at three months after deployment. Conclusion: The findings extend prior work by providing evidence that PTSD and physical symptoms may be mutually maintaining even when there is not a severe traumatic physical injury.

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

After traumatic exposure, individuals are at risk of developing symptoms of both pain and post-traumatic stress disorder (PTSD). Theory and research suggest a complex and potentially mutually maintaining relationship between these symptomatologies. However, findings are inconsistent and the applied methods are not always well suited for testing mutual maintenance. Cross-lagged designs can provide valuable insights into such temporal associations, but there is a need for a systematic review to assist clinicians and researchers in understanding the nature of the relationship. Thus, the aim of this systematic review was to identify, critically appraise, and synthesize results from cross-lagged studies on pain and PTSD symptomatology to assess the evidence for longitudinal reciprocity and potential mediators. Systematic searches resulted in 7 eligible studies that were deemed of acceptable quality with moderate risk of bias using the cohort study checklist from Scottish Intercollegiate Guidelines Network. Furthermore, synthesis of significant pathways in the cross-lagged models showed inconsistent evidence of both bidirectional and unidirectional interaction patterns between pain and PTSD symptomatology across time, hence not uniformly supporting the theoretical framework of mutual maintenance. In addition, the synthesis suggested that hyperarousal and intrusion symptoms may be of particular importance in these cross-lagged relationships, while there was inconclusive evidence of catastrophizing as a mediator. In conclusion, the findings suggest an entangled, but not necessarily mutually maintaining relationship between pain and PTSD symptomatology. However, major variations in findings and methodologies complicated synthesis, prompting careful interpretation and heightening the likelihood that future high-quality studies will change these conclusions.

Psychometric validation of the PTSD Checklist-5 among female Filipino migrant workers

Migrant populations are at increased risk for exposure to traumatic life events. Presently, there are no reliable and valid screening instruments for posttraumatic stress disorder (PTSD) among Filipino migrant workers, a population that numbers over 2.3 million worldwide. This study evaluated the psychometric properties of the PTSD Checklist for DSM-5 (PCL-5) in a sample of female Filipino migrant workers in Macao (SAR), China, in two studies. The first examined the reliability (internal and test-retest), convergent validity (with depression, anxiety, and rumination), and discriminant validity (with pain and social support) in a sample of 131 participants. The second study established criterion validity of the PCL-5 using the PTSD module of the Mini-International Neuropsychiatric Interview (MINI), delivered by a female Filipino psychologist as the criterion, in a sample of 100 participants. Results indicated excellent internal consistency (Cronbach's alpha = 0.95) and moderate 10-day test-retest reliability (ρ = 0.58, p < .001). PCL-5 scores correlated strongly with scores on measures of depression (ρ = 0.71, p < .001), anxiety (ρ = 0.61, p < .001), and rumination (ρ = 0.68, p < .001), supporting convergent validity. Discriminant validity was demonstrated by a weaker association with scores on measures of pain (ρ = 0.33, p < .001) and social support (ρ = -0.11, p = .22). The diagnostic accuracy of the scale was good (AUC = 0.87). The optimal cutoff score of 25 optimized sensitivity (0.89) while maintaining adequate specificity (0.73), with a weighted Kappa of κ[1]) = 0.82. Our results demonstrated that the PCL-5 is a reliable and valid screening instrument for use among female Filipino migrant workers.

The Role of Pain Catastrophizing in Cognitive Functioning Among Veterans With a History of Mild Traumatic Brain Injury

OBJECTIVE

To determine the role of pain catastrophizing (PC) in neuropsychological functioning in veterans with a history of mild traumatic brain injury (TBI).

PARTICIPANTS

Thirty-nine Iraq and Afghanistan combat veterans evaluated in the post-acute phase following mild TBI.

METHODS

Participants underwent psychiatric and TBI clinical interviews, neuropsychological tests, and self-report assessments of PC, pain intensity, depression, and posttraumatic stress disorder symptoms. Cognitive functioning composite scores of executive functioning, processing speed, and learning and memory were created. Composites were entered as dependent variables into separate linear regressions to examine relations with PC.

RESULTS

Greater PC was associated with worse executive functioning and processing speed even when controlling for confounding variables.

CONCLUSIONS

One's interpretation of pain, in addition to pain intensity, has implications for cognitive functioning. Future research is encouraged to determine whether adaptive pain coping mechanisms improve cognitive functioning or, alternatively, whether cognitive rehabilitation strategies reduce PC.

The aftermath of burn injury from the child's perspective: A qualitative study

A burn injury event and subsequent hospitalization are potentially distressing for children. To elucidate the child’s experience of pediatric burn injury, children’s reflections on the burn event and its aftermath were examined. Semi-structured interviews were conducted with eight children (12–17 years old). Using thematic analysis, interview transcripts were coded and codes were combined into overarching categories. Three categories were identified: vivid memories; the importance of parental support; psychosocial impact and coping. Implications for care are discussed in terms of assessing children’s appraisals, paying attention to the parent’s role, and preparing families for potential psychological barriers after discharge.

Catastrophizing, pain and traumatic stress symptoms following burns: A prospective study

BACKGROUND

Pain and posttraumatic stress disorder (PTSD) symptoms are significant problems in the aftermath of a burn injury and they often co-occur. Catastrophizing has been linked to both phenomena. The aim of this study was to investigate the underlying role of catastrophizing in PTSD symptoms and pain following burns.

METHODS

This prospective study included 216 patients with burns. PTSD symptoms and pain were measured during hospitalization (T1) and 6 (T2) and 12 months (T3) postburn. The Impact of Event Scale-Revised (IES-R) indexed PTSD symptoms. Acute pain (T1) was the mean pain during the first two weeks of hospitalization measured using an 11-point graphic numeric rating scale. Chronic pain was indexed using the single item 'average' pain from the Brief Pain Inventory (BPI). Catastrophizing was measured at T1 and T2 using the Cognitive Emotion Regulation Questionnaire (CERQ). Data were analysed using structural equation modelling (SEM).

RESULTS

The results showed that T2 catastrophizing mediated between acute and chronic PTSD symptoms, and T3 pain. Furthermore, the study revealed significant associations between catastrophizing, PTSD symptoms and pain at the respective measurements, and significant longitudinal associations between the constructs.

CONCLUSION

A negative cognitive-affective response to a burn event, such as catastrophizing, mediated the relationship between acute and chronic PTSD symptoms and later chronic pain. Screening for catastrophizing and acute PTSD symptoms is recommended to identify persons at risk for chronic PTSD symptoms and pain.

SIGNIFICANCE

The identification of individuals who have the tendency to catastrophize may assist in finding those at risk for development of both chronic PTSD symptoms and chronic pain. Individuals may benefit from early psychological therapy focussing on catastrophizing and acute PTSD symptoms that may ameliorate both chronic PTSD symptoms and pain.

The role of posttraumatic stress symptoms on chronic pain outcomes in chronic pain patients referred to rehabilitation

Objectives

Posttraumatic stress symptoms (PTSS) are highly prevalent in chronic pain patients and may affect pain symptomatology negatively, but there is still a great need to explore exactly how this occurs. Therefore, this study investigated differences in pain intensity, pain-related disability, and psychological distress between chronic pain patients not exposed to a trauma, patients exposed to a trauma with no PTSS, and patients exposed to a trauma with PTSS. Moreover, the moderating effects of PTSS on the associations between pain intensity and pain-related disability and psychological distress were investigated.

Methods

In this cross-sectional cohort study, data were consecutively collected over the course of a year in patients with chronic non-malignant pain referred for multidisciplinary pain rehabilitation at a Danish university hospital pain center using questionnaires assessing pain, pain-related disability, PTSS, anxiety, and depression.

Results

The final sample consisted of 682 chronic pain patients, who were divided into three subgroups (no trauma, 40.6%; trauma/no PTSS, 40.5%; trauma/PTSS, 18.9%). Chronic pain patients with PTSS reported significantly higher levels of pain intensity, pain-related disability, depression, and anxiety compared to chronic pain patients without a trauma and chronic pain patients without PTSS. Moreover, PTSS significantly moderated the associations between pain intensity and pain-related psychosocial disability, depression, and anxiety.

Conclusion

These results highlight the importance of assessing PTSS in chronic pain patients and suggest that PTSS have a specific influence on the association between pain intensity and more psychosocial aspects of the pain condition.

Predictors of Post-Traumatic Stress Disorder among Victims of Serious Motor Vehicle Accidents

BACKGROUND

Compelling evidence has shown that motor vehicle accidents have an enormous impact on mental health. Post-traumatic Stress Disorder (PTSD) is one of the most common psychological consequences in adult survivors of accidents, so it is important to understand the prevalence and predictors of this issue since delay causes damage to crucial daily functioning. This study aimed at investigating the prevalence and predictors of PTSD after motor vehicle accident.

METHODS

This cross-sectional study was conducted on 528 injured patients six weeks to six months after motor vehicle accident in Imam Reza Clinic of Poursina hospital, Rasht in 2015. Data collection tools were three questionnaires including post-traumatic stress-self report (PSS), Beck Depression Inventory (BDI-II), and the Numeric Rating Scale (NRS) for pain. The data were analyzed in SPSS (Version 19) using Chi-square, Fischer's exact test and multivariate logistic regression. Significance level was considered P≤0.05.

RESULTS

The prevalence of PTSD and depression was 30.49% and 19.89% in participants, respectively. Chi-square test indicated a significant relationship among age (P=0.02), sex (P<0.001), education level (P<0.001), work status (P<0.001) and PTSD. Participants who reported pain (P<0.001) and depression (P<0.001) were more likely to have high score of PTSD than the others. Multivariate logistic regression showed this significance in sex, depression, age, educational status and pain, as constant risk factors in developing PTSD after accident.

CONCLUSION

This study suggests that primary care setting should be readily prompted for diagnosis of these disorders in non-treatment seeking individuals in the community.

Co-occurrence of posttraumatic stress symptoms, pain, and disability 12 months after traumatic injury

Supplemental Digital Content is Available in the Text.

This study showed that PTSD is associated with worse pain and disability at 12 months after traumatic injury. The associations between PTSD criterion symptoms and pain outcomes highlight the likely occurrence of shared mechanisms, particularly between the experience of severe pain, hyperarousal, avoidance, and cognitive appraisals of stress or pain. New efforts are required to develop and validate interventions that can effectively treat comorbid pain and PTSD to prevent their long-term impacts on psychological wellbeing and socioeconomic position.

Introduction:

Chronic pain is common after traumatic injury and frequently co-occurs with posttraumatic stress disorder (PTSD) and PTSD symptoms (PTSS).

Objectives:

This study sought to understand the association between probable PTSD, PTSS, and pain.

Methods:

Four hundred thirty-three participants were recruited from the Victorian Orthopaedic Trauma Outcomes Registry and Victorian State Trauma Registry and completed outcome measures. Participants were predominantly male (n = 324, 74.8%) and aged 17-75 years at the time of their injury (M = 44.83 years, SD = 14.16). Participants completed the Posttraumatic Stress Disorder Checklist, Brief Pain Inventory, Pain Catastrophizing Scale, Pain Self-Efficacy Questionnaire, Tampa Scale of Kinesiophobia, EQ-5D-3L and Roland-Morris Disability Questionnaire 12 months after hospitalization for traumatic injury. Data were linked with injury and hospital admission data from the trauma registries.

Results:

Those who reported having current problems with pain were 3 times more likely to have probable PTSD than those without pain. Canonical correlation showed that pain outcomes (pain severity, interference, catastrophizing, kinesiophobia, self-efficacy, and disability) were associated with all PTSSs, but especially symptoms of cognition and affect, hyperarousal, and avoidance. Posttraumatic stress disorder symptoms, on the contrary, were predominantly associated with high catastrophizing and low self-efficacy. When controlling for demographics, pain and injury severity, depression, and self-efficacy explained the greatest proportion of the total relationship between PTSS and pain-related disability.

Conclusion:

Persons with both PTSS and chronic pain after injury may need tailored interventions to overcome fear-related beliefs and to increase their perception that they can engage in everyday activities, despite their pain.

A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications

The term 'regional interdependence' or RI has recently been introduced into the vernacular of physical therapy and rehabilitation literature as a clinical model of musculoskeletal assessment and intervention. The underlying premise of this model is that seemingly unrelated impairments in remote anatomical regions of the body may contribute to and be associated with a patient's primary report of symptoms. The clinical implication of this premise is that interventions directed at one region of the body will often have effects at remote and seeming unrelated areas. The formalized concept of RI is relatively new and was originally derived in an inductive manner from a variety of earlier publications and clinical observations. However, recent literature has provided additional support to the concept. The primary purpose of this article will be to further refine the operational definition for the concept of RI, examine supporting literature, discuss possible clinically relevant mechanisms, and conclude with a discussion of the implications of these findings on clinical practice and research.

Psychosocial recovery after serious injury

BACKGROUND

The 2010 iteration of the Global Burden of Disease statistics (Murray et al., 2012) points to the growing impact of injury and highlights the mounting burden of psychiatric disorder. It is essential to examine the intersection between these two contributors to disease burden.

METHODS

The Australian Injury Vulnerability Study collected data of over 1,000 injury patients from their initial hospitalization to 6 years post-injury. Structured clinical interviews were used to diagnose psychiatric disorder and self-report measures for disability and symptom severity.

RESULTS

A wide range of psychiatric disorders developed following injury, which included posttraumatic stress disorder, agoraphobia, depression, and substance use disorders (Bryant, O'Donnell, Creamer, Silove, & McFarlane, 2010). Although prevalence rates for these disorders were generally consistent over time, examination of trajectory data showed that different people had the disorders at different times. Importantly, the data showed that early anxiety, depression, and PTSD symptoms played a significant role in the development of long term disability after injury (Carty, O'Donnell, Evans, Kazantzis, & Creamer, 2011; O'Donnell et al., 2013).

CONCLUSIONS

These data support the view that transdiagnostic models for early intervention may be required to address the complex psychiatric disorder trajectories that develop after injury.

Chronic pain patients with possible co-morbid post-traumatic stress disorder admitted to multidisciplinary pain rehabilitation-a 1-year cohort study

BACKGROUND

Although post-traumatic stress disorder (PTSD) is a common co-morbidity in chronic pain, little is known about the association between PTSD and pain in the context of chronic pain rehabilitation.

OBJECTIVE

The aim of the present study was two-fold: (1) to investigate the association of a possible PTSD diagnosis with symptoms of pain, physical and mental functioning, as well as the use of opioids, and (2) to compare the outcome of multidisciplinary chronic pain rehabilitation for patients with a possible PTSD diagnosis at admission with patients without PTSD at admission.

METHOD

A consecutively referred cohort of 194 patients completed a baseline questionnaire at admission covering post-traumatic stress, pain symptoms, physical and mental functioning, as well as self-reported sleep quality and cognitive difficulties. Medication use was calculated from their medical records. A total of 95 were admitted to further multidisciplinary treatment and included in the outcome study.

RESULTS

A high prevalence of possible PTSD was found (26.3%). Patients with possible co-morbid PTSD experienced significantly poorer general and mental health, poorer sleep quality, and more cognitive problems as well as inferior social functioning compared to patients without PTSD. Possible co-morbid PTSD did not result in higher use of opioids or sedatives. Surprisingly, possible co-morbid PTSD at admission was not associated with lower levels of symptom reduction from pre- to post-treatment.

CONCLUSIONS

Possible co-morbid PTSD in chronic pain is a major problem associated with significantly poorer functioning on several domains. Nevertheless, our results indicate that pain-related symptoms could be treated with success despite possible co-morbid PTSD. However, since PTSD was only measured at admission it is not known whether rehabilitation actually reduced PTSD.

Combining biofeedback and Narrative Exposure Therapy for persistent pain and PTSD in refugees: a pilot study

OBJECTIVE

Many traumatised refugees suffer from both persistent pain and posttraumatic stress disorder (PTSD). To date, no specific guidelines exist for treatment of this group of patients. This paper presents data on a pilot treatment study conducted with 15 traumatised refugees with persistent pain and PTSD.

METHODS

Participants received 10 sessions of pain-focused treatment with biofeedback (BF) followed by 10 sessions of Narrative Exposure Therapy (NET). Structured interviews and standardised questionnaires were used to assess symptoms of pain intensity, pain disability, PTSD and quality of life directly before and after treatment and at 3 months follow-up.

RESULTS

Following the combined intervention, participants showed a significant reduction in both pain and PTSD symptoms, as well as improved quality of life. Additionally, biofeedback increased motivation for subsequent trauma-focused therapy, which in turn was related to larger PTSD treatment gains.

CONCLUSION

This pilot study provides initial evidence that combining BF and NET is safe, acceptable, and feasible in patients with co-morbid persistent pain and PTSD.

Predicting posttraumatic stress disorder symptoms and pain intensity following severe injury: the role of catastrophizing

BACKGROUND

A number of theories have proposed possible mechanisms that may explain the high rates of comorbidity between posttraumatic stress disorder (PTSD) and persistent pain; however, there has been limited research investigating these factors.

OBJECTIVE

The present study sought to prospectively examine whether catastrophizing predicted the development of PTSD symptoms and persistent pain following physical injury.

DESIGN

Participants (N=208) completed measures of PTSD symptomatology, pain intensity and catastrophizing during hospitalization following severe injury, and 3 and 12 months postinjury. Cross-lagged path analysis explored the longitudinal relationship between these variables.

RESULTS

Acute catastrophizing significantly predicted PTSD symptoms but not pain intensity 3 months postinjury. In turn, 3-month catastrophizing predicted pain intensity, but not PTSD symptoms 12 months postinjury. Indirect relations were also found between acute catastrophizing and 12-month PTSD symptoms and pain intensity. Relations were mediated via 3-month PTSD symptoms and 3-month catastrophizing, respectively. Acute symptoms did not predict 3-month catastrophizing and catastrophizing did not fully account for the relationship between PTSD symptoms and pain intensity.

CONCLUSIONS

Findings partially support theories that propose a role for catastrophizing processes in understanding vulnerability to pain and posttrauma symptomatology and, thus, a possible mechanism for comorbidity between these conditions.