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Support for the mutual maintenance of pain and post-traumatic stress disorder symptoms

Published online by Cambridge University Press:  08 October 2009

A. Liedl ,
M. O'Donnell ,
M. Creamer ,
D. Silove ,
A. McFarlane ,
C. Knaevelsrud  and
R. A. Bryant
A. Liedl*
Affiliation:
Department of Clinical Psychology and Psychotherapy, Technical University of Dresden, Germany Treatment Centre for Torture Victims, Berlin, Germany
M. O'Donnell
Affiliation:
Australian Centre for Posttraumatic Mental Health, Melbourne, Australia Department of Psychiatry, University of Melbourne, Australia National Trauma Research Institute, Melbourne, Australia
M. Creamer
Affiliation:
Australian Centre for Posttraumatic Mental Health, Melbourne, Australia Department of Psychiatry, University of Melbourne, Australia
D. Silove
Affiliation:
University of New South Wales, Sydney, Australia
A. McFarlane
Affiliation:
The Centre of Military and Veterans' Health, Adelaide, Australia
C. Knaevelsrud
Affiliation:
Treatment Centre for Torture Victims, Berlin, Germany Free University of Berlin, Germany
R. A. Bryant
Affiliation:
University of New South Wales, Sydney, Australia
*
*Address for correspondence: A. Liedl, Treatment Centre for Torture Victims Berlin (bzfo), Research Department, Turmstrasse 21, 10559Berlin, Germany. (Email: [email protected])
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Abstract

Background

Pain and post-traumatic stress disorder (PTSD) are frequently co-morbid in the aftermath of a traumatic event. Although several models attempt to explain the relationship between these two disorders, the mechanisms underlying the relationship remain unclear. The aim of this study was to investigate the relationship between each PTSD symptom cluster and pain over the course of post-traumatic adjustment.

Method

In a longitudinal study, injury patients (n=824) were assessed within 1 week post-injury, and then at 3 and 12 months. Pain was measured using a 100-mm Visual Analogue Scale (VAS). PTSD symptoms were assessed using the Clinician-Administered PTSD Scale (CAPS). Structural equation modelling (SEM) was used to identify causal relationships between pain and PTSD.

Results

In a saturated model we found that the relationship between acute pain and 12-month pain was mediated by arousal symptoms at 3 months. We also found that the relationship between baseline arousal and re-experiencing symptoms, and later 12-month arousal and re-experiencing symptoms, was mediated by 3-month pain levels. The final model showed a good fit [χ2=16.97, df=12, p>0.05, Comparative Fit Index (CFI)=0.999, root mean square error of approximation (RMSEA)=0.022].

Conclusions

These findings provide evidence of mutual maintenance between pain and PTSD.

Keywords

Mediatormutual maintenancepainpost-traumatic stress disorderstructural equation modelling
Type
Original Articles
Information
Psychological Medicine , Volume 40 , Issue 7 , July 2010 , pp. 1215 - 1223
Copyright
Copyright © Cambridge University Press 2009

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References

Andreski, P, Chilcoat, H, Breslau, N (1998). Post-traumatic stress disorder and somatization symptoms: a prospective study. Psychiatry Research 79, 131–138.CrossRefGoogle ScholarPubMed
Arbuckle, JL (2005). Amos™ 6.0 User's Guide. Amos Development Corporation: Spring House, PA.Google Scholar
Bair, MJ, Robinson, RL, Katon, W, Kroenke, K (2003). Depression and pain comorbidity: a literature review. Archives of Internal Medicine 163, 2433–2445.CrossRefGoogle ScholarPubMed
Baker, SP, O'Neil, B, Haddon, W, Long, WB (1974). The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. Journal of Trauma 14, 187–196.CrossRefGoogle ScholarPubMed
Beesdo, K, Jacobi, F, Hoyer, J, Low, N, Höfler, M, Wittchen, H-U (2009). Pain associated with anxiety and depressive disorders in a nationally representative population sample. Social Psychiatry and Psychiatric Epidemiology. Published online: 10 April 2009. doi: 10.1007/s00127-009-0045-1.Google Scholar
Bentler, PM (1990). Comparative fit indexes in structural models. Psychological Bulletin 107, 238–246.CrossRefGoogle ScholarPubMed
Blake, DD, Weathers, FW, Nagy, LM, Kaloupek, DG, Charney, DS, Keane, TM (1998). Clinician-Administered PTSD Scale for DSM-IV. National Center for Posttraumatic Stress Disorder: Boston, MA.Google Scholar
Browne, MW, Cudeck, R (1993). Alternative ways of assessing model fit. In Testing Structural Equation Models (ed. Long, K. A. B. J. S.), pp. 136–162. Sage: Newbury Park, CA.Google Scholar
Bryant, RA, Harvey, AG (1995). Processing threatening information in posttraumatic stress disorder. Journal of Abnormal Psychology 104, 537–541.CrossRefGoogle ScholarPubMed
Bryant, RA, Marosszeky, JE, Crooks, J, Baguley, I, Gurka, J (1999). Interaction of posttraumatic stress disorder and chronic pain following traumatic brain injury. Journal of Head Trauma Rehabilitation 14, 588–594.CrossRefGoogle ScholarPubMed
Burns, JW (2006). Arousal of negative emotions and symptom-specific reactivity in chronic low back pain patients. Emotion 6, 309–319.CrossRefGoogle ScholarPubMed
Campbell, DG, Felker, BL, Liu, CF, Yano, EM, Kirchner, JE, Chan, D, Rubenstein, LV, Chaney, EF (2007). Prevalence of depression–PTSD comorbidity: implications for clinical practice guidelines and primary care-based interventions. Journal of General Internal Medicine 22, 711–718.CrossRefGoogle ScholarPubMed
Clapp, JD, Beck, JG, Palyo, SA, Grant, DM (2008). An examination of the synergy of pain and PTSD on quality of life: additive or multiplicative effects? Pain 138, 301–309.CrossRefGoogle ScholarPubMed
Cook, AJ, Brawer, PA, Vowles, KE (2005). The fear-avoidance model of chronic pain: validation and age analysis using structural equation modeling. Pain 21, 195–206.Google Scholar
Creamer, M, Burgess, P, McFarlane, AC (2001). Post-traumatic stress disorder: findings from the Australian National Survey of Mental Health and Well-being. Psychological Medicine 31, 1237–1247.CrossRefGoogle ScholarPubMed
de Leeuw, R, Schmidt, JE, Carlson, CR (2005). Traumatic stressors and post-traumatic stress disorder symptoms in headache patients. Headache 45, 1365–1374.CrossRefGoogle ScholarPubMed
Dirkzwager, AJE, Van Der Velden, PG, Grievink, L, Yzermans, CJ (2007). Disaster-related posttraumatic stress disorder and physical health. Psychosomatic Medicine 69, 435–440.CrossRefGoogle ScholarPubMed
Finney, SJ, DiStefano, C (2006). Non-normal and categorical data in structural equation modeling. In Structural Equation Modeling: A Second Course (ed. Hancock and, G. R.Mueller, R. O.), pp. 269–314. Information Age Publishing: Greenwich, CT.Google Scholar
Harvey, AG, Bryant, RA, Rapee, RM (1996). Preconscious processing of threat in posttraumatic stress disorder. Cognitive Therapy and Research 20, 613–623.CrossRefGoogle Scholar
Heim, C, Ehlert, U, Hellhammer, DH (2000). The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders. Psychoneuroendocrinology 25, 1–35.CrossRefGoogle ScholarPubMed
Jenewein, J, Moergeli, H, Wittmann, L, Büchi, S, Kraemer, B, Schnyder, U (2009). Development of chronic pain following severe accidental injury. Results of a 3-year follow-up study. Journal of Psychosomatic Research 66, 119–126.CrossRefGoogle ScholarPubMed
Jensen, MP, Karoly, P, Braver, S (1986). The measurement of clinical pain intensity: a comparison of six methods. Pain 27, 117–126.CrossRefGoogle ScholarPubMed
Kessler, RC, Sonnega, A, Bromet, E, Hughes, M, Nelson, CB (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry 52, 1048–1060.CrossRefGoogle ScholarPubMed
Korte, SM, Koolhaas, JM, Wingfield, JC, McEwen, BS (2005). The Darwinian concept of stress: benefits of allostasis and costs of allostatic load and the trade-offs in health and disease. Neuroscience and Biobehavioral Reviews 29, 3–38.CrossRefGoogle ScholarPubMed
Leeuw, M, Goossens, MEJB, Linton, SJ, Crombez, G, Boersma, K, Vlaeyen, JWS (2007). The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. Journal of Behavioral Medicine 30, 77–94.CrossRefGoogle ScholarPubMed
Lethem, J, Slade, P, Troup, J, Bentley, G (1983). Outline of a fear avoidance model of exaggerated pain perception – I. Behaviour Research and Therapy 21, 401–408.CrossRefGoogle ScholarPubMed
Liedl, A, Knaevelsrud, C (2008). Chronic pain and PTSD: the Perpetual Avoidance Model and its treatment implications. Torture 18, 69–76.Google ScholarPubMed
McBeth, J, Silman, AJ, Gupta, A, Chiu, YH, Ray, D, Morriss, R, Dickens, C, King, Y, Macfarlane, GJ (2007). Moderation of psychosocial risk factors through dysfunction of the hypothalamic-pituitary-adrenal stress axis in the onset of chronic widespread musculoskeletal pain. Arthritis and Rheumatism 56, 360–371.CrossRefGoogle ScholarPubMed
McEwen, BS (2000). The neurobiology of stress: from serendipity to clinical relevance. Brain Research 886, 172–189.CrossRefGoogle ScholarPubMed
McFarlane, AC (2007). Stress-related musculoskeletal pain. Best Practice and Research in Clinical Rheumatology 21, 549–565.CrossRefGoogle ScholarPubMed
McFarlane, AC, Ellis, N, Barton, C, Browne, D, Van Hooff, M (2008). The conundrum of medically unexplained symptoms: questions to consider. Psychosomatics 49, 369–377.CrossRefGoogle ScholarPubMed
Merskey, H, Bogduk, N (1994). Classification of Chronic Pain. IASP Task Force on Taxonomy: Seattle.Google Scholar
Moores, KA, Clark, CR, McFarlane, AC, Brown, GC, Puce, A, Taylor, DJ (2008). Abnormal recruitment of working memory updating networks during maintenance of trauma-neutral information in post-traumatic stress disorder. Psychiatry Research 163, 156–170.CrossRefGoogle ScholarPubMed
Mueller, J, Karl, A, Denke, C, Mathier, F, Dittmann, J, Rohleder, N, Knaevelsrud, C (2009). Chronic pain in survivors of war and torture with PTSD – clinical relevance and preliminary findings on the feasibility of CBT-biofeedback. Cognitive Behaviour Therapy. Published online: 12 August 2009. doi: 10.1080/16506070902815024.Google Scholar
Norman, SB, Stein, MB, Dimsdale, JE, Hoyt, DB (2008). Pain in the aftermath of trauma is a risk factor for post-traumatic stress disorder. Psychological Medicine 38, 533–542.CrossRefGoogle ScholarPubMed
Norton, P, Asmundson, G (2003). Amending the fear-avoidance model of chronic pain: what is the role of physiological arousal? Behavior Therapy 34, 17–30.CrossRefGoogle Scholar
O'Donnell, M, Creamer, M, Pattison, P, Atkin, C (2004). Psychiatric morbidity following injury. American Journal of Psychiatry 161, 507–514.CrossRefGoogle ScholarPubMed
O'Donnell, ML, Bryant, RA, Creamer, M, Carty, J (2008). Mental health following traumatic injury: toward a health system model of early psychological intervention. Clinical Psychology Review 28, 387–406.CrossRefGoogle Scholar
Otis, JD, Keane, TM, Kerns, RD (2003). An examination of the relationship between chronic pain and post-traumatic stress disorder. Journal of Rehabilitation Research and Development 40, 397–405.CrossRefGoogle ScholarPubMed
Pillemer, S, Bradley, L, Crofford, L, Moldofsky, H, Chrousos, GP (1997). The neuroscience and endocrinology of fibromyalgia. Arthritis and Rheumatism 40, 1928–1939.CrossRefGoogle ScholarPubMed
Roberts, NP, Kitchiner, NJ, Kenardy, J, Bisson, JI (2009). Systematic review and meta-analysis of multiple-session early interventions following traumatic events. American Journal of Psychiatry 166, 293–301.CrossRefGoogle ScholarPubMed
Roelofs, J, Peters, ML, Vlaeyen, JW (2002). Selective attention for pain-related information in healthy individuals: the role of pain and fear. European Journal of Pain 6, 331–339.CrossRefGoogle ScholarPubMed
Roth, RS, Geisser, ME, Bates, R (2008). The relation of post-traumatic stress symptoms to depression and pain in patients with accident-related chronic pain. Journal of Pain 9, 588–596.CrossRefGoogle ScholarPubMed
Rubacka, JM, Schmeidler, J, Nomura, Y, Luthra, R, Rajendran, K, Abramovitz, R, Chemtob, CM (2008). The relationship between PTSD arousal symptoms and depression among mothers exposed to the World Trade Center attacks. Journal of Nervous and Mental Disease 196, 504–507.CrossRefGoogle Scholar
Sareen, J, Cox, BJ, Stein, MB, Afifi, TO, Fleet, C, Asmundson, GJG (2007). Physical and mental comorbidity, disability, and suicidal behavior associated with posttraumatic stress disorder in a large community sample. Psychosomatic Medicine 69, 242–248.CrossRefGoogle Scholar
Schermelleh-Engel, K, Moosbrugger, H, Mueller, H (2003). Evaluating the fit of structural equation models: tests of significance and descriptive goodness-of-fit measures. Methods of Psychological Research Online 8, 23–74.Google Scholar
Sharp, TJ, Harvey, AG (2001). Chronic pain and posttraumatic stress disorder: mutual maintenance? Clinical Psychology Review 21, 857–877.CrossRefGoogle ScholarPubMed
Shipherd, JC, Keyes, M, Jovanovic, T, Ready, DJ, Baltzell, D, Worley, V, Gordon-Brown, V, Hayslett, C, Duncan, E (2007). Veterans seeking treatment for posttraumatic stress disorder: what about comorbid chronic pain? Journal of Rehabilitation Research and Development 44, 153–165.CrossRefGoogle ScholarPubMed
Staud, R, Craggs, JG, Robinson, ME, Perlstein, WM, Price, DD (2007). Brain activity related to temporal summation of C-fiber evoked pain. Pain 129, 130–142.CrossRefGoogle ScholarPubMed
Villano, CL, Rosenblum, A, Magura, S, Fong, C, Cleland, C, Betzler, TF (2007). Prevalence and correlates of posttraumatic stress disorder and chronic severe pain in psychiatric outpatients. Journal of Rehabilitation Research and Development 44, 167–177.CrossRefGoogle ScholarPubMed
Vlaeyen, J, Linton, S (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 85, 317–332.CrossRefGoogle ScholarPubMed
Vlaeyen, JWS, Kole-Snijders, AMJ, Boeren, RGB, van Eek, H (1995). Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain 62, 363–372.CrossRefGoogle ScholarPubMed
Wall, PD, Melzack, R (1999). Textbook of Pain. Churchill Livingstone: Edinburgh.Google Scholar
Weathers, FW, Keane, TM, Davidson, J (2001). Clinician-administered PTSD scale: a review of the first ten years of research. Depression and Anxiety 13, 132–156.CrossRefGoogle Scholar
Whalley, MG, Farmer, E, Brewin, CR (2007). Pain flashbacks following the July 7th 2005 London bombings. Pain 132, 332–336.CrossRefGoogle ScholarPubMed
Zatzick, DF, Jurkovich, GJ, Gentilello, L, Wisner, D, Rivara, FP (2002). Posttraumatic stress, problem drinking, and functional outcomes after injury. Archives of Surgery 137, 200–205.CrossRefGoogle ScholarPubMed