John D. Otis

Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: polytrauma clinical triad.

This study examines the prevalence and coprevalence with which returning Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) veterans were reporting symptoms consistent with chronic pain, posttraumatic stress disorder (PTSD), and persistent postconcussive symptoms (PPCS). The medical records of 340 OIF/OEF veterans seen at a Department of Veterans Affairs Polytrauma Network Site were comprehensively reviewed. Analyses indicated a high prevalence of all three conditions in this population, with chronic pain, PTSD, and PPCS present in 81.5%, 68.2%, and 66.8%, respectively. Only 12 of the veterans (3.5%) had no chronic pain, PTSD, or PPCS. The frequency at which these three conditions were present in isolation (10.3%, 2.9%, and 5.3%, respectively) was significantly lower than the frequency at which they were present in combination with one another, with 42.1% of the sample being diagnosed with all three conditions simultaneously. The most common chronic pain locations were the back (58%) and head (55%). These results underscore the complexity of the presenting complaints in OIF/OEF veterans and support the importance of a multidisciplinary team approach to assessment and treatment.

An examination of the relationship between chronic pain and post-traumatic stress disorder

Chronic pain and post-traumatic stress disorder (PTSD) are frequently observed within the Department of Veterans Affairs healthcare system and are often associated with a significant level of affective distress and physical disability. Clinical practice and research suggest that these two conditions co-occur at a high rate and may interact in such a way as to negatively impact the course of either disorder; however, relatively little research has been conducted in this area. This review summarizes the current literature pertaining to the prevalence and development of chronic pain and PTSD. Research describing the comorbidity of both conditions is reviewed, and several theoretical models are presented to explain the mechanisms by which these two disorders may be maintained. Future directions for research and clinical implications are discussed.

Veterans' reports of pain and associations with ratings of health, health-risk behaviors, affective distress, and use of the healthcare system

The improved management of pain among veterans seeking care in Veterans Health Administration (VHA) facilities has been established as a priority. This study documents the high prevalence of reports of pain among a convenience sample of 685 veterans seeking care in a VHA primary care setting. Also reported are associations of pain complaints with self-rated health, an index of emotional distress, health-risk behaviors such as tobacco and alcohol use, health-related concerns about diet and weight, and perceptions of the availability of social support. The relationship between the presence of pain and use of outpatient and inpatient medical and mental health services is also examined. Nearly 50% of the sample reported that they experience pain regularly and that they were concerned about this problem at the time of the index visit to their primary care provider. Persons acknowledging the presence of pain, relative to those not reporting pain, were younger, reported worsening health over the past year, had greater emotional distress, used tobacco, had diet and/or weight concerns, and were found to use more outpatient medical, but not inpatient medical or mental health services. Results support the goals of the VHA National Pain Management Strategy designed to reduce unnecessary pain and suffering among veterans receiving care in VHA facilities.

The Development of an Integrated Treatment for Veterans with Comorbid Chronic Pain and Posttraumatic Stress Disorder

OBJECTIVE The purpose of this article is to describe the development of the first integrated treatment for Veterans with comorbid chronic pain and posttraumatic stress disorder (PTSD). DESIGN Descriptive, including pre- and posttreatment assessment results from a pilot study of six veterans with comorbid chronic pain and PTSD. SETTING Northeastern Department of Veterans Affairs Medical Center. INTERVENTIONS Using components of cognitive processing therapy (CPT) for PTSD and cognitive behavioral therapy (CBT) for chronic pain management, a 12-session integrated treatment for veterans with comorbid chronic pain and PTSD was developed. A therapist manual and patient workbook that included weekly readings and homework assignments were created. Participants received pre- and posttreatment evaluations using measures of pain, PTSD, physical disability, and psychological distress. The treatment development process is reviewed and the benefits and challenges of implementing this integrated treatment are presented. RESULTS Several themes emerged over the course of implementing the treatment, including the importance of establishing participant trust, regular therapy attendance, and addressing participant avoidance. Of the six participants recruited for the pilot study, three withdrew from the study and three completed the integrated treatment. Participants reported that they generally liked the format of treatment, appreciated learning about the ways that chronic pain and PTSD share some common symptoms, and ways that the two disorders can interact with one another. The assessment results of those who completed treatment suggest that this treatment approach is feasible and may have clinical benefit. CONCLUSIONS Participants appeared to benefit from receiving the integrated treatment for pain and PTSD. A randomized clinical trial is currently being conducted to evaluate the efficacy of this treatment approach.

Self-appraised problem solving and pain-relevant social support as predictors of the experience of chronic pain.

The purpose of this study was to examine the contributions of self-appraised problem-solving competence and pain-relevant social support to the prediction of pain, depression, and disability. The 234 chronic pain patients referred for participation in a comprehensive pain management program were administered self-report measures of pain, depression, disability, pain-relevant social support, and problem solving. Hierarchical multiple-regression analyses revealed that lower self-appraised problem-solving competence was related to increased pain, depression, and disability. Pain-relevant social support was directly related to pain and disability but indirectly related to depression. High levels of pain-relevant social support were found to buffer the relation between poorer self-appraised problem-solving competence and depressive symptoms. The results support the assessment of problem-solving skills in chronic pain patients and the investigation and utility of interventions aimed at increasing adaptive pain-relevant social support.

Complicating Factors Associated with Mild Traumatic Brain Injury: Impact on Pain and Posttraumatic Stress Disorder Treatment

The nature of combat in Iraq and Afghanistan has resulted in high rates of comorbidity among chronic pain, posttraumatic stress disorder (PTSD), and mild traumatic brain injury (mTBI) in Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). Although separate evidence-based psychological treatments have been developed for chronic pain and PTSD, far less is known about how to approach treatment when these conditions co-occur, and especially when they co-occur with mTBI. To provide the best care possible for OEF/OIF Veterans, clinicians need to have a clearer understanding of how to identify these conditions, ways in which these conditions may interact with one another, and ways in which existing evidence-based treatments can be modified to meet the needs of individuals with mTBI. The purpose of the present paper is to review the comorbidity of pain, PTSD, and mTBI in OEF/OIF Veterans, and provide recommendations to clinicians who provide care to Veterans with these conditions. First, we will begin with an overview of the presentation, symptomatology, and treatment of chronic pain and PTSD. The challenges associated with mTBI in OEF/OIF Veterans will be reported and data will be presented on the comorbidity among all three of these conditions in OEF/OIF Veterans. Second, we will present recommendations for providing psychological treatment for chronic pain and PTSD when comorbid with mTBI. Finally, the paper concludes with a discussion of the need for a multidisciplinary treatment approach, as well as a call for continued research to further refine existing treatments for these conditions.

Cognitive-behavioral therapy for chronic pain in the elderly

Cognitive-behavioral therapy has become a common nonpharmacologic treatment option for individuals experiencing chronic nonmalignant pain. This article begins with an overview of the cognitive-behavioral perspective on pain and pain management. The second section discusses relevant developmental issues and suggests refinements to cognitive-behavioral therapy for the elderly, followed by a case example describing the implementation of cognitive-behavioral therapy for an elderly gentleman in an ambulatory care setting. The details of assessment, treatment conceptualization and planning, intervention, and follow-up are explored in this context. This article concludes with suggestions for future refinements in the application of this approach in the management of chronic pain in the elderly.

The shared neuroanatomy and neurobiology of comorbid chronic pain and PTSD: therapeutic implications.

Chronic pain and posttraumatic stress disorder (PTSD) are disabling conditions that affect biological, psychological, and social domains of functioning. Clinical research demonstrates that patients who are affected by chronic pain and PTSD in combination experience greater pain, affective distress, and disability than patients with either condition alone. Additional research is needed to delineate the interrelated pathophysiology of chronic pain and PTSD, with the goal of facilitating more effective therapies to treat both conditions more effectively; current treatment strategies for chronic pain associated with PTSD have limited efficacy and place a heavy burden on patients, who must visit various specialists to manage these conditions separately. This article focuses on neurobiological factors that may contribute to the coprevalence and synergistic interactions of chronic pain and PTSD. First, we outline how circuits that mediate emotional distress and physiological threat, including pain, converge. Secondly, we discuss specific neurobiological mediators and modulators of these circuits that may contribute to chronic pain and PTSD symptoms. For example, neuropeptide Y, and the neuroactive steroids allopregnanolone and pregnanolone (together termed ALLO) have antistress and antinociceptive properties. Reduced levels of neuropeptide Y and ALLO have been implicated in the pathophysiology of both chronic pain and PTSD. The potential contribution of opioid and cannabinoid system factors also will be discussed. Finally, we address potential novel methods to restore the normal function of these systems. Such novel perspectives regarding disease and disease management are vital to the pursuit of relief for the many individuals who struggle with these disabling conditions.

Family therapy for persons experiencing pain: evidence for its effectiveness

Abstract The family context has been hypothesized to be particularly important in understanding, if not explaining, the development and perpetuation of chronic pain conditions. Family systems perspectives, the operant conditioning model of chronic pain, and cognitive-behavioral models have all encouraged investigation of the impact of chronic pain on the family and its members and, conversely, the potentially deleterious effects of maladaptive family responses in maintaining the disorder. This article offers a brief overview of relevant theoretical perspectives and the empirical research informed by them. A more detailed and critical review is presented of the few empirical investigations of the efficacy of pain treatment approaches involving the partner of the person experiencing pain. Implications of these studies for improving our understanding of the role of families in the perpetuation of chronic pain, particularly for the further refinement and evaluation of family and couples treatment approaches, are discussed.

Coping strategies and beliefs about pain in veterans with comorbid chronic pain and significant levels of posttraumatic stress disorder symptoms

The purpose of this study was to assess differences in beliefs about pain and coping strategies employed in veterans with comorbid chronic pain and posttraumatic stress disorder (PTSD), compared to veterans with chronic pain alone. It was hypothesized that veterans with comorbid chronic pain and significant levels of PTSD symptomatology would report higher levels of maladaptive coping strategies and beliefs about pain when compared to veterans with pain alone.