Original report| Volume 9, ISSUE 7, P588-596, July 2008

The Relation of Post-Traumatic Stress Symptoms to Depression and Pain in Patients With Accident-Related Chronic Pain


      Symptoms of post-traumatic stress disorder (PTSD) are a common comorbidity in patients with a history of accident-related chronic pain and depression. However, little is known regarding the influence of PTSD in contributing to the affective distress, pain experience, and disability associated with chronic pain in this population. This study used structural equation modeling to examine 3 models that assess these relations in a sample of chronic pain patients with accident-related pain. Subjects were assessed for pain experience, depressive symptoms, anxiety, PTSD symptoms, pain disability, and relevant demographic variables. Pearson correlations indicated that symptoms of depression were significantly related to more severe pain, disability, and PTSD symptoms. PTSD symptoms were significantly associated with higher disability. The model of best fit indicated that after controlling for the influence of anxiety on the dependent measures, PTSD symptoms have a direct influence on severity of depressive symptoms, whereas depressive symptoms have a direct influence on pain intensity and an indirect impact on pain intensity by way of their effect on disability. These data point to the importance of unresolved PTSD symptoms in contributing to the level of depression, pain, and disability exhibited by chronic pain patients and highlight the need to consider directed and primary treatment of PTSD in pain rehabilitation programs.


      This study highlights the impact of symptoms of PTSD on levels of depression, disability, and pain in patients with pain secondary to physical injury. Our results suggest that pain rehabilitation programs provide directed interventions for PTSD symptoms among this population to improve pain treatment outcomes.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Abramson L.U.
        • Seligman M.E.P.
        • Teasdale J.D.
        Learned helplessness in humans: Critique and reformulation.
        J Abnorm Psychol. 1978; 87: 49-74
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders.
        4th ed. American Psychiatric Press, Washington, DC1994
        • Asmundson G.J.G.
        • Coons M.J.
        • Taylor S.
        • Katz J.
        PTSD and the experience of pain: Research and clinical implications of shared vulnerability and mutual maintenance models.
        Can J Psychiatry. 2002; 47: 930-937
        • Blanchard E.B.
        • Buckley T.C.
        • Hickling E.J.
        • Taylor A.E.
        Post-traumatic stress disorder and comorbid major depression: Is the correlation an illusion?.
        J Anxiety Disord. 1998; 12: 21-37
        • Blanchard E.B.
        • Hickling E.
        After the Crash: Assessment and Treatment of Motor Vehicle Survivors.
        American Psychological Association, Washington, DC1997
        • Bryant R.A.
        • Harvey A.G.
        Avoidant coping style and post-traumatic stress disorder following motor vehicle accidents.
        Behav Res Ther. 1995; 33: 631-635
        • Bryant R.A.
        • Moulds M.L.
        • Guthrie R.M.
        • Dang S.T.
        • Nixon R.D.
        Imaginal exposure alone and imaginal exposure with cognitive restructuring in treatment of post-traumatic stress disorder.
        J Consult Clin Psychol. 2003; 71: 706-712
        • Burchiel K.J.
        • Anderson V.C.
        • Wilson B.J.
        • Denison D.B.
        • Olson K.A.
        • Shatin D.
        Prognostic factors of spinal cord stimulation for chronic back and leg pain.
        Neurosurgery. 1995; 36: 1101-1111
        • Byrne B.M.
        Structural Equation Modeling with AMOS: Basic Concepts, Applications, and Programming.
        Lawrence Erlbaum, Mahwah, NJ2001
        • Cook A.
        • Brawer P.A.
        • Vowles K.E.
        The fear-avoidance model of chronic pain validation and age analysis using structural equation modeling.
        Pain. 2006; 121: 195-206
        • Crooks J.
        • Tunks E.
        • Rideout E.
        • Browne J.
        Epidemiologic comparisons of persistent pain sufferers in a specialty pain clinic and in the community.
        Arch Phys Med Rehabil. 1986; 67: 451-455
        • Derogatis L.R.
        • Spencer P.M.
        The Brief Symptom Inventory (BSI): Administration, Scoring and Procedures Manual-I.
        1982 (Baltimore, MD, Johns Hopkins University School of Medicine, Clinical Psychometric Research)
        • Dolce J.J.
        • Crocker M.F.
        • Doleys D.M.
        Predicting outcome among chronic pain patients.
        Behav Res Ther. 1986; 24: 313-319
        • Foa E.B.
        • Rothbaum B.O.
        • Riggs D.
        • Murdock T.
        Treatment of PTSD in rape victims: A comparison between cognitive-behavioral procedures and counseling.
        J Consult Clin Psychol. 1991; 59: 715-723
        • Foa E.B.
        • Zinbarg R.
        • Rothbaum B.O.
        Uncontrollability and unpredictability in post-traumatic stress disorder: An animal model.
        Psychol Bull. 1992; 112: 218-238
      1. Follette V.M. Ruzek J.I. Abueg F.R. Cognitive-Behavioral Therapies for Trauma. Guilford Press, New York, NY1998
        • Geisser M.E.
        • Roth R.S.
        Knowledge of and agreement with chronic pain diagnosis: Relation to affective distress, pain beliefs and coping, pain intensity, and disability.
        J Occup Rehabil. 1998; 8: 73-88
        • Geisser M.E.
        • Roth R.S.
        • Bachman J.E.
        • Eckert T.A.
        The relationship between symptoms of post-traumatic stress disorder and pain, affective disturbance and disability among patients with accident and non-accident related pain.
        Pain. 1996; 66: 207-214
        • Geisser M.E.
        • Roth R.S.
        • Robinson M.E.
        Assessing depression among persons with chronic pain using the Center for Epidemiological Studies Depression Scale and the Beck Depression Inventory: A comparative analysis.
        Clin J Pain. 1997; 13: 163-170
        • Geracioti T.D.
        • Carpenter L.L.
        • Owens M.J.
        • Baker D.G.
        • Ekhator N.N.
        • Horn P.S.
        • Strawn J.R.
        • Sanacora G.
        • Kinkead B.
        • Price L.H.
        • Nemeroff C.B.
        Elevated cerebrospinal fluid substance P concentrations in post-traumatic stress disorder and major depression.
        Am J Psychiatry. 2006; 163: 637-643
        • Green B.L.
        • Krupnick J.L.
        • Chung J.
        • Siddique J.
        • Krause E.D.
        • Revicki D.
        • Frank L.
        • Miranda J.
        Impact of PTSD morbidity on one-year outcomes in a depression unit.
        J Clin Psychol. 2006; 62: 815-835
        • Hammen C.
        Stress and depression.
        Ann Rev Clin Psychol. 2005; 1: 293-319
        • Haythornthwaite J.A.
        • Seiber W.J.
        • Kerns R.D.
        Depression and the experience of chronic pain.
        J Consult Clin Psychol. 1991; 46: 177-184
        • Hickling E.J.
        • Blanchard E.B.
        Post-traumatic stress disorder and motor vehicle accidents.
        J Anxiety Disord. 1992; 6: 285-291
        • Holzberg A.D.
        • Geisser M.E.
        • Robinson M.E.
        The effects of depression and chronic pain on psychosocial and physical functioning.
        Clin J Pain. 1996; 12: 118-125
        • Hu L.
        • Bentler P.
        Fit indices in covariance structure modeling: Sensitivity to underparameterized model misspecification.
        Psychol Methods. 1998; 3: 424-453
        • Hu L.
        • Bentler P.
        Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives.
        Struct Equ Mod. 1999; 6: 1-55
        • Jones I.H.
        • Riley W.T.
        The post-accident syndrome: Variations in the clinical picture.
        Aust N Z J Psychiat. 1987; 221: 560-567
        • Keane T.M.
        • Barlow D.H.
        Post-traumatic stress disorder.
        in: Barlow D.H. Anxiety and Its Disorders. Guilford Press, New York, NY2002: 418-453
        • Keefe F.J.
        • Wilkins R.H.
        • Cook Jr, W.A.
        • Crisson J.E.
        • Muhlbaier L.H.
        Depression, pain and pain behavior.
        J Consult Clin Psychol. 1986; 54: 665-669
        • Keefe F.J.
        • Rumble M.E.
        • Scipio C.D.
        • Giordana L.A.
        • Perri L.M.
        Psychological aspects of persistent pain: Current status of the science.
        J Pain. 2004; 5: 195-211
        • Kerns R.D.
        • Turk D.C.
        • Rudy T.E.
        The West-Haven-Yale Multidimensional Pain Inventory (WHYMPI).
        Pain. 1985; 23: 345-356
        • Kessler R.C.
        • Sonnega A.
        • Bromet E.
        • Highes M.
        • Nelson C.B.
        Post-traumatic stress disorder in the national comorbidity survey.
        Arch Gen Psychiatry. 1995; 52: 1048-1060
        • Lanyon R.I.
        Assessing the misrepresentation of health problems.
        J Person Assess. 2003; 8: 1-10
        • Mathews A.
        • MacLeod C.
        Cognitive vulnerability to emotional disorders.
        Ann Rev Clin Psychol. 2005; 1: 167-195
        • McCracken L.M.
        • Eccleston C.
        A prospective study of acceptance of pain and patient functioning with chronic pain.
        Pain. 2005; 118: 164-169
        • Melzack R.
        The McGill Pain Questionnaire: Major properties and scoring methods.
        Pain. 1975; 1: 277-299
        • Muse M.
        Narcosynthesis in the treatment of post-traumatic chronic pain: A case study.
        Rehabil Psychol. 1984; 29: 113-118
        • Muse M.
        • Frigola G.
        Development of a quick screening instrument for detecting post-traumatic stress disorder in the chronic pain patient: Construction of the Post-traumatic Chronic Pain Test (PCPT).
        Clin J Pain. 1986; 2: 151-153
        • Nishith P.
        • Hearst D.E.
        • Mueser K.T.
        • Foa E.B.
        PTSD and major depression: methodological and treatment considerations in a single case design.
        Behav Ther. 1995; 26: 319-335
        • Nolen-Hoeksema S.
        Responses to depression and their effects on the duration of depressive episodes.
        J Abnorm Psychol. 1991; 100: 569-582
        • Radloff L.
        The Center for Epidemiological Studies-Depression scale: A self-report depression scale for research in the general population.
        J Appl Psychol Meas. 1977; 1: 385-401
        • Rudy T.E.
        • Kerns R.D.
        • Turk D.C.
        Chronic pain and depression: Toward a cognitive-behavioral mediation model.
        Pain. 1988; 35: 129-140
        • Ruggiero K.J.
        • Del Ben K.
        • Scott J.R.
        • Rabalais A.E.
        Psychometric properties of the PTSD Checklist, Civilian Version.
        J Traumatic Stress. 2003; 16: 495-502
        • Sharp T.J.
        • Harvey A.G.
        Chronic pain and post-traumatic stress disorder: Mutual maintenance?.
        Clin Psychol Rev. 2001; 21: 857-877
        • Sherman J.J.
        • Turk D.C.
        • Okifuji A.
        Prevalence and impact of post-traumatic stress disorder-like symptoms on patients with fibromyalgia syndrome.
        Clin J Pain. 2000; 16: 127-134
        • Spitzer R.L.
        • Williams J.B.W.
        • Gibbon M.
        • First M.B.
        Structured Clinical Interview for DSM-III-R.
        American Psychiatric Press, Washington, DC1990
        • Starr S.
        • Moulds M.L.
        The role of negative interpretations of intrusive memories in depression.
        J Affect Dis. 2006; 93: 125-132
        • Sullivan M.J.L.
        • Thorn B.
        • Haythornthwaite J.A.
        • Keefe F.
        • Martin M.
        • Bradley L.A.
        • Lefebvre J.C.
        Theoretical perspectives on the relation between catastrophizing and pain.
        Clin J Pain. 2001; 17: 52-64
        • Tait R.C.
        • Pollard C.A.
        • Margolis R.B.
        • Duckro P.N.
        • Krause S.
        The Pain Disability Index: Psychometric and validity data.
        Arch Phys Med Rehabil. 1987; 68: 438-441
        • Tait R.C.
        • Chibnall J.T.
        • Krause S.
        The Pain Disability Index: Psychometric properties.
        Pain. 1990; 40: 171-182
        • Toomey T.C.
        • Seville J.L.
        • Abashian S.W.
        • Finkel A.G.
        • Mann J.D.
        Circumstances of chronic pain onset: Relationship to pain description, coping and psychological distress.
        ([Abstract]) American Pain Society, Miami Beach, FL1994 (A-76)
        • Tsushima W.T.
        • Stoddard V.M.
        Ethnic group similarities in the biofeedback treatment of pain.
        Med Psychother. 1990; 3: 69-75
        • Turk D.C.
        • Okifuji A.
        Detecting depression in chronic pain patients: Adequacy of self-reports.
        Behav Res Ther. 1994; 32: 9-16
        • Turk D.C.
        • Okifuji A.
        Perception of traumatic onset, compensation status, and physical findings: Impact of pain severity, emotional distress, and disability in chronic pain patients.
        J Behav Med. 1996; 19: 435-453
        • Turk D.C.
        • Okifuji A.
        Psychological factors in chronic pain: Evolution and revolution.
        J Consult Clin Psychol. 2002; 70: 678-690
        • Vlaeyen J.W.S.
        • Kole-Snidjers A.M.J.
        • Rotteveel A.M.
        • Rvesink R.
        • Heuts P.H.T.G.
        The role of fear of movement (re)injury in pain disability.
        J Occup Rehabil. 1995; 5: 235-252
        • Vlaeyen J.W.S.
        • Linton S.J.
        Fear-avoidance and its consequences in musculoskeletal pain: A state of the art.
        Pain. 2000; 85: 317-332
        • Wald J.
        • Taylor S.
        • Federoff I.C.
        The challenge of treating PTSD in the context of chronic pain.
        in: Taylor S. Advances in the Treatment of Post-traumatic Stress Disorder: Cognitive-Behavioral Perspectives. Springer, New York, NY2004: 197-222
        • Zayfert C.
        • Fourt L.
        • Seville J.L.
        • Ferguson R.
        • Robinson A.B.
        PTSD symptoms in pain patients undergoing functional capacity evaluation.
        1999 (Paper presented at the annual meeting of the Society of Behavioral Medicine, San Diego, CA, March)
        • Zlotnick C.
        • Warshaw M.
        • Shea M.T.
        • Keller M.B.
        Trauma and chronic depression among patients with anxiety disorders.
        J Consult Clin Psychol. 1997; 65: 333-336