Advertisement

Longitudinal Interactions of Pain and Posttraumatic Stress Disorder Symptoms in U.S. Military Service Members Following Blast Exposure

  • Kelcey J. Stratton
    Correspondence
    Address reprint requests to Kelcey J. Stratton, PhD, Hunter Holmes McGuire VA Medical Center, 1201 Broad Rock Blvd (116-B), Richmond, VA 23249.
    Affiliations
    Hunter Holmes McGuire VA Medical Center, Richmond, Virginia

    Department of Psychology, Virginia Commonwealth University, Richmond, Virginia

    Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, Virginia
    Search for articles by this author
  • Shaunna L. Clark
    Affiliations
    Center for Biomarker Research and Personalized Medicine, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
    Search for articles by this author
  • Sage E. Hawn
    Affiliations
    Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, Virginia
    Search for articles by this author
  • Ananda B. Amstadter
    Affiliations
    Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, Virginia
    Search for articles by this author
  • David X. Cifu
    Affiliations
    Hunter Holmes McGuire VA Medical Center, Richmond, Virginia

    Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia
    Search for articles by this author
  • William C. Walker
    Affiliations
    Hunter Holmes McGuire VA Medical Center, Richmond, Virginia

    Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia
    Search for articles by this author

      Highlights

      • We examine longitudinal models of pain and PTSD symptoms among military personnel.
      • Pain and PTSD symptoms are strongly associated with one another across time.
      • PTSD symptoms show a particularly strong influence on subsequent pain symptoms.

      Abstract

      Military personnel returning from conflicts in Iraq and Afghanistan often endorse pain and posttraumatic stress disorder (PTSD) symptoms, either separately or concurrently. Associations between pain and PTSD symptoms may be further complicated by blast exposure from explosive munitions. Although many studies have reported on the prevalence and disability associated with polytraumatic injuries following combat, less is known about symptom maintenance over time. Accordingly, this study examined longitudinal interactive models of co-occurring pain and PTSD symptoms in a sample of 209 military personnel (mean age = 27.4 years, standard deviation = 7.6) who experienced combat-related blast exposure. Autoregressive cross-lagged analysis examined longitudinal associations between self-reported pain and PTSD symptoms over a 1-year period. The best-fitting covariate model indicated that pain and PTSD were significantly associated with one another across all assessment periods, χ2 (3) = 3.66, P = .30, Tucker-Lewis index = .98, comparative fit index = 1.00, root mean squared error of approximation = .03. PTSD symptoms had a particularly strong influence on subsequent pain symptoms. The relationship between pain and PTSD symptoms is related to older age, race, and traumatic brain injury characteristics. Results further the understanding of complex injuries among military personnel and highlight the need for comprehensive assessment and rehabilitation efforts addressing the interdependence of pain and co-occurring mental health conditions.

      Perspective

      This longitudinal study demonstrates that pain and PTSD symptoms strongly influence one another and interact across time. These findings have the potential to inform the integrative assessment and treatment of military personnel with polytrauma injuries and who are at risk for persistent deployment-related disorders.

      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:

      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

      References

        • Andersson H.I.
        • Ejlertsson G.R.
        • Leden I.
        • Rosenberg C.
        Chronic pain in a geographically defined general population: Studies of differences in age, gender, social class, and pain localization.
        Clin J Pain. 1993; 9: 174-182
        • 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
        • Bair M.J.
        • Robinson R.L.
        • Katon W.
        • Kroenke K.
        Depression and pain comorbidity: A literature review.
        Arch Intern Med. 2003; 163: 2433-2445
        • Bonanno G.A.
        • Mancini A.D.
        • Horton J.L.
        • Powell T.M.
        • Leardmann C.A.
        • Boyko E.J.
        • Wells T.S.
        • Hooper T.I.
        • Gackstetter G.D.
        • Smith T.C.
        Millennium Cohort Study Team: Trajectories of trauma symptoms and resilience in deployed US military service members: Prospective cohort study.
        Br J Psychiatry. 2012; 200: 317-323
        • Bonanno G.A.
        Loss, trauma, and human resilience. Have we underestimated the human capacity to thrive after extremely aversive events?.
        Am Psychol. 2004; 59: 20-28
        • Curran P.J.
        • Bollen K.A.
        The best of both worlds: Combining autoregressive and latent curve models.
        in: Collins L.M. Aline G. New Methods for the Analysis of Change. Decade of Behavior. American Psychological Association, Washington, DC2001: 107-135
        • Gatchel R.J.
        • Polatin P.B.
        • Kinney R.K.
        Predicting outcome of chronic back pain using clinical predictors of psychopathology: A prospective analysis.
        Health Psychol. 1995; 14: 415-420
        • Gatchel R.J.
        Comorbidity of chronic pain and mental health disorders: The biopsychosocial perspective.
        Am Psychol. 2004; 59: 795-805
        • Gibson C.
        Review of posttraumatic stress disorder and chronic pain: The path to integrated care.
        J Rehabil Res Dev. 2012; 49: 753-776
        • Gironda R.J.
        • Clark M.E.
        • Massengale J.P.
        • Walker R.L.
        Pain among veterans of Operations Enduring Freedom and Iraqi Freedom.
        Pain Med. 2006; 7: 339-343
        • Green C.R.
        • Anderson K.O.
        • Baker T.A.
        • Campbell L.C.
        • Decker S.
        • Fillingim R.B.
        • Kalauokalani D.A.
        • Lasch K.E.
        • Myers C.
        • Tait R.C.
        • Todd K.H.
        • Vallerand A.H.
        The unequal burden of pain: Confronting racial and ethnic disparities in pain.
        Pain Med. 2003; 4: 277-294
        • Gureje O.
        • Simon G.E.
        • Von Korff M.
        A cross-national study of the course of persistent pain in primary care.
        Pain. 2001; 92: 195-200
        • Hardt J.
        • Jacobsen C.
        • Goldberg J.
        • Nickel R.
        • Buchwald D.
        Prevalence of chronic pain in a representative sample in the United States.
        Pain Med. 2008; 9: 803-812
        • Hoge C.W.
        • Castro C.A.
        • Messer S.C.
        • McGurk D.
        • Cotting D.I.
        • Koffman R.L.
        Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care.
        N Engl J Med. 2004; 351: 13-22
        • Hu L.T.
        • Bentler P.M.
        Cutoff criteria for fit indices in covariance structure analysis: Conventional criteria versus new alternatives.
        Struct Equ Modeling. 1999; 6: 1-55
        • Jenewein J.
        • Wittmann L.
        • Moergeli H.
        • Creutzig J.
        • Schnyder U.
        Mutual influence of posttraumatic stress disorder symptoms and chronic pain among injured accident survivors: A longitudinal study.
        J Trauma Stress. 2009; 22: 540-548
        • Keogh E.
        • McCracken L.M.
        • Eccleston C.
        Gender moderates the association between depression and disability in chronic pain patients.
        Eur J Pain. 2006; 10: 413-422
        • Kessler R.C.
        • Chiu W.T.
        • Demier O.
        • Merikangas K.R.
        • Walters E.E.
        Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication.
        Arch Gen Psychiatry. 2005; 62: 617-627
        • Kessler R.C.
        • Sonnega A.
        • Bromet E.
        • Hughes M.
        • Nelson C.B.
        Posttraumatic stress disorder in the National Comorbidity Survey.
        Arch Gen Psychiatry. 1995; 52: 1048-1060
        • Koenen K.C.
        • Stellman J.M.
        • Stellman S.D.
        • Sommer Jr., J.F.
        Risk factors for course of posttraumatic stress disorder among Vietnam veterans: A 14-year follow-up of American Legionnaires.
        J Consult Clin Psychol. 2003; 71: 980-986
        • Lew H.L.
        • Otis J.D.
        • Tun C.
        • Kerns R.D.
        • Clark M.E.
        • Cifu D.X.
        Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: Polytrauma clinical triad.
        J Rehabil Res Dev. 2009; 46: 697-702
        • Melzack R.
        The short-form McGill Pain Questionnaire.
        Pain. 1987; 30: 191-197
        • Moeller-Bertram T.
        • Afari N.
        • Mostoufi S.
        • Fink D.S.
        • Johnson Wright L.
        • Baker D.G.
        Specific pain complaints in Iraq and Afghanistan veterans screening positive for post-traumatic stress disorder.
        Psychosomatics. 2014; 55: 172-178
        • Muthen L.K.
        • Muthen B.O.
        MPlus User's Guide.
        6th ed. Muthen & Muthen, Los Angeles1998-2010
        • National Center for PTSD
        Using the PTSD Checklist (PCL).
        Washington, DC, U.S. Department of Veterans Affairs, 2012
        • Outcalt S.D.
        • Yu Z.
        • Hoen H.M.
        • Pennington T.M.
        • Krebs E.E.
        Health care utilization among veterans with pain and posttraumatic stress symptoms.
        Pain Med. 2013 Feb 22; ([Epub ahead of print])
        • Palyo S.A.
        • Beck J.G.
        Post-traumatic stress disorder symptoms, pain, and perceived life control: Associations with psychosocial and physical functioning.
        Pain. 2005; 117: 121-127
        • Perilla J.L.
        • Norris F.H.
        • Lavizzo E.A.
        Ethnicity, culture, and disaster response: Identifying and explaining ethnic differences in PTSD six months after Hurricane Andrew.
        J Soc Clin Psychol. 2002; 21: 20-45
        • Perkins F.M.
        • Kehlet H.
        Chronic pain as an outcome of surgery: A review of predictive factors.
        Anesthesiology. 2000; 93: 1123-1133
        • Pietrzak R.H.
        • Goldstein R.B.
        • Southwick S.M.
        • Grant B.F.
        Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions.
        J Anxiety Disord. 2011; 25: 456-465
        • Rahim-Williams F.B.
        • Riley III, J.L.
        • Herrera D.
        • Campbell C.M.
        • Hastie B.A.
        • Fillingim R.B.
        Ethnic identity predicts experimental pain sensitivity in African Americans and Hispanics.
        Pain. 2007; 129: 177-184
        • Ramchand R.
        • Schell T.L.
        • Karney B.R.
        • Osilla K.C.
        • Burns R.M.
        • Caldarone L.B.
        Disparate prevalence estimates of PTSD among service members who served in Iraq and Afghanistan: Possible explanations.
        J Trauma Stress. 2010; 23: 59-68
        • Resnick H.S.
        • Kilpatrick D.G.
        • Dansky B.S.
        • Saunders B.E.
        • Best C.L.
        Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women.
        J Consult Clin Psychol. 1993; 61: 984-991
        • Richards J.
        • Meredith R.
        • Nepomuceno C.
        • Fine P.
        • Bennett G.
        Psychosocial aspects of chronic pain in spinal cord injury.
        Pain. 1980; 8: 355-366
        • Sayer N.A.
        • Rettmann N.A.
        • Carlson K.F.
        • Bernardy N.
        • Sigford B.J.
        • Hamblen J.L.
        • Friedman M.J.
        Veterans with history of mild traumatic brain injury and posttraumatic stress disorder: Challenges from provider perspective.
        J Rehabil Res Dev. 2009; 46: 703-716
        • Scherer M.
        • Burrows H.
        • Pinto R.
        • Somrack E.
        Characterizing self-reported dizziness and otovestibular impairment among blast-injured traumatic amputees: A pilot study.
        Mil Med. 2007; 172: 731-737
        • Schwarz G.E.
        Estimating the dimension of a model.
        Ann Stat. 1978; 6: 461-464
        • Sharp T.J.
        • Harvey A.G.
        Chronic pain and posttraumatic stress disorder: Mutual maintenance?.
        Clin Psychol Rev. 2001; 21: 857-877
        • Shipherd J.C.
        • Keyes M.
        • Jovanovic T.
        • Ready D.J.
        • Baltzell D.
        • Worley V.
        • Gordon-Brown V.
        • Hayslett C.
        • Duncan E.
        Veterans seeking treatment for posttraumatic stress disorder: What about comorbid chronic pain?.
        J Rehabil Res Dev. 2007; 44: 153-166
        • Sledjeski E.
        • Speisman B.
        • Dierker L.
        Does the number of lifetime traumas explain the relationship between PTSD and chronic medical conditions? Answers from the National Comorbidity Survey–Republican (NCS-R).
        J Behav Med. 2008; 31: 341-349
        • Sterling M.
        • Jull G.
        • Vicenzino B.
        • Kenardy J.
        • Darnell R.
        Physical and psychological factors predict outcome following whiplash injury.
        Pain. 2005; 114: 141-148
        • Taylor B.C.
        • Hagel E.M.
        • Carlson K.F.
        • Cifu D.X.
        • Cutting A.
        • Bidelspach D.E.
        • Sayer N.A.
        Prevalence and costs of co-occurring traumatic brain injury with and without psychiatric disturbance and pain among Afghanistan and Iraq War veteran VA users.
        Med Care. 2012; 50: 342-346
        • Ullrich P.M.
        • Lincoln R.K.
        • Tackett M.J.
        • Miskevics S.
        • Smith B.M.
        • Weaver F.M.
        Pain, depression, and health care utilization over time after spinal cord injury.
        Rehabil Psychol. 2013; 58: 158-165
        • Villano C.
        • Rosenblum A.
        • Magura S.
        • Fong C.
        • Cleland C.
        • Betzler T.
        Prevalence and correlates of posttraumatic stress disorder and chronic severe pain in psychiatric outpatients.
        J Rehabil Res Dev. 2007; 44: 167
        • Walker W.C.
        • McDonald S.D.
        • Ketchum J.M.
        • Nichols M.
        • Cifu D.X.
        Identification of transient altered consciousness induced by military-related blast exposure and its relation to postconcussion symptoms.
        J Head Trauma Rehabil. 2013; 28: 68-76
      1. Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM: The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Proceedings of the 9th Annual Meeting of the International Society for Traumatic Stress Studies, 1993.