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Number and Type of Post-Traumatic Stress Disorder Symptom Domains Are Associated With Patient-Reported Outcomes in Patients With Chronic Pain

Published:January 04, 2018DOI:https://doi.org/10.1016/j.jpain.2017.12.262

      Highlights

      • Post-traumatic stress disorder (PTSD) was associated with chronic pain outcomes.
      • Even 1 PTSD symptom was associated with poorer pain-related outcomes overall.
      • The PTSD symptom of numbness or detachment was particularly important.
      • Subsyndromal PTSD and numbness or detachment are important in chronic pain.

      Abstract

      Post-traumatic stress disorder (PTSD) commonly accompanies complex chronic pain, yet PTSD is often overlooked in chronic pain management. Using the 4-item Primary Care (PC)-PTSD screening tool, we evaluated the relationship between the number and type of PC-PTSD symptoms endorsed and a set of patient-reported outcomes, including: pain intensity and interference, function, mood, quality of life, and substance abuse risk in a consecutive sample of patients with chronic pain (n = 4,402). Patients completed PainTracker, a Web-based patient-reported outcome tool that provides a multidimensional evaluation of chronic pain, as part of their intake evaluation at a specialty pain clinic in a community setting. Twenty-seven percent of the sample met PC-PTSD screening criteria for PTSD by endorsing 3 of the 4 symptom domains. Significant ordinal trends were observed between increasing number of PTSD symptoms and all outcomes evaluated. The occurrence of even 1 PTSD symptom was associated with overall poorer outcomes, suggesting that subsyndromal PTSD is clinically significant in the context of chronic pain. Among the 4 PTSD domains assessed, “numbness/detachment” was most strongly associated with negative pain outcomes in relative weight analysis. Results from this cross-sectional study suggest that a range of pain-related outcomes may be significantly related to comorbid PTSD.

      Perspective

      We present evidence that PTSD symptoms are significantly related to a broad set of pain-related patient-reported outcomes. These findings highlight the need to evaluate for PTSD symptoms in patients with chronic pain, especially feelings of numbness or detachment from others, to improve understanding and management of chronic pain.

      Key words

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      References

        • Akerblom S.
        • Perrin S.
        • Rivano Fischer M.
        • McCracken L.M.
        The impact of PTSD on functioning in patients seeking treatment for chronic pain and validation of the posttraumatic diagnostic scale.
        Int J Behav Med. 2017; 24: 249-259
        • Andersen T.E.
        • Andersen L.A.
        • Andersen P.G.
        Chronic pain patients with possible co-morbid post-traumatic stress disorder admitted to multidisciplinary pain rehabilitation-a 1-year cohort study.
        Eur J Psychotraumatol. 2014; (Aug 8; [Epub ahead of print])
        • Asmundson G.J.
        • 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
        • Asmundson G.J.
        • Wright K.D.
        • Stein M.B.
        Pain and PTSD symptoms in female veterans.
        Eur J Pain. 2004; 8: 345-350
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders.
        5th ed. American Psychiatric Association, 2013 (Washington, D.C.)
        • Bliese P.D.
        • Wright K.M.
        • Adler A.B.
        • Cabrera O.
        • Castro C.A.
        • Hoge C.W.
        Validating the primary care posttraumatic stress disorder screen and the posttraumatic stress disorder checklist with soldiers returning from combat.
        J Consult Clin Psychol. 2008; 76: 272-281
        • Bremner J.D.
        • Southwick S.M.
        • Darnell A.
        • Charney D.S.
        Chronic PTSD in Vietnam combat veterans: Course of illness and substance abuse.
        Am J Psychiatry. 1996; 153: 369-375
        • Bush K.
        • Kivlahan D.R.
        • McDonell M.B.
        • Fihn S.D.
        • Bradley K.A.
        The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test.
        Arch Intern Med. 1998; 158: 1789-1795
        • Cella D.
        • Riley W.
        • Stone A.
        • Rothrock N.
        • Reeve B.
        • Yount S.
        • Amtmann D.
        • Bode R.
        • Buysse D.
        • Choi S.
        • Cook K.
        • Devellis R.
        • DeWalt D.
        • Fries J.F.
        • Gershon R.
        • Hahn E.A.
        • Lai J.S.
        • Pilkonis P.
        • Revicki D.
        • Rose M.
        • Weinfurt K.
        • Hays R.
        • PROMIS Cooperative Group
        The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005–2008.
        J Clin Epidemiol. 2010; 63: 1179-1194
        • Cho S.K.
        • Heiby E.M.
        • McCracken L.M.
        • Moon D.E.
        • Lee J.H.
        Daily functioning in chronic pain: Study of structural relations with posttraumatic stress disorder symptoms, pain intensity, and pain avoidance.
        Korean J Pain. 2011; 24: 13-21
        • Clapp J.D.
        • Beck J.G.
        • Palyo S.A.
        • Grant D.M.
        An examination of the synergy of pain and PTSD on quality of life: Additive or multiplicative effects?.
        Pain. 2008; 138: 301-309
        • Creamer M.
        • Burgess P.
        • McFarlane A.C.
        Post-traumatic stress disorder: Findings from the Australian National Survey of Mental Health and Well-being.
        Psychol Med. 2001; 31: 1237-1247
        • Cyders M.A.
        • Burris J.L.
        • Carlson C.R.
        Disaggregating the relationship between posttraumatic stress disorder symptom clusters and chronic orofacial pain: Implications for the prediction of health outcomes with PTSD symptom clusters.
        Ann Behav Med. 2011; 41: 1-12
        • Dawson D.A.
        • Grant B.F.
        • Stinson F.S.
        • Zhou Y.
        Effectiveness of the derived Alcohol Use Disorders Identification Test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the US general population.
        Alcohol Clin Exp Res. 2005; 29: 844-854
        • Fairbank J.C.
        • Couper J.
        • Davies J.B.
        • O'Brien J.P.
        The Oswestry low back pain disability questionnaire.
        Physiotherapy. 1980; 66: 271-273
        • Fairbank J.C.
        • Pynsent P.B.
        The Oswestry Disability Index.
        Spine. 2000; 25 (discussion: 2952): 2940-2952
        • Fetzner M.G.
        • McMillan K.A.
        • Asmundson G.J.
        Similarities in specific physical health disorder prevalence among formerly deployed Canadian forces veterans with full and subsyndromal PTSD.
        Depress Anxiety. 2012; 29: 958-965
        • Freedy J.R.
        • Steenkamp M.M.
        • Magruder K.M.
        • Yeager D.E.
        • Zoller J.S.
        • Hueston W.J.
        • Carek P.J.
        Post-traumatic stress disorder screening test performance in civilian primary care.
        Fam Pract. 2010; 27: 615-624
        • 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
        • Hanley J.
        • deRoon-Cassini T.
        • Brasel K.
        Efficiency of a four-item posttraumatic stress disorder screen in trauma patients.
        J Trauma Acute Care Surg. 2013; 75: 722-727
        • 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
        • Johnson J.W.
        A heuristic method for estimating the relative weight of predictor variables in multiple regression.
        Multivariate Behav Res. 2000; 35: 1-19
        • Katz J.
        • Asmundson G.J.
        • McRae K.
        • Halket E.
        Emotional numbing and pain intensity predict the development of pain disability up to one year after lateral thoracotomy.
        Eur J Pain. 2009; 13: 870-878
        • Krebs E.E.
        • Bair M.J.
        • Damush T.M.
        • Tu W.
        • Wu J.
        • Kroenke K.
        Comparative responsiveness of pain outcome measures among primary care patients with musculoskeletal pain.
        Med Care. 2010; 48: 1007-1014
        • Krebs E.E.
        • Lorenz K.A.
        • Bair M.J.
        • Damush T.M.
        • Wu J.
        • Sutherland J.M.
        • Asch S.M.
        • Kroenke K.
        Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference.
        J Gen Intern Med. 2009; 24: 733-738
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.
        A new measure of depression severity: The PHQ-9.
        J Gen Intern Med. 2000; 15: 78
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.
        The PHQ-9: Validity of a brief depression severity measure.
        J Gen Intern Med. 2001; 16: 606-613
        • Lopez-Martinez A.E.
        • Ramirez-Maestre C.
        • Esteve R.
        An examination of the structural link between post-traumatic stress symptoms and chronic pain in the framework of fear-avoidance models.
        Eur J Pain. 2014; 18: 1129-1138
        • McWilliams L.A.
        • Cox B.J.
        • Enns M.W.
        Mood and anxiety disorders associated with chronic pain: An examination in a nationally representative sample.
        Pain. 2003; 106: 127-133
        • Morasco B.J.
        • Lovejoy T.I.
        • Lu M.
        • Turk D.C.
        • Lewis L.
        • Dobscha S.K.
        The relationship between PTSD and chronic pain: Mediating role of coping strategies and depression.
        Pain. 2013; 154: 609-616
        • Olff M.
        Sex and gender differences in post-traumatic stress disorder: An update.
        Eur J Psychotraumatol. 2017; (Jul 27; [Epub ahead of print])
        • Pietrzak R.H.
        • Goldstein R.B.
        • Southwick S.M.
        • Grant B.F.
        Medical comorbidity of full and partial posttraumatic stress disorder in US adults: Results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions.
        Psychosom Med. 2011; 73: 697-707
        • 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
        • Pietrzak R.H.
        • Schechter C.B.
        • Bromet E.J.
        • Katz C.L.
        • Reissman D.B.
        • Ozbay F.
        • Sharma V.
        • Crane M.
        • Harrison D.
        • Herbert R.
        • Levin S.M.
        • Luft B.J.
        • Moline J.M.
        • Stellman J.M.
        • Udasin I.G.
        • Landrigan P.J.
        • Southwick S.M.
        The burden of full and subsyndromal posttraumatic stress disorder among police involved in the World Trade Center rescue and recovery effort.
        J Psychiatr Res. 2012; 46: 835-842
        • Prins A.
        • Ouimette P.
        • Kimerling R.
        • Cameron R.P.
        • Hugelshofer D.S.
        • Shaw-Hegwer J.
        • Thrailkill A.
        • Gusman F.D.
        • Sheikh J.I.
        The primary care PTSD screen (PC-PTSD): Development and operating characteristics.
        Primary Care Psychiatry. 2003; 9: 9-14
        • Roy-Byrne P.
        • Smith W.R.
        • Goldberg J.
        • Afari N.
        • Buchwald D.
        Post-traumatic stress disorder among patients with chronic pain and chronic fatigue.
        Psychol Med. 2004; 34: 363-368
        • Ruscio A.M.
        • Ruscio J.
        • Keane T.M.
        The latent structure of posttraumatic stress disorder: A taxometric investigation of reactions to extreme stress.
        J Abnorm Psychol. 2002; 111: 290-301
        • Saltychev M.
        • Mattie R.
        • McCormick Z.
        • Barlund E.
        • Laimi K.
        Psychometric properties of the Oswestry Disability Index.
        Int J Rehabil Res. 2017; 40: 202-208
        • Schnurr P.P.
        A guide to the literature on partial PTSD.
        PTSD Research Quarterly. 2014; 25: 1-8
        • Schorn M.M.
        • Doorenbos A.Z.
        • Gordon D.
        • Read-Williams P.
        Survey of primary-care providers on perceived benefits of and barriers to PainTracker.
        J Nurse Pract. 2014; 10: 781-786
        • Sharp T.J.
        • Harvey A.G.
        Chronic pain and posttraumatic stress disorder: Mutual maintenance?.
        Clin Psychol Rev. 2001; 21: 857-877
        • Spitzer R.L.
        • Kroenke K.
        • Williams J.B.
        • Lowe B.
        A brief measure for assessing generalized anxiety disorder: The GAD-7.
        Arch Intern Med. 2006; 166: 1092-1097
        • Stalnacke B.M.
        • Ostman A.
        Post-traumatic stress in patients with injury-related chronic pain participating in a multimodal pain rehabilitation program.
        Neuropsychiatr Dis Treat. 2010; 6: 59-66
        • Stein M.B.
        • Walker J.R.
        • Hazen A.L.
        • Forde D.R.
        Full and partial posttraumatic stress disorder: Findings from a community survey.
        Am J Psychiatry. 1997; 154: 1114-1119
        • Tonidandel S.
        • LeBreton J.M.
        RWA Web: A free, comprehensive, web-based, and user-friendly tool for relative weight analyses.
        J Bus Psychol. 2015; 30: 207-216
        • Tsui P.
        • Stein T.
        • Sonty N.
        The relationship among PTSD symptoms, chronic pain acceptance and disability.
        J Pain. 2010; 11: S58
        • Turk D.C.
        A diathesis-stress model of chronic pain and disability following traumatic injury.
        Pain Res Manag. 2002; 7: 9-19
        • Vianin M.
        Psychometric properties and clinical usefulness of the Oswestry Disability Index.
        J Chiropr Med. 2008; 7: 161-163
        • Webster L.R.
        • Webster R.M.
        Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the Opioid Risk Tool.
        Pain Med. 2005; 6: 432-442
        • Zlotnick C.
        • Franklin C.L.
        • Zimmerman M.
        Does “subthreshold” posttraumatic stress disorder have any clinical relevance?.
        Compr Psychiatry. 2002; 43: 413-419