Abstract
Background and aims
A sizable body of research has elucidated the significant role of psychological reactions to trauma on pain coping and outcomes. In order to best inform intervention development and clinical care for patients with both trauma and pain at the tertiary care level, greater clarity is needed regarding the magnitude of these effects and the specific pathways through which they may or may not function at the time of first presentation to such a treatment setting. To achieve this, the current study examined the cross-sectional relationships between traumatic etiology of pain, psychological distress (anger, depressive symptoms, and PTSD symptoms), and pain outcomes (pain catastrophizing, physical function, disability status).
Methods
Using a structural path modeling approach, analyses were conducted using a large sample of individuals with chronic pain (n = 637) seeking new medical evaluation at a tertiary pain management center, using the Collaborative Health Outcomes Information Registry (CHOIR). We hypothesized that the relationships between traumatic etiology of pain and poorer pain outcomes would be mediated by higher levels of psychological distress.
Results
Our analyses revealed modest relationships between self-reported traumatic etiology of pain and pain catastrophizing, physical function, and disability status. In comparison, there were stronger relationships between indices of psychological distress and pain catastrophizing, but a weaker pattern of associations between psychological distress and physical function and disability measures.
Conclusions
To the relatively small extent that self-reported traumatic etiology of pain correlates with pain-related outcomes, these relationships appear to be due primarily to the presence of psychiatric symptoms and manifest most notably in the context of psychological responses to pain (i.e. catastrophizing about pain).
Implications
Findings from this study highlight the need for early intervention for patients with traumatic onset of pain and for clinicians at tertiary pain centers to include more detailed assessments of psychological distress and trauma as a component of comprehensive chronic pain treatment.
Authors’ statements
Research funding: Authors acknowledge funding support from National Institutes of Health (NIH) National Center for Complementary and Integrative Health (NCCIH) R01AT008561 (BDD and SCM), P01AT006651 (SCM) and P01AT006651S1 (SCM and BDD); NIH National Institute on Drug Abuse (NIDA) K24DA029262 (SCM); NIH Pain Consortium HHSN271201200728P (SCM); and from the Chris Redlich Pain Research Endowment (SCM).
Conflict of interest: Authors state no conflict of interest.
Informed consent: Informed consent has been obtained from all individuals included in this study.
Ethical approval: The research related to human use complies with all the relevant national regulations, institutional policies and was performed in accordance with the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee.
References
[1] Edwards RR, Dworkin RH, Sullivan MD, Turk DC, Wasan AD. The role of psychosocial processes in the development and maintenance of chronic pain. J Pain 2016;17:T70–92.10.1016/j.jpain.2016.01.001Search in Google Scholar
[2] Meints S, Edwards R. Evaluating psychosocial contributions to chronic pain outcomes. Prog Neuropsychopharmacol Biol Psychiatry 2018;87:168–82.10.1016/j.pnpbp.2018.01.017Search in Google Scholar
[3] Geisser ME, Roth RS, Bachman JE, Eckert TA. 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;66:207–14.10.1016/0304-3959(96)03038-2Search in Google Scholar
[4] Turk DC, Okifuji A. What factors affect physicians’ decisions to prescribe opioids for chronic noncancer pain patients? Clin J Pain 1997;13:330–6.10.1097/00002508-199712000-00011Search in Google Scholar PubMed
[5] Turk DC, Okifuji A. Perception of traumatic onset, compensation status, and physical findings: impact on pain severity, emotional distress, and disability in chronic pain patients. J Behav Med 1996;19:435–53.10.1007/BF01857677Search in Google Scholar PubMed
[6] Brennstuhl MJ, Tarquinio C, Montel S. Chronic pain and PTSD: evolving views on their comorbidity. Perspect Psychiatr care 2015;51:295–304.10.1111/ppc.12093Search in Google Scholar PubMed
[7] Åkerblom S, Perrin S, Fischer MR, McCracken LM. 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;24:249–59.10.1007/s12529-017-9641-8Search in Google Scholar PubMed PubMed Central
[8] Kongsted A, Bendix T, Qerama E, Kasch H, Bach FW,Korsholm L, Jensen T. Acute stress response and recovery after whiplash injuries. A one-year prospective study. Eur J Pain 2008;12:455–63.10.1016/j.ejpain.2007.07.008Search in Google Scholar PubMed
[9] 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;22:540–8.10.1002/jts.20453Search in Google Scholar PubMed
[10] Powers A, Fani N, Pallos A, Stevens J, Ressler KJ, Bradley B. Childhood abuse and the experience of pain in adulthood: the mediating effects of PTSD and emotion dysregulation on pain levels and pain-related functional impairment. Psychosomatics 2014;55:491–9.10.1016/j.psym.2013.10.004Search in Google Scholar PubMed PubMed Central
[11] Lang AJ, Laffaye C, Satz LE, McQuaid JR, Malcarne VL, Dresselhaus TR, Stein MB. Relationships among childhood maltreatment, PTSD, and health in female veterans in primary care. Child Abuse Negl 2006;30:1281–92.10.1016/j.chiabu.2006.06.005Search in Google Scholar
[12] Raphael KG, Widom CS. Post-traumatic stress disorder moderates the relation between documented childhood victimization and pain 30 years later. Pain 2011;152:163–9.10.1016/j.pain.2010.10.014Search in Google Scholar
[13] Aaron LA, Bradley LA, Alarcón GS, Triana-Alexander M, Alexander RW, Martin MY, Alberts KR. Perceived physical and emotional trauma as precipitating events in fibromyalgia. Associations with health care seeking and disability status but not pain severity. Arthritis Rheumatol 1997;40:453–60.10.1002/art.1780400311Search in Google Scholar
[14] Andersen TE, Andersen L-AC, Andersen PG. 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;5:23235.10.3402/ejpt.v5.23235Search in Google Scholar
[15] Morasco BJ, Lovejoy TI, Lu M, Turk DC, Lewis L, Dobscha SK. The relationship between PTSD and chronic pain: mediating role of coping strategies and depression. Pain 2013;154:609–16.10.1016/j.pain.2013.01.001Search in Google Scholar
[16] Ravn SL, Vaegter HB, Cardel T, Andersen TE. The role of posttraumatic stress symptoms on chronic pain outcomes in chronic pain patients referred to rehabilitation. J Pain Res 2018;11:527.10.2147/JPR.S155241Search in Google Scholar
[17] Ruiz-Párraga GT, López-Martínez AE. The contribution of posttraumatic stress symptoms to chronic pain adjustment. Health Psychol 2014;33:958.10.1037/hea0000040Search in Google Scholar
[18] Siqveland J, Ruud T, Hauff E. Post-traumatic stress disorder moderates the relationship between trauma exposure and chronic pain. Eur J Psychotraumatol 2017;8:1375337.10.1080/20008198.2017.1375337Search in Google Scholar
[19] Sharp TJ, Harvey AG. Chronic pain and posttraumatic stress disorder: mutual maintenance? Clin Psychol Rev 2001;21:857–77.10.1016/S0272-7358(00)00071-4Search in Google Scholar
[20] Ravn SL, Hartvigsen J, Hansen M, Sterling M, Andersen TE. Do post-traumatic pain and post-traumatic stress symptomatology mutually maintain each other? A systematic review of cross-lagged studies. Pain 2018;159:2159–69.10.1097/j.pain.0000000000001331Search in Google Scholar PubMed
[21] Asmundson GJ, Coons MJ, 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;47:930–7.10.1177/070674370204701004Search in Google Scholar PubMed
[22] Andersen TE, Karstoft KI, Brink O, Elklit A. Pain-catastrophizing and fear-avoidance beliefs as mediators between post-traumatic stress symptoms and pain following whiplash injury–A prospective cohort study. Eur J Pain 2016;20:1241–52.10.1002/ejp.848Search in Google Scholar PubMed
[23] Sullivan MJ, Bishop SR, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess 1995;7:524.10.1037/1040-3590.7.4.524Search in Google Scholar
[24] Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Expert Rev Neurother 2009;9:745–58.10.1586/ern.09.34Search in Google Scholar PubMed PubMed Central
[25] Leung L. Pain catastrophizing: an updated review. Indian J Psychol Med 2012;34:204.10.4103/0253-7176.106012Search in Google Scholar PubMed PubMed Central
[26] Sullivan MJ, Thibault P, Simmonds MJ, Milioto M, Cantin A-P, Velly AM. Pain, perceived injustice and the persistence of post-traumatic stress symptoms during the course of rehabilitation for whiplash injuries. Pain 2009;145:325–31.10.1016/j.pain.2009.06.031Search in Google Scholar PubMed
[27] Ciccone DS, Kline A. A longitudinal study of pain and pain catastrophizing in a cohort of National Guard troops at risk for PTSD. Pain 2012;153:2055–60.10.1016/j.pain.2012.06.015Search in Google Scholar PubMed
[28] Castillo RC, MacKenzie EJ, Wegener ST, Bosse MJ, Group LS. Prevalence of chronic pain seven years following limb threatening lower extremity trauma. Pain 2006;124:321–9.10.1016/j.pain.2006.04.020Search in Google Scholar PubMed
[29] Roth RS, Geisser ME, Bates R. The relation of post-traumatic stress symptoms to depression and pain in patients with accident-related chronic pain. J Pain 2008;9:588–96.10.1016/j.jpain.2008.01.333Search in Google Scholar PubMed
[30] Hah JM, Sturgeon JA, Zocca J, Sharifzadeh Y, Mackey SC. Factors associated with prescription opioid misuse in a cross-sectional cohort of patients with chronic non-cancer pain. J Pain Res 2017;10:979.10.2147/JPR.S131979Search in Google Scholar PubMed PubMed Central
[31] Sharifzadeh Y, Kao M-C, Sturgeon JA, Rico TJ, Mackey S, Darnall BD. Pain catastrophizing moderates relationships between pain intensity and opioid prescriptionnonlinear sex differences revealed using a learning health system. Anesthesiology 2017;127:136–46.10.1097/ALN.0000000000001656Search in Google Scholar
[32] Karayannis NV, Sturgeon JA, Chih-Kao M, Cooley C, Mackey SC. Pain interference and physical function demonstrate poor longitudinal association in people living with pain: a PROMIS investigation. Pain 2017;158:1063.10.1097/j.pain.0000000000000881Search in Google Scholar
[33] Sturgeon JA, Dixon EA, Darnall BD, Mackey SC. Contributions of physical function and satisfaction with social roles to emotional distress in chronic pain: a Collaborative Health Outcomes Information Registry (CHOIR) Study. Pain 2015;156:2627–33.10.1097/j.pain.0000000000000313Search in Google Scholar
[34] Sturgeon JA, Darnall BD, Kao M-CJ, Mackey SC. Physical and psychological correlates of fatigue and physical function: a Collaborative Health Outcomes Information Registry (CHOIR) study. J Pain 2015;16:291–8. e1.10.1016/j.jpain.2014.12.004Search in Google Scholar
[35] Sturgeon JA, Carriere JS, Kao M-CJ, Rico T, Darnall BD, Mackey SC. Social disruption mediates the relationship between perceived injustice and anger in chronic pain: a collaborative health outcomes information registry study. Ann Behav Med 2016;50:802–12.10.1007/s12160-016-9808-6Search in Google Scholar
[36] Cameron RP, Gusman D. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Prim Care Psychiatry 2003;9:9–14.10.1185/135525703125002360Search in Google Scholar
[37] Kroenke K, Outcalt S, Krebs E, Bair MJ, Wu J, Chumbler N, Yu Z. Association between anxiety, health-related quality of life and functional impairment in primary care patients with chronic pain. Gen Hosp Psychiatry 2013;35:359–65.10.1016/j.genhosppsych.2013.03.020Search in Google Scholar
[38] Osman A, Barrios FX, Gutierrez PM, Kopper BA, Merrifield T, Grittmann L. The Pain Catastrophizing Scale: further psychometric evaluation with adult samples. J Behav Med 2000;23:351–65.10.1023/A:1005548801037Search in Google Scholar
[39] Van Damme S, Crombez G, Bijttebier P, Goubert L, Van Houdenhove B. A confirmatory factor analysis of the Pain Catastrophizing Scale: invariant factor structure across clinical and non-clinical populations. Pain 2002;96:319–24.10.1016/S0304-3959(01)00463-8Search in Google Scholar
[40] Gershon RC, Rothrock N, Hanrahan R, Bass M, Cella D. The use of PROMIS and assessment center to deliver patient-reported outcome measures in clinical research. J Appl Meas 2010;11:304.Search in Google Scholar
[41] Pilkonis PA, Choi SW, Reise SP, Stover AM, Riley WT, Cella D, PROMIS Cooperative Group. Item banks for measuring emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS®): depression, anxiety, and anger. Assessment 2011;18:263–83.10.1177/1073191111411667Search in Google Scholar PubMed PubMed Central
[42] Cella D, Riley W, Stone A, Rothrock N, Reeve B, Yount S, et al. Initial adult health item banks and first wave testing of the patient-reported outcomes measurement information system (PROMIS™) network: 2005–2008. J Clin Epidemiol 2010;63:1179.10.1016/j.jclinepi.2010.04.011Search in Google Scholar
[43] Cook KF, Jensen SE, Schalet BD, Beaumont JL, Amtmann D, Czajkowski S, Dewalk DA, Fries JF, Pilkonis PA, Reeve BB, Stone AA, Weinfurt KP, Cella D. PROMIS measures of pain, fatigue, negative affect, physical function, and social function demonstrated clinical validity across a range of chronic conditions. J Clin Epidemiol 2016;73:89–102.10.1016/j.jclinepi.2015.08.038Search in Google Scholar
[44] Farrar JT, Young JP, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 2001;94:149–58.10.1016/S0304-3959(01)00349-9Search in Google Scholar
[45] Buss AH, Perry M. The aggression questionnaire. J Pers Soc Psychol 1992;63:452.10.1037/t00691-000Search in Google Scholar
[46] Fries JF, Spitz PW, Young DY. The dimensions of health outcomes: the health assessment questionnaire, disability and pain scales. J Rheumatol 1981;9:789–93.Search in Google Scholar
[47] Kroenke K, Strine TW, Spitzer RL, Williams JB, Berry JT, Mokdad AH. The PHQ-8 as a measure of current depression in the general population. J Affect Disord 2009;114:163–73.10.1016/j.jad.2008.06.026Search in Google Scholar PubMed
[48] MacKinnon DP, Lockwood CM, Hoffman JM, West SG, Sheets V. A comparison of methods to test mediation and other intervening variable effects. Psychol Methods 2002;7:83.10.1037/1082-989X.7.1.83Search in Google Scholar
[49] Ullman JB, Bentler PM. Structural equation modeling. Handb Psychol 2003:607–34.10.1002/0471264385.wei0224Search in Google Scholar
[50] Hall AM, Kamper SJ, Maher CG, Latimer J, Ferreira ML, Nicholas MK. Symptoms of depression and stress mediate the effect of pain on disability. Pain 2011;152:1044–51.10.1016/j.pain.2011.01.014Search in Google Scholar PubMed
[51] Hung C-I, Liu C-Y, Fu T-S. Depression: an important factor associated with disability among patients with chronic low back pain. Int J Psychiatry Med 2015;49:187–98.10.1177/0091217415573937Search in Google Scholar PubMed
[52] Carty J, O’Donnell M, Evans L, Kazantzis N, Creamer M.Predicting posttraumatic stress disorder symptoms and pain intensity following severe injury: The role of catastrophizing. Eur J Psychotraumatol 2011;2:5652.10.3402/ejpt.v2i0.5652Search in Google Scholar PubMed PubMed Central
[53] Otis JD, Keane TM, Kerns RD. An examination of the relationship between chronic pain and post-traumatic stress disorder. J Rehabil Res Dev 2003;40:397.10.1682/JRRD.2003.09.0397Search in Google Scholar PubMed
[54] Jenewein J, Moergeli H, Wittmann L, Büchi S, Kraemer B, Schnyder U. Development of chronic pain following severe accidental injury. Results of a 3-year follow-up study. J Psychosom Res 2009;66:119–26.10.1016/j.jpsychores.2008.07.011Search in Google Scholar PubMed
[55] Darnall BD, Sturgeon JA, Kao M-C, Hah JM, Mackey SC. From catastrophizing to recovery: a pilot study of a single-session treatment for pain catastrophizing. J Pain Res 2014;7:219.10.2147/JPR.S62329Search in Google Scholar PubMed PubMed Central
[56] Smeets RJ, Vlaeyen JW, Kester AD, Knottnerus JA. Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. J Pain 2006;7:261–71.10.1016/j.jpain.2005.10.011Search in Google Scholar PubMed
[57] Jensen MP, Turner JA, Romano JM. Changes in beliefs, catastrophizing, and coping are associated with improvement in multidisciplinary pain treatment. J Consult Clin Psychol 2001;69:655.10.1037/0022-006X.69.4.655Search in Google Scholar
[58] Kerns RD, Sellinger J, Goodin BR. Psychological treatment of chronic pain. Ann Rev Clin Psychol 2011;7:411–34.10.1146/annurev-clinpsy-090310-120430Search in Google Scholar PubMed
[59] Ehlers A, Clark DM, Hackmann A, McManus F, Fennell M. Cognitive therapy for post-traumatic stress disorder: development and evaluation. Behav Res Ther 2005;43:413–31.10.1016/j.brat.2004.03.006Search in Google Scholar PubMed
[60] Schütze R, Rees C, Smith A, Slater H, Campbell JM, O’Sullivan P. How can we best reduce pain catastrophizing in adults with chronic noncancer pain? A systematic review and meta-analysis. J Pain 2018;19:233–56.10.1016/j.jpain.2017.09.010Search in Google Scholar PubMed
[61] Herbert MS, Malaktaris AL, Dochat C, Thomas ML, Wetherell JL, Afari N. Acceptance and commitment therapy for chronic pain: does post-traumatic stress disorder influence treatment outcomes? Pain Med 2019;20:1728–36.10.1093/pm/pny272Search in Google Scholar PubMed
[62] McGeary D, Moore M, Vriend CA, Peterson AL, Gatchel RJ. The evaluation and treatment of comorbid pain and PTSD in a military setting: an overview. J Clin Psychol Med Settings 2011;18:155.10.1007/s10880-011-9236-5Search in Google Scholar PubMed
[63] Otis JD, Keane TM, Kerns RD, Monson C, Scioli E. The development of an integrated treatment for veterans with comorbid chronic pain and posttraumatic stress disorder. Pain Med 2009;10:1300–11.10.1111/j.1526-4637.2009.00715.xSearch in Google Scholar PubMed
©2020 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.
