Skip to content
Licensed Unlicensed Requires Authentication Published by De Gruyter April 27, 2020

Military veterans with and without post-traumatic stress disorder: results from a chronic pain management programme

Jannie Van Der Merwe, Suzanne Brook, Claire Fear, Maxwell J. Benjamin, Gerald Libby, Amanda C. de C. Williams and Andrew P. Baranowski


Background and aims

There is very little published evaluation of the treatment of military veterans with chronic pain, with or without post-traumatic stress disorder. Few clinical services offer integrated treatment for veterans with chronic pain and PTSD. Such veterans experience difficulty in accessing treatment for either condition: services may consider each condition as a contraindication to treatment of the other. Veterans are therefore often passed from one specialist service to another without adequate treatment. The veteran pain management programme (PMP) in the UK was established to meet the needs of veterans suffering from chronic pain with or without PTSD; this is the first evaluation.


The PMP was advertised online via veteran charities. Veterans self-referred with accompanying information from General Practitioners. Veterans were then invited for an inter-disciplinary assessment and if appropriate invited onto the next PMP. Exclusion criteria included; current severe PTSD, severe depression with active suicidal ideation, moderate to severe personality disorder, or who were unable to self-care in the accommodation available. Treatment was by a team of experienced pain management clinicians: clinical psychologist, physiotherapist, nurse, medical consultant and psychiatrist. The PMP was delivered over 10 days: five residential days then five single days over the subsequent 6 months. The PMP combines cognitive behavioural treatment, which has the strongest evidence base, with more recent developments from mindfulness-based CBT for pain and compassion-focused therapy. Standard pain management strategies were adapted to meet the specific needs of the population, recognising the tendency to use demanding activity to manage post-traumatic stress symptoms. Domains of outcome were pain, mood, function, confidence and changes in medication use.


One hundred and sixty four military veterans started treatment in 19 programmes, and 158 completed. Results from those with high and low PTSD were compared; overall improvements in all domains were statistically significant: mood, self-efficacy and confidence, and those with PTSD showed a reduction (4.3/24 points on the IES-6). At the end of the programme the data showed that 17% reduced opioid medication and 25% stopped all opioid use.


Veterans made clinically and statistically significant improvements, including those with co-existing PTSD, who also reduced their symptom level. This serves to demonstrate the feasibility of treating veterans with both chronic pain and PTSD using a PMP model of care.


Military veterans experiencing both chronic pain and PTSD can be treated in a PMP adapted for their specific needs by an experienced clinical team.

Corresponding author: Jannie Van Der Merwe, BA Hons Clin Psych, MA Clin Psych, DTh DipClinHyp, CPsychol, AFBPsS, Consultant Clinical Psychologist, King Edward VII’s Hospital, Centre of Veterans’ Health, Charterhouse, 56 Weymouth Street, London W1G 6NX, UK, Phone: +442074674370


We would like to thank King Edward VII’s Hospital which hosted the programme, organised fundraising and provided administration, The J Davy Foundation, ABF-The Soldiers Charity, Howard De Walden Trust, The Lord Majors Big Curry Lunch, Supporting Wounded Veterans, The Joron Charitable Trust, Help 4 Hero’s and HM Treasury/LIBOR for financial support. We would also like to thank the following from King Edward VII’s Hospital; Caroline Dunne (Veteran PMP Service Administrator), Tim Brawn (Director of Fundraising and Veterans’ Health), Dr Dominic Aldington (Consultant in Pain Medicine) and Jane Taylor (Coordinator, Centre for Veterans’ Health).

  1. Authors’ statements

  2. Research funding: Authors state no funding involved.

  3. Conflict of interest: Authors state no conflict of interest.

  4. Informed consent: Informed consent has been obtained from all individuals included in this study.

  5. 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.


[1] Otis JD, Gregor K, Hardway C, Morrison J, Scioli E, Sanderson K. An examination of the co-morbidity between chronic pain and posttraumatic stress disorder on U.S. veterans. Psychol Serv 2010;7:126–35.10.1037/a0020512Search in Google Scholar

[2] Braš M, Milunović V, Boban M, Brajković L, Benković V, Đorđević V, Polašek O. Quality of life in Croatian Homeland war (1991-1995) veterans who suffer from post-traumatic stress disorder and chronic pain. Health Qual Life Outcomes 2011;9:56.10.1186/1477-7525-9-56Search in Google Scholar PubMed PubMed Central

[3] Lew HL, Otis JD, Tun C, Kerns RD, Clark ME, Cifu DX. Prevalence of chronic pain, posttraumatic stress disorder, and persistent post concussive symptoms in OIF/OEF veterans: polytrauma clinical triad. JRRD 2009;46:697–702.10.1682/JRRD.2009.01.0006Search in Google Scholar PubMed

[4] Williamson V, Diehle J, Dunn R, Jones N, Greenberg N. The impact of military service on health and well-being. Occup Med 2019;69:64–70.10.1093/occmed/kqy139Search in Google Scholar PubMed

[5] Goodell S, Druss BG, Reisinger Walker E: based on a research synthesis by Druss and Reisinger. Mental disorders and medical co morbidity; The Synthesis Project. The Robert Wood Johnson foundation. Policy brief No. 21. 21 February 2011.Search in Google Scholar

[6] Buist-Bouwman MA, De Graff R, Vollebergh WAM, Ormel J. Comorbidity of physical and mental disorders and the effect on work-loss days. Acta Psychiatr Scand 2006;111:436–43.10.1111/j.1600-0447.2005.00513.xSearch in Google Scholar PubMed

[7] Morgan L, Aldington D. Comorbid chronic pain and post-traumatic stress disorder in UK veterans: a lot of theory but not enough evidence. Br J Pain 2019. in Google Scholar PubMed PubMed Central

[8] Ravn S, Hartvigsen J, Hanse M, Sterling M, Elmose T. 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

[9] Otis JD, Keane TM, Kerns RD. An examination of the relationship between chronic pain and post-traumatic stress disorder. JRRD 2003;40:397–406.10.1682/JRRD.2003.09.0397Search in Google Scholar PubMed

[10] Asmundson G, Coons M, 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

[11] Bosco M, Gallinati J, Clark M. Conceptualizing and treating comorbid chronic pain and PTSD. Pain Res Treat 2013;2013:174728.10.1155/2013/174728Search in Google Scholar PubMed PubMed Central

[12] Plagge JM, Lu MW, Lovejoy TI, Karl AI, Dobscha SK. Treatment of comorbid pain and PTSD in returning veterans: a collaborative approach utilizing behavioural activation. Pain Med 2013;14:1164–72.10.1111/pme.12155Search in Google Scholar PubMed

[13] Otis JD. Chronic pain and PTSD. Presentation at satellite meeting, pain in military veterans: after the conflict, the battle continues. IASP World Congress. Boston, 2018.Search in Google Scholar

[14] Turk DC, Gatchel RJ, editors. Psychological approaches to pain management. 3rd ed, A practitioner’s handbook, 2018. ISBN: 9781462528530.Search in Google Scholar

[15] Faculty of Pain Medicine, Royal College of Anaesthetists. Core Standards for Pain Management Services in the UK, 2015. in Google Scholar

[16] NICE guidelines NG116 Post-traumatic stress disorder. 2018 Dec. Available at in Google Scholar

[17] Dalton J, Thomas S, Melton H, Harden M, Eastwood A. The provision of services in the UK for UK armed forces veterans with PTSD: a rapid evidence synthesis. 2018 Feb. White rose research online. URL for this paper: http// in Google Scholar PubMed

[18] 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

[19] Kerns R, Heapy A. Advances in pain management for veterans: current status of research and future directions. JRRD 2016;53:vii–x.10.1682/JRRD.2015.10.0196Search in Google Scholar PubMed

[20] King’s Centre for Military Health Research, September 2018. The mental health of the UK armed forces (September 2018 version). in Google Scholar

[21] Gauntlett-Gilbert J, Wilson S. Veterans and chronic pain. Br J Pain 2013;7:79–84.10.1177/2049463713482082Search in Google Scholar PubMed PubMed Central

[22] Diehle J, Greenberg N. Counting the costs. King’s Centre for Military Health Research. 2015 Nov, Commissioned by Help for Heroes. in Google Scholar

[23] Murphy D, Busuttil W. Focusing on the mental health of treatment-seeking veterans. JRAMC 2018;164:3–4.10.1136/jramc-2017-000844Search in Google Scholar PubMed

[24] Wyldbore M, Aldington D. Trauma pain – a military perspective. Br J Pain 2013;7:74–8.10.1177/2049463713487515Search in Google Scholar PubMed PubMed Central

[25] DSM-5 – American Psychiatric Association https://www. in Google Scholar

[26] ICD-10 Version:2010 – World Health Organization in Google Scholar

[27] Williams ACDC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev 2012;11. in Google Scholar PubMed PubMed Central

[28] Veehof MM, Trompetter HR, Bohlmeijer ET, Schreurs KMG. Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review. Cogn Behav Ther 2016;45:5–31.10.1080/16506073.2015.1098724Search in Google Scholar PubMed

[29] Purdie F, Morley S. Self-compassion, pain, and breaking a social contract. Pain 2015;156:2354–63.10.1097/j.pain.0000000000000287Search in Google Scholar PubMed

[30] Cleeland CS, Ryan KM. Pain assessment: global use of the brief pain inventory. Ann Acad Med Singapore 1994;23:129–38.Search in Google Scholar

[31] Tan KP, Jensen MP, Thomby JI, Shanti BF. Validation of the brief pain inventory for chronic non malignant pain. J Pain 2004;5:133–7.10.1016/j.jpain.2003.12.005Search in Google Scholar PubMed

[32] Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP, Kerns RD, Stucki G, Allen RR, Bellamy N, Carr DB, Chandler J, Cowan P, Dionne R, Galer BS, Hertz S, Jadad AR, Kramer LD, Manning DC, Martin S, et al. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain 2008;113:9–19.10.1016/j.pain.2004.09.012Search in Google Scholar PubMed

[33] Barkham M, Bewick B, Mullinb T, Gilbodyc S, Connella J,Cahillbet J, Mellor-Clark J, Richards D, Unsworth G, Evans C. The CORE-10: a short measure of psychological distress for routine use in the psychological therapies. Counsell Psychother Res 2013;13:3–13.10.1080/14733145.2012.729069Search in Google Scholar

[34] Thoresen S, Tambs K, Hussain A, Heir T, Venke AJ,Bisson JI. Brief measure of posttraumatic stress reactions: impact of event scale-6. Soc Psychiatry Psychiatr Epidemiol 2010;45:405–12.10.1007/s00127-009-0073-xSearch in Google Scholar PubMed

[35] Creamer M, Bell R, Failla S. Psychometric properties of the impact of event scale – revised. Behav Res Ther 2003;41:1489–96.10.1016/j.brat.2003.07.010Search in Google Scholar PubMed

[36] Ruggiero KJ, Rheingold AA, Resnick HS, Kilpatrick DG, Galea S. Comparison of two widely used PTSD-screening instruments: implications for public mental health planning. J Trauma Stress 2006;19:699–707.10.1002/jts.20141Search in Google Scholar PubMed

[37] Sullivan MJ, Bishop SR, Pivik J. The pain catastrophizing scale; development and validation. Psychol Assess 1995;7:524-32.10.1037/1040-3590.7.4.524Search in Google Scholar

[38] Sullivan PF, Daly MJ, O’Donovan M. Genetic architectures of psychiatric disorders: the emerging picture and its implications. Nat Rev Genet 2012;13:537–51.10.1038/nrg3240Search in Google Scholar PubMed PubMed Central

[39] Wheeler C, Williams ACDC, Morley SJ. Meta-analysis of the psychometric properties of the pain catastrophising scale and associations with participant characteristics. Pain 2019;160:1946–53.10.1097/j.pain.0000000000001494Search in Google Scholar PubMed

[40] Nicholas MK. The pain self-efficacy questionnaire: taking pain into account. Eur J Pain 2012;11:153–63.10.1016/j.ejpain.2005.12.008Search in Google Scholar PubMed

[41] Nicholas MK, Asghari A, Blyth FM. What do the numbers mean? Normative data in chronic pain patients. Pain 2008;134:158–73.10.1016/j.pain.2007.04.007Search in Google Scholar PubMed

[42] Smith JG, Knight L, Stewart A, Smith EL, McCracken LM. Clinical effectiveness of a residential pain management programme – comparing a large recent sample with previously published outcome data. Br J Pain 2016;10:46–58.10.1177/2049463715601445Search in Google Scholar PubMed PubMed Central

Received: 2019-12-20
Revised: 2020-03-30
Accepted: 2020-03-31
Published Online: 2020-04-27
Published in Print: 2021-07-27

©2020 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.