It is common for individuals with symptoms of posttraumatic stress disorder (PTSD) to present with co-occurring pain problems, and vice versa. However, the relation between these conditions often goes unrecognized in clinical settings. In this paper, we describe potential relations between PTSD and chronic pain and their implications for assessment and treatment. To accomplish this, we discuss phenomenological similarities of these conditions, the prevalence of chronic pain in patients with PTSD, and the prevalence of PTSD in patients with chronic pain. We also present several possible explanations for the co-occurrence of these disorders, based primarily on the notions of shared vulnerability and mutual maintenance. The paper concludes with an overview of future research directions, as well as practical recommendations for assessing and treating patients who present with co-occurring PTSD or chronic pain symptoms.
ResnickHSYehudaRAciernoR.Acute post-rape plasma cortisol, alcohol use, and PTSD symptom profile among recent rape victims. Ann N Y Acad Sci1991;21:433–6.
2.
SchnurrPPJankowskiMK. PTSD and physical health: Review and synthesis. Semin Clin Neuropsychiatry1999;4:295–304.
American Psychiatric Association. Diagnostic and statistical manual for mental disorders, 4th ed.Text Revision.Washington (DC): American Psychiatric Association; 2000.
5.
SeedatSSteinMB. Posttraumatic stress disorder: A review of recent findings. Curr Psychiatry Rep2001;3:288–94.
6.
AsmundsonGJGFrombachIMcQuaidJPedrelliPLenoxRSteinMB. Dimensionality of posttraumatic stress symptoms: A confirmatory factor analysis of DSM-IV symptom clusters and other symptom models. Behav Res Ther2000;38:203–14.
7.
BuckleyTCBlanchardEBHicklingEJ. A confirmatory factor analysis of post-traumatic stress symptoms. Behav Res ther1998;36:1091–9.
8.
KingDWLeskinGAKingLAWeathersFW. Confirmatory factor analysis of the clinician-administered PTSD scale: Evidence for the dimensionality of posttraumatic stress disorder. Psychol Assess1998;10:90–6.
9.
TaylorSKuchKKochWJCrockettDJPasseyG.The structure of posttraumatic stress symptoms. J Abnorm Psychol1998;107:154–60.
10.
TaylorSFedoroffIKochWJThordarsonDSFecteauGNickiRM. Posttraumatic stress disorder arising after road traffic collisions: Patterns of response to cognitive-behavior therapy. J Consult Clin Psychol2001;69:541–51.
11.
TaylorSThordarsonDSMaxfieldLFedoroffICLovellKOgrodniczukJ.Comparative efficacy, speed, and adverse effects of three treatments for PTSD: Exposure therapy, EMDR, and relaxation training. J Consult Clin Psychol. Forthcoming.
12.
AsmundsonGJGWrightKD. The biopsychosocial model of pain. In: HadjistavropoulosTCraigKD, editors. Pain: Psychological perspectives. New Jersey: Erlbaum; Forthcoming.
13.
MelzackR.From the gate to the neuromatrix. Pain1999;82 (Suppl 6):121–6.
14.
WallPW. On the relation of injury to pain. Pain1978;6:253–64.
15.
BonicaJJ. Achievements of the past and challenges of the future. In: BonicaJJLinblomUIggoA, editors. Proceedings from the 3rd World Congress on Pain. Advances in Pain Research and Therapy1987;5:1–36.
16.
MerskyHBogduckN.Classification of chronic pain: Descriptions of chronic pain syndromes and definitions of pain terms, 2nd ed.Seattle (WA): IASP Press; 1994.
17.
WaddellGRichardsonJ.Observation of overt pain behaviour by physicians during routine clinical examination of patients with low back pain. J Psychosom Res1992;36:77–87.
18.
NachemsonAL. Newest knowledge of low back pain. Clin Orthop1992;279:8–20.
19.
SpenglerDMBigosSJMartinNA. Back injuries in industry: A retrospective study: Overview and cost analysis. Spine1986;11:241–5.
20.
International Association for the Study of Pain. Classification of chronic pain. Pain1986;(Suppl 3):1–226.
21.
VlaeyenJWSLintonSJ. Fear-avoidance and its consequences in musculoskeletal pain: A state of the art. Pain2000;85:317–32.
22.
EcclestonCCrombezGAldrichSStannardC.Attention and somatic awareness in chronic pain. Pain1997;72:209–15.
23.
McNallyRJAmirN.Perceptual implicit memory for trauma-related information in post-traumatic stress disorder. Cognition and Emotion1996;10:603–7.
24.
SniderBSAsmundsonGJGWieseKC. Automatic and strategic processing of threat cues in patients with chronic pain: A modified-stroop evaluation. Clin J Pain2000;16:144–54.
25.
LangPJ. The emotion probe: Studies of emotion and attention. Am Psychol1995;50:372–85.
26.
AsmundsonGJGNortonPJNortonRG. Beyond pain: The role of fear and avoidance in chronicity. Clin Psychol Rev1999;19:97–119.
27.
IbarraPBruehlSPMcCubbinJACarlsonCRWilsonJFNortonJAMontgomeryTB. The unusual reaction of opioid blockage with naltrexone in a case of post-traumatic stress disorder. J Trauma Stress1994;7:303–9.
28.
KosekEEkholmJHanssonP.Sensory dysfunction in fibromyalgia patients with implications for pathogenic mechanisms. Pain1996;68:375–83.
29.
BeckhamJCCrawfordALFeldmanMEKirbyACHertzbergMADavidsonJRT, and Others Chronic posttraumatic stress disorder and chronic pain in Vietnam combat veterans. J Psychosom Res1997;43:379–89.
30.
BeckhamJCMooreSDFeldmanMEHertzbergMAKirbyACFairbankJA. Health status, somatization, and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder. Am J Psychiatry1998;155:1565–9.
31.
KimerlingRClumGAWolfeJ.Relationships among trauma exposure, chronic posttraumatic stress disorder symptoms, and self-reported health in women: Replication and extension. J Trauma Stress2000;13:115–28.
32.
WagnerAWWolfeJRotnitskyAProctorSPEricksonDJ. An investigation of the impact of posttraumatic stress disorder on physical health. J Trauma Stress2000;13:41–55.
33.
EngelCCLiuXMcCarthyBDMillerRFUrsanoR.Relationship of physical symptoms to posttraumatic stress disorder among veterans seeking care for Gulf War-related health concerns. Psychosom Med2000;62:739–45.
34.
ZatzickDMarmarCRWeissDSBrownerWSMetzlerTJGoldingJM, and others Post-traumatic stress disorder and functioning and quality of life outcomes in a nationally representative sample of male Vietnam veterans. Am J Psychiatry1997;154:1690–5.
35.
BryantRAMarosszekyJECrooksJBaguleyIJGurkaJA. Interaction of posttraumatic stress disorder and chronic pain following traumatic brain injury. J Head Trauma Rehabil1999;14:588–94.
36.
MarshallRPJormAFGraysonDAO'TooleBI. Posttraumatic stress disorder and other predictors of health care consumption by Vietnam veterans. Psychiatr Serv1998;49:1609–11.
37.
WhitePFaustmanW.Coexisting physical conditions among inpatients with post-traumatic stress disorder. Mil Med1989;154:66–71.
38.
McFarlaneACAtchisonMRafalowiczEPapayP.Physical symptoms in post-traumatic stress disorder. J Psychosom Res1994;38:715–26.
39.
AmirMKaplanZNeumannLSharabaniRShaniNBuskilaD.Posttraumatic stress disorder tenderness and fibromyalgia. J Psychosom Res1997;42:607–13.
40.
HubbardJRealmutoGMNorthwoodAKMastenAS. Comorbidity of psychiatric diagnoses with posttraumatic stress disorder in survivors of childhood trauma. J Am Acad Child Adolesc Psychiatry1995;34:1167–73.
41.
AndreskiPChilcoatHBreslauN.Post-traumatic stress disorder and somatization symptoms: A prospective study. Psychiatry Res1998;79:131–8.
42.
AsmundsonGJGNortonRGAllerdingsMDNortonPJLarsenDK. Posttraumatic stress disorder and work-related injury. J Anxiety Disord1998;12:57–69.
43.
BoninMFNortonGRAsmundsonGJGDicurzioSPidlubneyS.Drinking away the hurt: The nature and prevalence of PTSD in substance abuse patients attending a community-based treatment program. J Behav Ther Exp Psychiatry2000;31:55–66.
44.
GeisserMERothRSBachmanJEEckertTA. The relationship between symptoms of post-traumatic stress disorder and pain, affective disturbance and disability among patients with accident and non-accident related pain. Pain1996;66:207–14.
45.
ShermanJJTurkDCOkifujiA.Prevalence and impact of posttraumatic stress disorder: Like symptoms on patients with fibromyalgia syndrome. Clin J Pain2000;16:127–34.
46.
WalkerRDHowardMOAndersonBWalkerPSLambertMDSuchinskyRJohnsonM.Diagnosis and hospital readmission rates of female veterans with substance-related disorders. Psychiatr Serv1995;46:932–7.
47.
BenediktRAKolbLC. Preliminary findings on chronic pain and posttraumatic stress disorder. Am J Psychiatry1986;143:908–10.
48.
HicklingEJBlanchardEB. Post-traumatic stress disorder and motor vehicle accidents. J Anxiety Disord1992;6:285–91.
49.
TaylorSKochWJ. Anxiety disorders due to motor vehicle accidents: Nature and treatment. Clin Psychol Rev1995;15:721–38.
50.
CoxBJMcWilliamsL.Mood and anxiety disorders in relation to chronic pain: Evidence from the National Comorbidity Study. Pain Res Manag2002;7 (Suppl A):11A.
51.
KernsRDTurkDCRudyTE. The West-Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain1985;23:345–56.
52.
TurkDCRudyTE. Towards a comprehensive assessment of chronic pain patients. Behav Res Ther1987;25:237–49.
53.
TurkDCRudyTE. Toward an empirically derived taxonomy of chronic pain patients: Integration of psychological assessment data. J Consult Clin Psychol1988;56:233–8.
54.
AsmundsonGJGBoninMFFrombachIKNortonRG. Evidence of a disposition toward fearfulness and vulnerability to posttraumatic stress in dysfunctional pain patients. Behav Res Ther2000;38:801–12.
55.
ReissSMcNallyRJ. The expectancy model of fear. In: ReissSBootzinRR, editors. Theoretical issues in behavior therapy. New York: Academic Press;1985. p 107–21.
56.
TaylorS.Anxiety sensitivity: Theory, research, and treatment of the fear of anxiety. New Jersey: Lawrence Erlbaum Associates; 1999.
57.
TaylorSKochWJMcNallyRJ. How does anxiety sensitivity vary across the anxiety disorders?J Anxiety Disord1992;6:249–59.
58.
TaylorS.Anxiety sensitivity and its implications for understanding and treating PTSD. Journal of Cognitive Psychotherapy. Forthcoming.
59.
KuchKCoxBJEvansRShulmanI.Phobias, panic, and pain in 55 survivors of road vehicle accidents. J Anxiety Disord1994;8:181–7.
60.
AsmundsonGJGNortonRG. Anxiety sensitivity in patients with physically unexplained chronic back pain: A preliminary report. Behav Res Ther1995;33:771–7.
61.
PlehnKPetersonRAWilliamsDA. Anxiety sensitivity: Its relationship to functional status in patients with chronic pain. Journal of Occupational Rehabilitation1998;8:213–22.
62.
FedoroffICTaylorSAsmundsonGJGKochWJ. Cognitive factors in traumatic stress reactions: Predicting PTSD symptoms from anxiety sensitivity and beliefs about harmful events. Behavioural and Cognitive Psychotherapy2000;28:5–15.
63.
TaylorS.Understanding and treating panic disorder: Cognitive-behavioural approaches. Chichester: Wiley; 2000.
64.
AsmundsonGJG. Empirical findings, clinical implications, and future directions. In: Anxiety sensitivity and chronic pa In: TaylorS, editor. Anxiety sensitivity: Theory, research, and treatment of the fear of anxiety. New Jersey: Lawrence Erlbaum Associates; 1999. p 269–85.
65.
AsmundsonGJGTaylorS.Role of anxiety sensitivity in pain-related fear and avoidance. J Behavl Med1996;19:577–86.
66.
MurisPVlaeyenJWSMeestersCVertongenS.Anxiety sensitivity and fear of pain in children. Percept Mot Skills2001;92:452–8.
67.
SteinMBJangKLLivesleyWJ. Heritability of anxiety sensitivity: A twin study. Am J Psychiatry1999;156:246–51.
68.
JangKLSteinMBTaylorSLivesleyWJ. Gender differences in the etiology of anxiety sensitivity: A twin study. Jouornal of Gender Specific Medicine1999;2:39–44.
69.
SteinMBJangKLTaylorSVernonPALivesleyWJ. Genetic and environmental influences on trauma exposure and posttraumatic stress disorder symptoms: A general population twin study. Am J Psychiatry2002;159:000–000 . [Q11}.
70.
BackonjaMM. The neural basis of chronic pain, its plasticity and modulation. Behav Brain Sci1997;20:435–7.
71.
McCarsonKEEnnaSJ. Nociceptive regulation of GABA-sub(B) receptor gene expression in rat spinal cord. Neuropharmacology1999;38:1767–73.
72.
DesseinPHShiptonEACloeteyA.Fibromyalgia as a syndrome of neuroendocrine deficiency: A hypothetical model with therapeutic implications. Pain Reviews1997;4:70–88.
73.
KjorsvikAStorksonRTjolsenAHoleK.Differential effects of activation of lumbar and thoracic 5-HT- sub(2A/2C) receptors on nociception in rats. Pharmacol Biochem Behav1997;56:523–7.
74.
BoutonMEMinekaSBarlowDH. A modern learning theory perspective on the etiology of panic disorder. Psychol Rev2001;108:4–32.
75.
AsmundsonGJGWrightKDMcCrearyDRPedlarD.Posttraumatic stress disorder symptoms in United Nations peacekeepers: An examination of factor structure in peacekeepers with and without chronic pain. Cognitive Behaviour Therapy. Forthcoming.
76.
SalomonsTVOstermanJEGaglieseLKatzJ.Pain flashbacks in posttraumatic stress disorder. Clin J Pain. Forthcoming.
77.
PitmanRKSandersKMZusmanRMHealyARCheemaFLaskoNB, and others. Pilot study of secondary prevention of posttraumatic stress disorder with propranolol. Biol Psychiatry2002;51:189–92.
78.
CattellRB. Matched determiners vs. factor invariance: A reply to Korth. Multivariate Behavioral Research1978;13:431–48.
79.
EngelCCJrEngelALCampbellSJMcFallMERussoJKatonWJ. Posttraumatic stress disorders symptoms and precombat sexual and physical abuse in Desert Storm veterans. J Nerv Ment Dis1993;181:683–8.
80.
BeckJGFreemanJBShipherdJCHamblenJLLacknerFM. Specificity of stroop interference in patients with pain and PTSD. J Abnorm Psychol2001;110:536–43.
81.
FirstMBSpitzerRLGibbonMWilliamsJBW. Structured clinical interview for DSM-IV-TR axis I disorders, research version, non-patient ed. (SCID-I/NP). New York: Biometrics Research, New York State Psychiatric Institute; 2001.
KernsRDJacobMC. Assessment of the psychosocial context of the experience of chronic pain. In: TurkDCMelzackR, editors. Handbook of pain assessment.New York: Guilford Press; 1992. p 235–53.
84.
McCrackenLMZayfertCGrossRT. The Pain Anxiety Symptoms Scale: Development and validation of a scale to measure fear of pain. Pain1992;50:67–73.
85.
BlakeDDWeathersFWNagyLMKaloupekDGCharneyDSKeaneTM. Clinician administered PTSD scale (revised). Boston: Behavioral Science Division, Boston National Center for Post-Traumatic Stress Disorder; 1997.
86.
FoaEBRiggsDSDancuCVRothbaumBO. Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. J Trauma Stress1993;6:459–73.
87.
WeathersFWLitzBTHermanDSHuskaJAKeaneTM. The PTSD checklist: Reliability, validity, and diagnostic utility. Paper presented at the Annual meeting of the International Society for Traumatic Stress Studies; 1993; San Antonio (TX).
88.
PetersonRAReissS.Anxiety Sensitivity Index Revised test manual(OH): IDS Publishing Corporation;1993.
89.
FoaEBJaycoxLH. Cognitive-behavioral treatment of post-traumatic stress disorder. In: SpiegelD, editor. The practice of psychotherapy.Washington (DC): American Psychiatric Press; Forthcoming.
90.
GatchelRJTurkDC. Psychological approaches to pain management: A practitioner's handbook. New York: Guilford Press; 1996.
91.
PhilipsHCRachmanSJ. The psychological management of chronic pain: A treatment manual. 2nd ed.New York: Springer; 1996.
