Skip to main content

Advertisement

Log in

Comorbidity of post-traumatic stress disorder and chronic pain: Implications for clinical and forensic assessment

  • Published:
Current Review of Pain Aims and scope Submit manuscript

Abstract

A summary of the current state of science is presented with reference to post-traumatic stress disorder (PTSD) and pain. Historical development of the diagnosis, current nosology, epidemiology, pathophysiology, and controversies are discussed. Issues of evaluation are reviewed, with specific reference to forensic assessment.

Treatment outcome studies are briefly reviewed, with a review of currently accepted treatment interventions, including pharmacologic and behavioral modalities. An emphasis is placed on an integrated treatment plan in which chronic pain and PTSD both are present.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

  1. van der Kolk BA, McFarlane AC, Weisaeth L: Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York: The Guilford Press; 1996. Comprehensive review of PTSD with author contributions from most experts in the field.

    Google Scholar 

  2. Herman JL: Trauma and Recovery. New York, Basic Books, 1992.

    Google Scholar 

  3. Chibnall JT, Duckro PN: Post-traumatic stress disorder in chronic post-traumatic headache patients. Headache 1994, 134: 357–361.

    Article  Google Scholar 

  4. Diagnostic and Statistical Manual of Mental Disorders, IV. Washington, DC: American Psychiatric Association, 1992:1–17.

  5. Saigh PA, Bremner DJ: The History of Posttraumatic Stress Disorder in Posttraumatic Stress Disorder: A Comprehensive Text. Edited by Saigh PA, Bremner DJ. Boston: Allyn and Bacon; 1999.

    Google Scholar 

  6. Barker P: Regeneration. New York: Penguin Books; 1991.

    Google Scholar 

  7. Barker P: The Eye in the Door. New York: Penguin Books; 1993.

    Google Scholar 

  8. Barker P: The Ghost Road. New York: Penguin Books; 1991.

    Google Scholar 

  9. Freud S: Fixation to Trauma: The Unconscious in the Complete Introductory Lectures on Psychoanalysis. Edited by Strachey J. New York: W.W. Norton and Co.; 1966.

    Google Scholar 

  10. Southard EE:Shellshock.Boston:Leonasrd;1919.

  11. Terr LC: Too Scared to Cry. New York: Harper & Row; 1990.

    Google Scholar 

  12. Burgess AW, Holmstrom LL: Rape trauma. Am J Psychiatry 1974, 131: 981–986.

    CAS  PubMed  Google Scholar 

  13. Walker LE: Battered Woman Syndrome.New York: Springer Publishing Company; 1984.

    Google Scholar 

  14. Pope HG, Hudson JI, Bodkin JA, Oliva P: Questionable validity of „dissociative amnesia’ in trauma victims. Evidence from prospective studies. Br J Psychiatry 1998, 172: 210–217.

    Article  PubMed  Google Scholar 

  15. van der Kolk BA, McFarlane AC: The Black Hole of Trauma in Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. Edited by van der Kolk BA et al. New York: The Guilford Press; 1996.

    Google Scholar 

  16. Herman JL: Sequelae of prolonged and repeated trauma. Evidence for a complex posttraumatic syndrome (DESNOS). In Posttraumatic Stress Disorder: DSM IV and Beyond. Edited by Davidson JRT, Foa EB. Washington, DC: American Psychiatric Press; 1993: 412.

    Google Scholar 

  17. Briere J: Psychological Assessment of Adult Posttraumatic Stress Disorder. Washington, DC: American Psychological Association; 1997.

    Book  Google Scholar 

  18. Reynolds JL: Post-traumatic stress disorder after childbirth: the phenomenon of traumatic birth. CMAJ 1997, 156: 831–835.

    PubMed Central  CAS  PubMed  Google Scholar 

  19. Curzon G, Hutson PH, Kennett GA, et al.: Characteristics of analgesias induced by brief or prolonged stress. In Stress-Induced Analgesia. Edited by Kelly DD. New York: The New York Academy of Sciences; 1986: 93–103.

    Google Scholar 

  20. Anisman H, Zacharko RM: Behavioral and neurochemical consequences associated with stressors. In Stress-Induced Analgesia. Edited by Kelly DD. New York: The New York Academy of Sciences; 1986: 205–225.

    Google Scholar 

  21. Vidal C, Jacob J: Hyperalgesia induced by emotional stress in the rat: an experimental animal model of human anxiogenic hyperalgesia. In Stress-Induced Analgesia. Edited by Kelly DD. New York: The New York Academy of Sciences; 1986: 73–81.

    Google Scholar 

  22. Henry JP: Psychological and physiological responses to stress. Acta Physiol Scand Suppl 1997, 640: 10–25.

    CAS  PubMed  Google Scholar 

  23. Willer C, Ernst M: Somatovegetative changes in stress-induced analgesia in man: an electrophysiological and pharmacological study. In Stress-Induced Analgesia. Edited by Kelly DD. New York: The New York Academy of Sciences; 1986: 256–272.

    Google Scholar 

  24. Golier J, Yehuda R: Neuroendocrine activity and memory related impairments in posttraumatic stress disorder. Dev Psychopathol 1998, 10: 857–869.

    Article  CAS  PubMed  Google Scholar 

  25. Hayes RL, Katayama Y: Range of environmental stimuli producing nociceptive suppression: implications of neural mechanisms. In Stress-Induced Analgesia. Edited by Kelly DD. New York: The New York Academy of Sciences; 1986: 1–13.

    Google Scholar 

  26. Clark WC, Yang JC, Janal MN: Altered pain and visual sensitivity in humans: the effects of acute and chronic stress. In Stress-Induced Analgesia. Edited by Kelly DD. New York: The New York Academy of Sciences; 1986: 116–129.

    Google Scholar 

  27. Miczek KA, Thompson ML, Shuster L: Analgesia following defeat in an aggressive encounter: development of tolerance and changes in opioid receptors. In Stress-Induced Analgesia. Edited by Kelly DD. New York: The New York Academy of Sciences; 1986: 14–29.

    Google Scholar 

  28. Marek P, Panocka I, Sadowski B: Involvement of humoral factors in the mechanism of stress-induced analgesia in mice. In Stress-Induced Analgesia. Edited by Kelly DD. New York: The New York Academy of Sciences; 1986: 361–370.

    Google Scholar 

  29. Markou A, Matthews K, Overstreet DH, et al.: Flinders resistant hypocholinergic rats exhibit startle sensitization and reduced startle thresholds. Biol Psychiatry 1994, 36: 680–688.

    Article  CAS  PubMed  Google Scholar 

  30. Koopman C, Classen C, Cardena E, et al.: When disaster strikes, acute stress disorder may follow. J Traumatic Stress 1995, 8: 29–46.

    Article  CAS  Google Scholar 

  31. Thomsen JF, Mortensen B, Rask A, et al.: Post-traumatic stress disorder following violent events at the workplace. Experiences with patients referred to a department of occupational medicine [in Danish]. Ugeskr Laeger 1996, 158: 6461–6466.

    CAS  PubMed  Google Scholar 

  32. Scott MJ, Stradling SG: Post-traumatic stress disorder without the trauma. Br J Clin Psychol 1994, 33(pt 1): 71–74.

    Article  PubMed  Google Scholar 

  33. 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 pain. Pain 1996, 66: 207–214.

    Article  CAS  PubMed  Google Scholar 

  34. Toomey TC, Hernandez JT, Gittelman DF, Hulka JF: Relationship of physical and sexual abuse to pain and psychological assessment variables in chronic pelvic pain patients. Pain 1993, 53: 105–109.

    Article  CAS  PubMed  Google Scholar 

  35. Breslau N, Davis GC, Andreski P: Risk factors for PTSD related traumatic events: a prospective analysis. Am J Psychiatry 1995, 152: 529–535.

    Article  CAS  PubMed  Google Scholar 

  36. McFarlane AC, de Girolamo G: The nature of traumatic stressors and the epidemiology of posttraumatic reactions. In Traumatic Stress. Edited by van der Kolk BA et al. New York: The Guilford Press; 1996: 129–154.

    Google Scholar 

  37. Silove D: The psychosocial effects of torture, mass human rights violations, and refugee trauma: toward an integrated conceptual framework. J Nerv Ment Dis 1999, 187: 200–207.

    Article  CAS  PubMed  Google Scholar 

  38. Taal LA, Faber AW: Post-traumatic stress, pain, and anxiety in adult burn victims. Burns 1997, 23: 545–549.

    Article  CAS  PubMed  Google Scholar 

  39. Kulich RJ, Baker W: Psychological evaluation of the chronic pain patient. In Evaluation and Treatment of Chronic Pain. Edited by Aronoff G. Media, PA: Williams & Wilkins; 1999: 301–312.

    Google Scholar 

  40. Briquet P: Traite Clinique et Therapeutique de L’hysterie. Paris: Balliere; 1859.

    Google Scholar 

  41. Walker EA, Katon WJ, Neraas K, et al.: Dissociation in women with chronic pelvic pain. Am J Psychiatry 1992, 149: 534–537.

    Article  CAS  PubMed  Google Scholar 

  42. Saxe G, Chinman G, Berkowitz R, et al.: Somatization in patients with dissociative disorders. Am J Psychiatry 1994, 151: 1329–1335.

    Article  CAS  PubMed  Google Scholar 

  43. McFarlane AC, Atchinson M, Rafalowicz E, Papay P: Physical symptoms in post-traumatic stress disorder. J Psychosom Res 1994, 38: 715–726.

    Article  CAS  PubMed  Google Scholar 

  44. Goldberg RT, Pachas WN, Keith D: Relationship between traumatic events in childhood and chronic pain. Disabil Rehabil 1999, 21: 23–30.

    Article  CAS  PubMed  Google Scholar 

  45. Andreski P, Chilcoat H, Breslau N: Post-traumatic stress disorder and somatization symptoms: a prospective study. Psychiatry Res 1998, 79: 131–138.

    Article  CAS  PubMed  Google Scholar 

  46. Rothbaum B, Foa E: Cognitive-behavioral therapy for posttraumatic stress disorder. In Traumatic Stress. Edited by van der Kolk BA et al. New York: Guilford Press; 1996: 491–509. Review of short-term approaches for treatment of PTSD, with a specific focus on review of treatment components.

    Google Scholar 

  47. Loewenstein RJ: Somatoform disorders in victims of incest and child abuse. In Incest-Related Syndromes of Adult Psychopathology. Edited by Kluft RP. Washington, DC: American Psychiatric Press; 1990: 75–111.

    Google Scholar 

  48. Pribor EF, Yutzy SH, Dean T, Wetzel RD: Briquet’s syndrome, dissociation, and abuse. Am J Psychiatry 1993, 150: 1507–1511.

    Article  CAS  PubMed  Google Scholar 

  49. Hyams KC, Wignall FS, Roswell R: War syndromes and their evaluation: from the U.S. Civil War to the Persian Gulf War. Ann Intern Med 1996, 125: 398–405.

    Article  CAS  PubMed  Google Scholar 

  50. Shalev AY, Bleich A, Ursano RJ: Posttraumatic stress disorder: somatic comorbidity and effort in tolerance. Psychosomatics 1990, 31: 197–230.

    Article  CAS  PubMed  Google Scholar 

  51. Solomon Z, Mikulincer M: Combat stress reaction, posttraumatic stress disorder, and somatic complaints among Israeli soldiers. J Psychosom Res 1987, 31: 131–137.

    Article  CAS  PubMed  Google Scholar 

  52. Beckham JC, Crawford AL, Feldman ME, et al.: Chronic posttraumatic stress disorder and chronic pain in Vietnam combat veterans. J Psychosom Res 1997, 43: 378–389.

    Article  Google Scholar 

  53. Wilson JP, Keane TM: Assessing Psychological Trauma and PTSD. New York: The Guilford Press; 1997. This book offers the most comprehensive review of treatment instruments for PTSD+.

    Google Scholar 

  54. Blanchard EB, Hickling EJ: After the Crash: Assessment and Treatment of Motor Vehicle Accident Survivors. Washington, DC: American Psychological Association; 1997. The authors offer a comprehensive review of prior research on MVAs and PTSD, as well as a clinically useful treatment protocol.

    Book  Google Scholar 

  55. Norris FH: Epidemiology of trauma: frequency and impact of different potentially traumatic events on different demographic groups. J Consult Clin Psychol 1992, 60: 409–418.

    Article  CAS  PubMed  Google Scholar 

  56. Kuch K, Cox BJ, Evans RJ: Post-traumatic stress disorder and motor vehicle accidents: a multidisciplinary overview. Can J Psychiatry 1996, 41: 429–434.

    CAS  PubMed  Google Scholar 

  57. Kuch K, Evans RJ, Shulan I: Phobias, panic, and pain in 55 survivors of road accidents. J Anxiety Disord 1994, 8: 181–187.

    Article  Google Scholar 

  58. Kuch K, Evans RJ, Watson PC, et al.: Road vehicle accidents and phobias in 60 patients with fibromyalgia. J Anxiety Disord 1991, 5: 273–280.

    Article  Google Scholar 

  59. Jaspers JP: Whiplash and post-traumatic stress. Disabil Rehabil 1998, 20: 397–404.

    Article  CAS  PubMed  Google Scholar 

  60. Hickling EJ, Blanchard EB, Schwartz SP, Silverman DJ: Headaches and motor vehicle accidents: results of psychological treatment of post-traumatic headache. Headache Q 1992, 3: 285–289.

    Google Scholar 

  61. Hickling EJ, Blanchard EB, Silverman DJ, Schwartz SP: Motor vehicle accidents, headaches, and post-traumatic stress disorder: assessment findings in a consecutive series. Headache 1992, 32: 147–151.

    Article  CAS  PubMed  Google Scholar 

  62. Aghabeigi B, Feinmann C, Harris M: Prevalence of posttraumatic stress disorder in patients with chronic idiopathic facial pain. Br J Oral Maxillofac Surg 1992, 30: 360–364.

    Article  CAS  PubMed  Google Scholar 

  63. Bryant RA: Post-traumatic stress disorder, flashbacks, and pseudo memories in closed head injury. J Traumatic Stress 1996, 9: 621–629.

    Article  CAS  Google Scholar 

  64. Schreiber S, Galai-Gat T: Uncontrolled pain following physical injury as the core-trauma in post-traumatic stress disorder. Pain 1993, 54: 107–110.

    Article  CAS  PubMed  Google Scholar 

  65. Ehlert U, Heim C, Hellhammer DH: Chronic pelvic pain as a somatoform disorder. Psychother Psychosom 1999, 68: 87–94.

    Article  CAS  PubMed  Google Scholar 

  66. Heim C, Ehlert U, Hanker JP, Hellhammer DH: Abuse related post-traumatic stress disorder and alterations of the hypothalamic-pituitary-adrenal axis in women with chronic pelvic pain. Psychosom Med 1998, 60: 309–318.

    Article  CAS  PubMed  Google Scholar 

  67. Drossman DA, Lesserman J, Nacham G, et al.: Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Ann Intern Med 1995, 113: 828–833.

    Article  Google Scholar 

  68. Benedict RA, Kolb LC: Preliminary findings on chronic pain and posttraumatic stress disorder. Am J Psychol 1986, 143: 908–910.

    Article  Google Scholar 

  69. Lebovitz AH, Yarmush J, Lefkowitz M: Reflex sympathetic dystrophy and posttraumatic stress disorder. Multidisciplinary evaluation and treatment. Clin J Pain 1990, 6: 153–157.

    Article  Google Scholar 

  70. Morrison J: Childhood sexual histories of women with somatization disorder. Am J Psychiatry 1989, 146: 239–241.

    Article  CAS  PubMed  Google Scholar 

  71. Tarrier N: Psychological co-morbidity in adult burn patients: prevalence and treatment. J Ment Health 1995, 4: 51–62.

    Article  Google Scholar 

  72. Pitman R, Sparr LF, Saunders LS, McFarlane AC: Legal issues in posttraumatic stress disorder. In Traumatic Stress. Edited by van der Kolk BA et al.N ew York: The Guilford Press; 1996: 378–397. Detailed review of forensic issues in the assessment of PTSD.

    Google Scholar 

  73. Weintraub MI: Chronic pain in litigation, what is the relationship? In Neurology Clinics: Malingering and Conversion Reactions. Edited by Weintraub MI. Philadelphia: W.B. Saunders; 1995: 341–349.

    Google Scholar 

  74. Asmundson GJ, Norton GR, Allerdings MD, et al.: Posttraumatic stress disorder and work related injury. J Anxiety Disord 1998, 12: 57–69.

    Article  CAS  PubMed  Google Scholar 

  75. Grossi G, Soares JJ, Angesleva J, Perski A: Psychosocial correlates of long-term sick leave among patients with musculoskeletal pain. Pain 1999, 80: 607–619.

    Article  CAS  PubMed  Google Scholar 

  76. Follette VM, Ruzek JI, Abueg FR: Cognitive Behavioral Therapies for Trauma. New York, Guilford Press; 1998. Recent outcomes studies are summarized, and treatment components of each study are listed in detail.

    Google Scholar 

  77. Yehuda R: Managing anger and aggression in patients with posttraumatic stress disorder. J Clin Psychiatry 1999, 60(suppl 15): 33–37.

    PubMed  Google Scholar 

  78. DeVore JR: Psychological comorbidity following motor vehicle accidents. Phys Med Rehabil: State Art Rev 1998, 12: 111–132.

    Google Scholar 

  79. Ruzek JI, Polusny MA, Abueg FR: Assessment and treatment of concurrent posttraumatic stress disorder and substance abuse. In Cognitive Behavioral Therapies for Trauma. Edited by Follette VM et al. New York: Guilford Press; 1998: 226–255.

    Google Scholar 

  80. Darves-Bornoz JM, Delmotte I, Benhamou P, et al.: Syndrome secondary to post traumatic stress disorder and addictive behaviors [in French]. Ann Med Psychol (Paris) 1996, 154: 190–194.

    CAS  Google Scholar 

  81. Newman E, Kaloupek DG, Keane T: Assessment of posttraumatic stress disorder in clinical and research settings. In Traumatic Stress. Edited by van der Kolk BA et al. New York:: Guilford Press; 1996: 242–275. The best overview of assessment instruments for use with PTSD, including a review of populations studied and psychometric properties of the assessment devices.

    Google Scholar 

  82. Spitzer RL, Williams JB, Gibbon M, First MB: Structured Clinical Interview for DSM III-R, patient edn (SCID-P). New York: Biomentrics Research Dept., New York State Psychiatric Institute; 1990.

    Google Scholar 

  83. Robins LN, Helzer JE, Croughan JL, Ratliff KS: National Institute of Mental Health diagnostic interview schedule: it’s history, characteristics, and validity. Arch Gen Psychiatry 1981, 38: 381–389.

    Article  CAS  PubMed  Google Scholar 

  84. Foa EB, Riggs DS, Dancu CV, Rothbaum BO: Etiology of postrtraumatic stress disorder in Vietnam veterans: analysis of pre-military and combat exposure influences. J Consult Clin Psychol 1993, 52: 79–87.

    Article  Google Scholar 

  85. Hammerberg M: Penn inventory for post traumatic stress disorders: psychomentric properties. Psychological assessment. J Consult Clin Psychol 1992, 4: 67–76.

    Google Scholar 

  86. Briere J, Elliot DM, Jarris K, Cotman A: The trauma symptom inventory: reliability and validity in a clinical sample. J Interpersonal Violence 1995, 10: 387–401.

    Article  Google Scholar 

  87. Pittman RK, Orr SP: Psychophysiologic testing for posttraumatic stress disorder: forensic psychiatric application. Bull Am Acad Psychiatry Law 1993, 21: 37–52.

    Google Scholar 

  88. Rose S, Bisson J: Brief early psychological interventions following trauma: a systematic review of the literature. J Traumatic Stress 1998, 11: 697–710.

    Article  CAS  Google Scholar 

  89. Foa E, Davidson J, Frances A: Treatment of PTSD, the NIH expert consensus guideline series. J Clin Psychiatry 1999, 60(suppl): 16.

    Google Scholar 

  90. Solomon SD, Gerity ET, Muff AM: Efficacy of treatment for posttraumatic stress disorder. J Am Med Assoc 1992, 268: 633–638.

    Article  CAS  Google Scholar 

  91. Lindy J: Psychoanalytic psychotherapy of posttraumatic stress disorder. The nature of the therapeutic relationship. In Traumatic Stress. Edited by van der Kolk BA et al. New York: Guilford Press; 1996: 525–536.

    Google Scholar 

  92. Muris P, Merckelbach H: Traumatic memories, eye movements, phobia, and panic: a critical note on the proliferation of EMDR. J Anxiety Disord 1999, 13: 209–223.

    Article  CAS  PubMed  Google Scholar 

  93. Muse M: Stress-related post-traumatic chronic pain syndrome: behavioral approach to treatment. Pain 1986, 25: 389–394.

    Article  CAS  PubMed  Google Scholar 

  94. Hickling EJ, Blanchard EB, Silverman DJ, Schwartz SP: Motor vehicle accidents, headaches, and post-traumatic stress disorder: assessment findings in a consecutive series. Headache 1992, 32: 147–151.

    Article  CAS  PubMed  Google Scholar 

  95. Ptacek JT, Patterson DR, Montgomery BK, Heimback DM: Pain, coping and adjustment in patients with burns: preliminary findings from a prospective study. J Pain Symptom Manage 1995, 10: 446–455.

    Article  CAS  PubMed  Google Scholar 

  96. van der Kolk BA, McFarlane, Weisaeth: The Pharmacological Treatment of Posttraumatic Stress Disorder: A Comprehensive Text. Edited by Saigh PA, Bremner DJ. Boston: Allyn and Bacon; 1999: 510–524.

    Google Scholar 

  97. Sutherland SM, Davidson JRT: Pharmacological Treatment of Posttraumatic Stress Disorder in Postraumatic Stress Disorder: A Comprehensive Text. Edited by Saigh PA, Bremner DJ. Boston: Allyn and Bacon; 1999.

    Google Scholar 

  98. Pies RW: Handbook of Essential Psychopharmacology. Washington, DC: American Psychiatric Press; 1998.

    Google Scholar 

  99. Bowman ML: Individual differences in posttraumatic stress: problems with the DSM IV model. Can J Psychiatry 1999, 44: 21–33.

    CAS  PubMed  Google Scholar 

  100. Ouimette PC, Brown PJ, Najavits LM: Course and treatment of patients with both substance use and posttraumatic stress disorders. Addict Behav 1998, 23: 785–795.

    Article  CAS  PubMed  Google Scholar 

  101. Kulich RJ: Forensic assessment: ethical and clinical practice issues for the pain clinician. Curr Rev Pain 1999, 3: 61–66.

    Article  Google Scholar 

  102. Raifman LJ: Problems of diagnosis and legal causation in courtroom use of post-traumatic stress disorder. Behav Sci Law 1983, 1: 115–131.

    Article  Google Scholar 

  103. Sparr LF: Post-traumatic stress disorder, does it exist? In Neurol Clin 1995: 413–429. Critical forensic review of PTSD, with a discussion on misuse of the diagnostic criteria.

  104. Steinberg CE: The Daubert decision: an update on the Frye rule. Am Acad Psychiatry Law Newslett 1993, 18: 66–69.

    Google Scholar 

  105. Rogers R, Salekin RT, Sewell KW: Validation of the millon clinical multiaxial inventory for Axis II disorders: does it meet the Daubert standard? Law Human Behav 1999, 23: 425–443. Summary of the Daubert decision with reference to psychologic testing and requirements for error rates.

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Rights and permissions

Reprints and permissions

About this article

Cite this article

Kulich, R.J., Mencher, P., Bertrand, C. et al. Comorbidity of post-traumatic stress disorder and chronic pain: Implications for clinical and forensic assessment. Current Review of Pain 4, 36–48 (2000). https://doi.org/10.1007/s11916-000-0008-4

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11916-000-0008-4

Keywords

Navigation