The role of sleep quality on the relationship between posttraumatic stress symptoms and pain in women

  • Rachel AaronEmail author
  • Melanie Noel
  • Joanne Dudeney
  • Anna Wilson
  • Amy Holley
  • Tonya Palermo


Pain frequently co-occurs with elevated posttraumatic stress symptoms (PTSS); women are at elevated risk for their co-occurrence. PTSS and pain are associated with poor sleep quality; yet, little research has examined how sleep impacts their co-occurrence. The current study examines the indirect role of sleep on the relationship between PTSS and pain. A community sample of 182 women completed psychometrically-sound questionnaires assessing PTSS, sleep quality, pain characteristics, depression and anxiety symptoms, and anxiety sensitivity. We examined how sleep quality impacted associations among PTSS and pain intensity and pain interference, while controlling for key psychological factors. Greater PTSS was associated with worse pain interference, and poor sleep quality had a significant indirect effect on this relationship. Sleep may represent a modifiable behavioral mechanism that contributes to the mutual maintenance of PTSS and pain in women. Future research is needed to further clarify the role of sleep quality in their co-occurrence.


Chronic pain Posttraumatic stress disorder Sleep quality 



We thank Caitlin Murrary for her assistance in the revision of this manuscript.


Rachel Aaron is supported by T32GM086270 awarded to Tonya Palermo; Tonya Palermo is supported by K24HD060068; Melanie Noel is supported by the Vi Riddell Pain Initiative of the Alberta Children’s Hospital Research Institute. This research was supported by a Hearst Grant awarded to Melanie Noel by the Center for Child Health, Behavior and Development at the Seattle Children’s Hospital Research Institute.

Compliance with ethical standards

Conflict of interest

Rachel Aaron, Melanie Noel, Joanne Dudeney, Anna Wilson, Amy Holley, and Tonya Palermo declare that they have no conflict of interest.

Human and animal rights and Informed consent

All procedures followed were in accordance with ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study.

Supplementary material

10865_2019_16_MOESM1_ESM.docx (15 kb)
Supplementary material 1 (DOCX 14 kb)


  1. APA. (2013). Diagnostic and statistical manual of mental disorders (DSM-5 ® ). American Psychiatric Pub.Google Scholar
  2. Asmundson, G. J., Coons, M. J., Taylor, S., & Katz, J. (2002). PTSD and the experience of pain: research and clinical implications of shared vulnerability and mutual maintenance models. The Canadian Journal of Psychiatry, 47, 930–937.CrossRefGoogle Scholar
  3. Asmundson, G. J., & Katz, J. (2009). Understanding the co-occurrence of anxiety disorders and chronic pain: State-of-the-art. Depression and Anxiety, 26, 888–901.CrossRefGoogle Scholar
  4. Asmundson, G. J., Wright, K. D., & Stein, M. B. (2004). Pain and PTSD symptoms in female veterans. European Journal of Pain, 8, 345–350.CrossRefGoogle Scholar
  5. Axén, I. (2016). Pain-related sleep disturbance: A prospective study with repeated measures. The Clinical journal of pain, 32, 254–259.CrossRefGoogle Scholar
  6. Babson, K. A., & Feldner, M. T. (2010). Temporal relations between sleep problems and both traumatic event exposure and PTSD: A critical review of the empirical literature. Journal of Anxiety Disorders, 24, 1–15.CrossRefGoogle Scholar
  7. Bigatti, S. M., Hernandez, A. M., Cronan, T. A., & Rand, K. L. (2008). Sleep disturbances in fibromyalgia syndrome: Relationship to pain and depression. Arthritis Care & Research, 59, 961–967.CrossRefGoogle Scholar
  8. Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K., & Domino, J. L. (2015). The posttraumatic stress disorder checklist for DSM-5 (PCL-5): Development and initial psychometric evaluation. Journal of Traumatic Stress, 28, 489–498.CrossRefGoogle Scholar
  9. Boakye, P. A., Olechowski, C., Rashiq, S., Verrier, M. J., Kerr, B., Witmans, M., et al. (2016). A critical review of neurobiological factors involved in the interactions between chronic pain, depression, and sleep disruption. The Clinical Journal of Pain, 32, 327–336.CrossRefGoogle Scholar
  10. Bovin, M. J., Marx, B. P., Weathers, F. W., Gallagher, M. W., Rodriguez, P., Schnurr, P. P., et al. (2016). Psychometric properties of the PTSD checklist for diagnostic and statistical manual of mental disorders—fifth edition (PCL-5) in veterans. Psychological Assessment, 28, 1379.CrossRefGoogle Scholar
  11. Burke, A. L., Mathias, J. L., & Denson, L. A. (2015). Psychological functioning of people living with chronic pain: A meta-analytic review. British Journal of Clinical Psychology, 54, 345–360.CrossRefGoogle Scholar
  12. Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28, 193–213.CrossRefGoogle Scholar
  13. Cella, D., Riley, W., Stone, A., Rothrock, N., Reeve, B., Yount, S., et al. (2010). Initial adult health item banks and first wave testing of the patient-reported outcomes measurement information system (PROMIS™) network: 2005–2008. Journal of Clinical Epidemiology, 63, 1179.CrossRefGoogle Scholar
  14. Cox, R. C., & Olatunji, B. O. (2016). A systematic review of sleep disturbance in anxiety and related disorders. Journal of Anxiety Disorders, 37, 104–129.CrossRefGoogle Scholar
  15. de Souza, L., Benedito-Silva, A. A., Pires, M. L. N., Poyares, D., Tufik, S., & Calil, H. M. (2003). Further validation of actigraphy for sleep studies. Sleep, 26, 81–85.CrossRefGoogle Scholar
  16. Deimling, G. T., Bowman, K. F., Sterns, S., Wagner, L. J., & Kahana, B. (2006). Cancer-related health worries and psychological distress among older adult, long-term cancer survivors. Psycho-Oncology: Journal of the Psychological, Social and Behavioral Dimensions of Cancer, 15, 306–320.CrossRefGoogle Scholar
  17. Edwards, R. R., Almeida, D. M., Klick, B., Haythornthwaite, J. A., & Smith, M. T. (2008). Duration of sleep contributes to next-day pain report in the general population. PAIN®, 137, 202–207.CrossRefGoogle Scholar
  18. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14, 245–258.CrossRefGoogle Scholar
  19. Finan, P. H., Goodin, B. R., & Smith, M. T. (2013). The association of sleep and pain: an update and a path forward. The Journal of Pain, 14, 1539–1552.CrossRefGoogle Scholar
  20. Finan, P. H., Richards, J. M., Gamaldo, C. E., Han, D., Leoutsakos, J. M., Salas, R., et al. (2016). Validation of a wireless, self-application, ambulatory electroencephalographic sleep monitoring device in healthy volunteers. Journal of Clinical Sleep Medicine, 12, 1443.CrossRefGoogle Scholar
  21. Gaskin, D. J., & Richard, P. (2012). The economic costs of pain in the United States. The Journal of Pain, 13, 715–724.CrossRefGoogle Scholar
  22. Ho, F. Y.-Y., Chan, C. S., & Tang, K. N.-S. (2016). Cognitive-behavioral therapy for sleep disturbances in treating posttraumatic stress disorder symptoms: a meta-analysis of randomized controlled trials. Clinical Psychology Review, 43, 90–102.CrossRefGoogle Scholar
  23. Holley, A., Wilson, A., Noel, M., & Palermo, T. (2016). Post-traumatic stress symptoms in children and adolescents with chronic pain: A topical review of the literature and a proposed framework for future research. European Journal of Pain, 20, 1371–1383.CrossRefGoogle Scholar
  24. Johannes, C. B., Le, T. K., Zhou, X., Johnston, J. A., & Dworkin, R. H. (2010). The prevalence of chronic pain in United States adults: results of an Internet-based survey. The Journal of Pain, 11, 1230–1239.CrossRefGoogle Scholar
  25. Jungquist, C. R., O’Brien, C., Matteson-Rusby, S., Smith, M. T., Pigeon, W. R., Xia, Y., et al. (2010). The efficacy of cognitive-behavioral therapy for insomnia in patients with chronic pain. Sleep Medicine, 11, 302–309.CrossRefGoogle Scholar
  26. Kelly, G. A., Blake, C., Power, C. K., O’keeffe, D., & Fullen, B. M. (2011). The association between chronic low back pain and sleep: A systematic review. The Clinical journal of pain, 27, 169–181.CrossRefGoogle Scholar
  27. Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H. U. (2012). Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research, 21, 169–184.CrossRefGoogle Scholar
  28. Koren, D., Arnon, I., Lavie, P., & Klein, E. (2002). Sleep complaints as early predictors of posttraumatic stress disorder: A 1-year prospective study of injured survivors of motor vehicle accidents. American Journal of Psychiatry, 159, 855–857.CrossRefGoogle Scholar
  29. Lillis, T. A., Gerhart, J., Bouchard, L. C., Cvengros, J., O’Mahony, S., Kopkash, K.,… Burns, J. (2017). Sleep disturbance mediates the association of post-traumatic stress disorder symptoms and pain in patients with cancer. American Journal of Hospice and Palliative Medicine ®, 1049909117739299.Google Scholar
  30. McCracken, L. M., & Vowles, K. E. (2014). Acceptance and commitment therapy and mindfulness for chronic pain: Model, process, and progress. American Psychologist, 69, 178.CrossRefGoogle Scholar
  31. McLean, C. P., Asnaani, A., Litz, B. T., & Hofmann, S. G. (2011). Gender differences in anxiety disorders: Prevalence, course of illness, comorbidity and burden of illness. Journal of Psychiatric Research, 45, 1027–1035.CrossRefGoogle Scholar
  32. Merskey, H., & Bogduk, N. (1994). Classification of chronic pain (2nd ed.). Seattle: IASP.Google Scholar
  33. Morasco, B. J., Lovejoy, T. I., Lu, M., Turk, D. C., Lewis, L., & Dobscha, S. K. (2013). The relationship between PTSD and chronic pain: mediating role of coping strategies and depression. Pain, 154, 609–616.CrossRefGoogle Scholar
  34. Nahin, R. L. (2015). Estimates of pain prevalence and severity in adults: United States, 2012. The Journal of Pain, 16, 769–780.CrossRefGoogle Scholar
  35. Nelson, S. M., Cunningham, N. R., & Kashikar-Zuck, S. (2017). A conceptual framework for understanding the role of adverse childhood experiences in pediatric chronic pain. The Clinical Journal of Pain, 33, 264–270.Google Scholar
  36. Noel, M., Vinall, J., Tomfohr-Madsen, L., Holley, A., Wilson, A. C., & Palermo, T. M. (2018). Sleep mediates the association between PTSD symptoms and chronic pain in youth. The Journal of Pain, 19, 67–75.CrossRefGoogle Scholar
  37. Noel, M., Wilson, A. C., Holley, A., Durkin, L., Patton, M., & Palermo, T. M. (2016). Posttraumatic stress disorder symptoms in youth with vs without chronic pain. Pain, 157, 2277–2284.CrossRefGoogle Scholar
  38. O’brien, E. M., Waxenberg, L. B., Atchison, J. W., Gremillion, H. A., Staud, R. M., McCrae, C. S., et al. (2010). Negative mood mediates the effect of poor sleep on pain among chronic pain patients. The Clinical Journal of Pain, 26, 310–319.CrossRefGoogle Scholar
  39. Ødegård, S. S., Sand, T., Engstrøm, M., Zwart, J.-A., & Hagen, K. (2013). The impact of headache and chronic musculoskeletal complaints on the risk of insomnia: longitudinal data from the Nord-Trøndelag health study. The journal of headache and pain, 14, 24.CrossRefGoogle Scholar
  40. Pavlova, M., Ference, J., Hancock, M., & Noel, M. (2017). Disentangling the sleep-pain relationship in pediatric chronic pain: The mediating role of internalizing mental health symptoms. Pain research and management, 2017.Google Scholar
  41. Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40, 879–891.CrossRefGoogle Scholar
  42. Quartana, P. J., Wickwire, E. M., Klick, B., Grace, E., & Smith, M. T. (2010). Naturalistic changes in insomnia symptoms and pain in temporomandibular joint disorder: A cross-lagged panel analysis. PAIN®, 149, 325–331.CrossRefGoogle Scholar
  43. Sharp, T. J., & Harvey, A. G. (2001). Chronic pain and posttraumatic stress disorder: mutual maintenance? Clinical Psychology Review, 21, 857–877.CrossRefGoogle Scholar
  44. Siqveland, J., Hussain, A., Lindstrøm, J. C., Ruud, T., & Hauff, E. (2017). Prevalence of posttraumatic stress disorder in persons with chronic pain: A meta-analysis. Frontiers in Psychiatry, 8, 164.CrossRefGoogle Scholar
  45. Smith, M. T., & Haythornthwaite, J. A. (2004). How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature. Sleep Medicine Reviews, 8, 119–132.CrossRefGoogle Scholar
  46. Stratton, K. J., Clark, S. L., Hawn, S. E., Amstadter, A. B., Cifu, D. X., & Walker, W. C. (2014). Longitudinal interactions of pain and posttraumatic stress disorder symptoms in US Military service members following blast exposure. The Journal of Pain, 15, 1023–1032.CrossRefGoogle Scholar
  47. Taylor, D. J., Mallory, L. J., Lichstein, K. L., Durrence, H. H., Riedel, B. W., & Bush, A. J. (2007a). Comorbidity of chronic insomnia with medical problems. Sleep, 30, 213–218.CrossRefGoogle Scholar
  48. Taylor, D. J., & Pruiksma, K. E. (2014). Cognitive and behavioural therapy for insomnia (CBT-I) in psychiatric populations: A systematic review. International Review of Psychiatry, 26, 205–213.CrossRefGoogle Scholar
  49. Taylor, S., Zvolensky, M. J., Cox, B. J., Deacon, B., Heimberg, R. G., Ledley, D. R., et al. (2007b). Robust dimensions of anxiety sensitivity: Development and initial validation of the Anxiety Sensitivity Index-3. Psychological Assessment, 19, 176.CrossRefGoogle Scholar
  50. Trauer, J. M., Qian, M. Y., Doyle, J. S., Rajaratnam, S. M., & Cunnington, D. (2015). Cognitive behavioral therapy for chronic insomnia: A systematic review and meta-analysis. Annals of Internal Medicine, 163, 191–204.CrossRefGoogle Scholar
  51. Tunks, E. R., Crook, J., & Weir, R. (2008). Epidemiology of chronic pain with psychological comorbidity: Prevalence, risk, course, and prognosis. The Canadian Journal of Psychiatry, 53, 224–234.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Seattle Children’s Research InstituteUniversity of WashingtonSeattleUSA
  2. 2.Johns Hopkins MedicineBaltimoreUSA
  3. 3.Alberta Children’s Hospital and Research InstituteUniversity of CalgaryCalgaryCanada
  4. 4.Oregon Health & Science UniversityPortlandUSA

Personalised recommendations