Skip to main content

Posttraumatic stress disorder and correlates of disease activity among veterans with ankylosing spondylitis


The objective of this retrospective study was to evaluate the prevalence of comorbid Posttraumatic stress disorder (PTSD) and the association of PTSD with pain, disease activity, and medication use in ankylosing spondylitis (AS). Veterans with one or more visit to an outpatient rheumatology clinic at a single Veterans Affairs site during a 2-year study period were identified by ICD codes for AS and included if there was documentation of AS diagnosis by a rheumatologist. Data were collected on PTSD diagnosis, demographics, pain scores, disease activity by the Bath AS Disease Activity Index (BASDAI), and medication use. Characteristics were compared by PTSD status using t tests for continuous variables and Chi-square or Fischer’s exact test for categorical variables. Of 113 Veterans with AS, 20 (18%) had a diagnosis of PTSD. Those with PTSD were significantly younger, 52 ± 17 years, as compared to those without PTSD, 59 ± 14 years (p = 0.04). BASDAI was recorded for 30% with a mean score of 4.3 ± 2.0. Those with PTSD had higher mean pain and BASDAI scores as compared to those without PTSD (p = 0.06 for both comparisons). Prescribed medications were similar for both groups in regards to synthetic disease modifying antirheumatic drugs (DMARDs), biologics, and opioids, although those with PTSD were significantly more likely to receive NSAIDs (p = 0.03). Veterans with AS and comorbid PTSD were younger and had higher reported pain and disease activity scores compared to those without PTSD in this single site study. These findings underscore the importance of identifying PTSD in patients with AS.

This is a preview of subscription content, access via your institution.

We’re sorry, something doesn't seem to be working properly.

Please try refreshing the page. If that doesn't work, please contact support so we can address the problem.

Fig. 1


  1. 1.

    Lancaster CL, Teeters JB, Gros DF, Back SE (2016) Posttraumatic stress disorder: overview of evidence-based assessment and treatment. J Clin Med 5:105

    Article  PubMed Central  Google Scholar 

  2. 2.

    Magruder KM, Frueh BC, Knapp RG, Davis L, Hamner MB, Martin RH, Gold PB, Arana GW (2005) Prevalence of posttraumatic stress disorder in Veterans Affairs primary care clinics. Gen Hosp Psychiatry 27:169–179

    Article  PubMed  Google Scholar 

  3. 3.

    Coughlin SS (2011) Post-traumatic stress disorder and cardiovascular disease. Open Cardiovasc Med J 5:164–170

    Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Boscarino JA, Forsberg CW, Goldberg J (2010) A twin study of the association between PTSD symptoms and rheumatoid arthritis. Psychosom Med 72:481–486

    Article  PubMed  Google Scholar 

  5. 5.

    Lee YC, Agnew-Blais J, Malspeis S, Keyes K, Costenbader K, Kubzansky LD, Roberts AL, Koenen KC, Karlson EW (2016) Post-traumatic stress disorder and risk for incident rheumatoid arthritis. Arthritis Care Res 68:292–298

    Article  Google Scholar 

  6. 6.

    Mikuls TR, Padala PR, Sayles HR, Yu F, Michaud K, Caplan L, Kerr GS, Reimold A, Cannon GW, Richards JS, Lazaro D (2013) Prospective study of posttraumatic stress disorder and disease activity outcomes in US veterans with rheumatoid arthritis. Arthritis Care Res 65:227–234

    Article  Google Scholar 

  7. 7.

    Singh JA, Strand V (2009) Spondyloarthritis is associated with poor function and physical health-related quality of life. J Rheumatol 36:1012–1020

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Ward MM (1998) Quality of life in patients with ankylosing spondylitis. Rheum Dis Clin N Am 24:815–827

    CAS  Article  Google Scholar 

  9. 9.

    Smolen JS, Braun J, Dougados M, Emery P, FitzGerald O, Helliwell P, Kavanaugh A, Kvien TK, Landewé R, Luger T, Mease P (2014) Treating spondyloarthritis, including ankylosing spondylitis and psoriatic arthritis, to target: recommendations of an international task force. Ann Rheum Dis 73:6–16

    Article  PubMed  Google Scholar 

  10. 10.

    Bakland G, Gran JT, Nossent JC (2011) Increased mortality in ankylosing spondylitis is related to disease activity. Ann Rheum Dis 70:1921–1925

    Article  PubMed  Google Scholar 

  11. 11.

    Orbai AM, Ogdie A (2016) Patient-reported outcomes in psoriatic arthritis. Rheum Dis Clin N Am 42:265–283

    Article  Google Scholar 

  12. 12.

    Ramiro S, van der Heijde D, van Tubergen A, Stolwijk C, Dougados M, Van den Bosch F, Landewé R (2014) Higher disease activity leads to more structural damage in the spine in ankylosing spondylitis: 12-year longitudinal data from the OASIS cohort. Ann Rheum Dis 73:1455–1461

    Article  PubMed  Google Scholar 

  13. 13.

    Poddubnyy D, Protopopov M, Haibel H, Braun J, Rudwaleit M, Sieper J (2016) High disease activity according to the Ankylosing Spondylitis Disease Activity Score is associated with accelerated radiographic spinal progression in patients with early axial spondyloarthritis: results from the GErman SPondyloarthritis Inception Cohort. Ann Rheum Dis 75:2114–2118

    Article  PubMed  Google Scholar 

  14. 14.

    Roy-Byrne P, Smith WR, Goldberg J, Afari N, Buchwald D (2004) Post-traumatic stress disorder among patients with chronic pain and chronic fatigue. Psychol Med 34:363–368

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Otis JD, Keane TM, Kerns RD (2003) An examination of the relationship between chronic pain and post-traumatic stress disorder. J Rehabil Res Dev 40:397

    Article  PubMed  Google Scholar 

  16. 16.

    Wach J, Letroublon MC, Coury F, Tebib JG (2016) Fibromyalgia in spondyloarthritis: effect on disease activity assessment in clinical practice. J Rheumatol 43:2056–2063

    Article  PubMed  Google Scholar 

  17. 17.

    Seal KH, Shi Y, Cohen G, Cohen BE, Maguen S, Krebs EE, Neylan TC (2012) Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA 307:940–947

    CAS  PubMed  Google Scholar 

  18. 18.

    Outcalt SD, Yu Z, Hoen HM, Pennington TM, Krebs EE (2014) Health care utilization among veterans with pain and posttraumatic stress symptoms. Pain Med 15:1872–1879

    Article  PubMed  Google Scholar 

  19. 19.

    Otis JD, Keane TM, Kerns RD, Monson C, Scioli E (2009) The development of an integrated treatment for veterans with comorbid chronic pain and posttraumatic stress disorder. Pain Med 10:1300–1311

    Article  PubMed  Google Scholar 

  20. 20.

    Friedman MJ (2004) Acknowledging the psychiatric cost of war. New Engl J Med 351:75–77

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Singh JA, Holmgren AR, Krug H, Noorbaloochi S (2007) Accuracy of the diagnoses of spondylarthritides in veterans affairs medical center databases. Arthritis Care Res 57:648–655

    Article  Google Scholar 

  22. 22.

    Gravely AA, Cutting A, Nugent S, Grill J (2011) Validity of PTSD diagnoses in VA administrative data: comparison of VA administrative PTSD diagnoses to self-reported PTSD checklist scores. J Rehabil Res Dev 48:21

    Article  PubMed  Google Scholar 

  23. 23.

    Krebs EE, Carey TS, Weinberger M (2007) Accuracy of the pain numeric rating scale as a screening test in primary care. J Gen Intern Med 22:1453–1458

    Article  PubMed  PubMed Central  Google Scholar 

  24. 24.

    van der Heijde D, Lie E, Kvien TK, Sieper J, Van den Bosch F, Listing J, Braun J, Landewé R (2009) ASDAS, a highly discriminatory ASAS-endorsed disease activity score in patients with ankylosing spondylitis. Ann Rheum Dis 68:1811–1818

    Article  PubMed  Google Scholar 

  25. 25.

    Reveille JD (2015) Biomarkers for diagnosis, monitoring of progression, and treatment responses in ankylosing spondylitis and axial spondyloarthritis. Clin Rheumatol 34:1009–1018

    Article  PubMed  PubMed Central  Google Scholar 

Download references


We would like to acknowledge Dr. Atul Deodhar for his review of the manuscript.


Dr. Jennifer L. Barton was supported by the NIH (Grant K23-AR-064372). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Department of Veterans Affairs.

Author information



Corresponding author

Correspondence to Jean Liew.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This study was approved by the institutional review board of the Veterans Affairs Portland Health Care System and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Informed consent

Informed consent for individual participants included in the study was waived by the institutional review board of the Veterans Affairs Portland Health Care System, as individuals were not contacted by study coordinators and individual data was de-identified.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Liew, J., Lucas Williams, J., Dobscha, S. et al. Posttraumatic stress disorder and correlates of disease activity among veterans with ankylosing spondylitis. Rheumatol Int 37, 1765–1769 (2017).

Download citation


  • Ankylosing spondylitis
  • Posttraumatic stress disorder
  • Disease activity
  • Pain