The Explanatory Role of Insomnia in the Relationship between Pain Intensity and Posttraumatic Stress Symptom Severity among Trauma-Exposed Latinos in a Federally Qualified Health Center

  • Andrew H. Rogers
  • Jafar Bakhshaie
  • Andres G. Viana
  • Chad Lemaire
  • Monica Garza
  • Melissa Ochoa-Perez
  • Joseph W. Ditre
  • Nubia A. Mayorga
  • Michael J. Zvolensky


Latinos, one of the fastest growing populations in the United States, suffer from high rates of posttraumatic stress symptoms (PTS) and its clinical correlates (e.g., disability). Although research suggests the experience of pain is closely related to PTS among trauma-exposed groups, there has been little exploration of the processes that may link pain intensity to greater PTS among trauma-exposed Latinos. The current study explored insomnia, a common problem associated with both pain intensity and PTS, as a mechanism in the association between pain intensity and PTS among trauma-exposed Latinos (N = 208, Mage = 39.39 years, SD = 11.48) attending a Federally Qualified Health Center. Results indicated that insomnia partially explained the relationship between pain intensity and PTS total score (B = 0.25, 95% CI [0.12, 0.43]), as well as re-experiencing (B = 0.09, 95% CI [0.04, 0.17]), avoidance (B = 0.09, 95% CI [0.04, 0.17]), and arousal symptoms (B = 0.10, 95% CI [0.04, 0.17]). Future work is needed to explore the extent to which insomnia accounts for relations between pain and PTS using longitudinal designs to further clarify theoretical health disparity models involving these comorbid conditions.


Latinos Insomnia Pain Posttraumatic stress Federally Qualified Health Center 


  1. 1.
    Colby SL, Ortman JM. Projections of the size and composition of the U.S. population: 2014 to 2060. Washington D.C.: 2014.Google Scholar
  2. 2.
    Alegria M, Woo M. Conceptual issues in Latino mental health. In: Villarruel FA, Carlo G, Grau JM, Azmitia M, Cabrera NJ, Chahin TJ, editors. Handb. US Lat. psychol. dev. community-based perspect. Thousand Oaks: Sage Publications, Inc; 2009. p. 15–30.Google Scholar
  3. 3.
    Cochran SD, Mays VM, Alegria M, Ortega AN, Takeuchi D. Mental health and substance use disorders among Latino and Asian American lesbian, gay, and bisexual adults. J Consult Clin Psychol. 2007;75:785–94. Scholar
  4. 4.
    Perilla JL, Norris FH, Lavizzo EA. Ethnicity, culture, and disaster response: identifying and explaining ethnic differences in PTSD six months after Hurricane Andrew. J Soc Clin Psychol. 2002;21:20–45. Scholar
  5. 5.
    Pole N, Best SR, Weiss DS, Metzler T, Liberman AM, Fagan J, et al. Effects of gender and ethnicity on duty-related posttraumatic stress symptoms among urban police officers. J Nerv Ment Dis. 2001;189:442–8.CrossRefPubMedGoogle Scholar
  6. 6.
    Sareen J, Cox BJ, Stein MB, Afifi TO, Fleet C, Asmundson GJG. Physical and mental comorbidity, disability, and suicidal behavior associated with posttraumatic stress disorder in a large community sample. Psychosom Med. 2007;69:242–8. Scholar
  7. 7.
    Eisenman DP, Gelberg L, Liu H, Shapiro MF. Mental health and health-related quality of life among adult Latino primary care patients living in the United States with previous exposure to political violence. JAMA. 2003;290:627–34. Scholar
  8. 8.
    Green CR, Anderson KO, Baker TA, Campbell LC, Decker S, Fillingim RB, et al. The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Med Malden Mass. 2003;4:277–94.CrossRefGoogle Scholar
  9. 9.
    Epps CD, Ware LJ, Packard A. Ethnic wait time differences in analgesic administration in the emergency department. Pain Manag Nurs Off J Am Soc Pain Manag Nurs. 2008;9:26–32. Scholar
  10. 10.
    Nguyen M, Ugarte C, Fuller I, Haas G, Portenoy RK. Access to care for chronic pain: racial and ethnic differences. J Pain Off J Am Pain Soc. 2005;6:301–14. Scholar
  11. 11.
    Portenoy RK, Ugarte C, Fuller I, Haas G. Population-based survey of pain in the United States: differences among white, African American, and Hispanic subjects. J Pain Off J Am Pain Soc. 2004;5:317–28. Scholar
  12. 12.
    Berry PH, Dahl JL. The new JCAHO pain standards: implications for pain management nurses. Pain Manag Nurs Off J Am Soc Pain Manag Nurs. 2000;1:3–12. Scholar
  13. 13.
    Zvolensky MJ, Bakhshaie J, Paulus DJ, Langdon KJ, Garza M, Valdivieso J, et al. Exploring the mechanism underlying the association between pain intensity and mental health among Latinos. J Nerv Ment Dis. 2017;205:300–7. Scholar
  14. 14.
    Kelly U. Intimate partner violence, physical health, posttraumatic stress disorder, depression, and quality of life in Latinas. West J Emerg Med. 2010;11:247–51.PubMedPubMedCentralGoogle Scholar
  15. 15.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Arlington, VA: American Psychiatric Association; 2013.CrossRefGoogle Scholar
  16. 16.
    Roberts RE, Roberts CR, Chen IG. Ethnocultural differences in sleep complaints among adolescents. J Nerv Ment Dis. 2000;188:222–9.CrossRefPubMedGoogle Scholar
  17. 17.
    Morphy H, Dunn KM, Lewis M, Boardman HF, Croft PR. Epidemiology of insomnia: a longitudinal study in a UK population. Sleep. 2007;30:274–80. Scholar
  18. 18.
    Allen KD, Renner JB, Devellis B, Helmick CG, Jordan JM. Osteoarthritis and sleep: the Johnston County osteoarthritis project. J Rheumatol. 2008;35:1102–7.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Menefee LA, Cohen MJ, Anderson WR, Doghramji K, Frank ED, Lee H. Sleep disturbance and nonmalignant chronic pain: a comprehensive review of the literature. Pain Med Malden Mass. 2000;1:156–72. Scholar
  20. 20.
    Morin CM, Gibson D, Wade J. Self-reported sleep and mood disturbance in chronic pain patients. Clin J Pain. 1998;14(4):311–4.CrossRefPubMedGoogle Scholar
  21. 21.
    Smith MT, Perlis ML, Smith MS, Giles DE, Carmody TP. Sleep quality and presleep arousal in chronic pain. J Behav Med. 2000;23:1–13.CrossRefPubMedGoogle Scholar
  22. 22.
    Baglioni C, Spiegelhalder K, Lombardo C, Riemann D. Sleep and emotions: a focus on insomnia. Sleep Med Rev. 2010;14:227–38. Scholar
  23. 23.
    Kahn M, Sheppes G, Sadeh A. Sleep and emotions: bidirectional links and underlying mechanisms. Int J Psychophysiol. 2013;89:218–28. Scholar
  24. 24.
    Walker MP, van der Helm E. Overnight therapy? The role of sleep in emotional brain processing. Psychol Bull. 2009;135:731–48. Scholar
  25. 25.
    Gehrman P, Seelig AD, Jacobson IG, Boyko EJ, Hooper TI, Gackstetter GD, et al. Predeployment sleep duration and insomnia symptoms as risk factors for new-onset mental health disorders following military deployment. Sleep. 2013;36:1009–18. Scholar
  26. 26.
    Motomura Y, Kitamura S, Oba K, Terasawa Y, Enomoto M, Katayose Y, et al. Sleep debt elicits negative emotional reaction through diminished amygdala-anterior cingulate functional connectivity. PLoS One. 2013;8:e56578. CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Yoo S-S, Hu PT, Gujar N, Jolesz FA, Walker MP. A deficit in the ability to form new human memories without sleep. Nat Neurosci. 2007;10:385–92.CrossRefPubMedGoogle Scholar
  28. 28.
    Goldstein AN, Walker MP. The role of sleep in emotional brain function. Annu Rev Clin Psychol. 2014;10:679–708. Scholar
  29. 29.
    Lang KP, Veazey-Morris K, Andrasik F. Exploring the role of insomnia in the relation between PTSD and pain in veterans with polytrauma injuries. J Head Trauma Rehabil. 2014;29:44–53. Scholar
  30. 30.
    Department of Health and Human Services. Federally qualified health center. Department of Health and Human Services, Centers for Medicare and Medicaid Services; 2017.Google Scholar
  31. 31.
    Vega WA, Lopez SR. Priority issues in Latino mental health services research. Ment Health Serv Res. 2001;3:189–200. CrossRefPubMedGoogle Scholar
  32. 32.
    Jimenez DE, Bartels SJ, Cardenas V, Alegría M. Stigmatizing attitudes toward mental illness among racial/ethnic older adults in primary care. Int J Geriatr Psychiatry. 2013;28:1061–8. Scholar
  33. 33.
    Von Korff M, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain. 1992;50:133–49.CrossRefGoogle Scholar
  34. 34.
    Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(Suppl 20):22–33. quiz 34–57PubMedGoogle Scholar
  35. 35.
    Foa EB, Cashman L, Jaycox L, Perry K. The validation of a self-report measure of posttraumatic stress disorder: the posttraumatic diagnostic scale. Psychol Assess. 1997;9:445–51.CrossRefGoogle Scholar
  36. 36.
    Paulus DJ, Viana AG, Ditre JW, Bakhshaie J, Garza M, Cardoso JB, et al. Synergistic effects of pain and alcohol use in relation to depressive and anxiety symptoms among Latinos in primary care. Cogn Behav Ther. 2017;46:478–92. Scholar
  37. 37.
    Viana AG, Paulus DJ, Bakhshaie J, Garza M, Valdivieso J, Ochoa-Perez M, et al. Emotional nonacceptance within the context of traumatic event exposure: the explanatory role of anxiety sensitivity for traumatic stress symptoms and disability among Latinos in a primary care setting. Gen Hosp Psychiatry. 2017;44:30–7. Scholar
  38. 38.
    Watson D, O’Hara MW, Simms LJ, Kotov R, Chmielewski M, McDade-Montez EA, et al. Development and validation of the Inventory of Depression and Anxiety Symptoms (IDAS). Psychol Assess. 2007;19:253–68. Scholar
  39. 39.
    Watson D, O’Hara MW, Chmielewski M, McDade-Montez EA, Koffel E, Naragon K, et al. Further validation of the IDAS: evidence of convergent, discriminant, criterion, and incremental validity. Psychol Assess. 2008;20:248–59. Scholar
  40. 40.
    Zvolensky MJ, Bakhshaie J, Garza M, Valdivieso J, Ortiz M, Bogiaizian D, et al. The role of anxiety sensitivity in the relation between experiential avoidance and anxious arousal, depressive, and suicidal symptoms among Latinos in primary care. Cogn Ther Res. 2015;39:688–96. Scholar
  41. 41.
    Hayes AF. Introduction to mediation, moderation, and conditional process anlaysis: a regression-based approach. New York: Guilford Press; 2013.Google Scholar
  42. 42.
    Zvolensky MJ, Paulus DJ, Bakhshaie J, Garza M, Ochoa-Perez M, Medvedeva A, et al. Interactive effect of negative affectivity and anxiety sensitivity in terms of mental health among Latinos in primary care. Psychiatry Res. 2016;243:35–42. Scholar
  43. 43.
    Hayes AF, Preacher KJ. Conditional process modeling using structural equation modeling to examine contingent causal processes. Struct. equ. model. Second course. 2nd ed., Information Age Publishing; 2013, p. 219–66.Google Scholar
  44. 44.
    Preacher KJ, Hayes AF. Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behav Res Methods. 2008;40:879–91. Scholar
  45. 45.
    Ditlevsen S, Christensen U, Lynch J, Damsgaard MT, Keiding N. The mediation proportion: a structural equation approach for estimating the proportion of exposure effect on outcome explained by an intermediate variable. Epidemiology. 2005;16:114–20. CrossRefPubMedGoogle Scholar
  46. 46.
    Preacher KJ, Kelley K. Effect size measures for mediation models: quantitative strategies for communicating indirect effects. Psychol Methods. 2011;16:93–115. Scholar
  47. 47.
    Thompson K, Petrov M, Bulls H, Bradley L, Gooding B, Fillingim R. Insomnia severity predicts clinical and experimental measures of pain and physical function in adults with symptomatic knee osteoarthritis. J Pain. 2017;18:S79. Scholar
  48. 48.
    Vitiello MV, Rybarczyk B, Von Korff M, Stepanski EJ. Cognitive behavioral therapy for insomnia improves sleep and decreases pain in older adults with co-morbid insomnia and osteoarthritis. J Clin Sleep Med JCSM Off Publ Am Acad Sleep Med. 2009;5:355–62.Google Scholar
  49. 49.
    Ehring T, Quack D. Emotion regulation difficulties in trauma survivors: the role of trauma type and PTSD symptom severity. Behav Ther. 2010;41:587–98. Scholar
  50. 50.
    Kira I, Lewandowski L, Somers CL, Yoon JS, Chiodo L. The effects of trauma types, cumulative trauma, and PTSD on IQ in two highly traumatized adolescent groups. Psychol Trauma Theory Res Pract Policy. 2012;4:128–39. Scholar
  51. 51.
    Morin CM. Cognitive-behavioral therapy of insomnia. Sleep Med Clin. 2006;1:375–86. Scholar
  52. 52.
    Currie SR, Wilson KG, Pontefract AJ, deLaplante L. Cognitive-behavioral treatment of insomnia secondary to chronic pain. J Consult Clin Psychol. 2000;68:407–16.CrossRefPubMedGoogle Scholar
  53. 53.
    Alegría M, Chatterji P, Wells K, Cao Z, Chen C, Takeuchi D, et al. Disparity in depression treatment among racial and ethnic minority populations in the United States. Psychiatr Serv Wash DC. 2008;59:1264–72. Scholar
  54. 54.
    Edinger JD, Fins AI. The distribution and clinical significance of sleep time misperceptions among insomniacs. Sleep. 1995;18:232–9.CrossRefPubMedGoogle Scholar

Copyright information

© W. Montague Cobb-NMA Health Institute 2018

Authors and Affiliations

  • Andrew H. Rogers
    • 1
  • Jafar Bakhshaie
    • 1
  • Andres G. Viana
    • 1
  • Chad Lemaire
    • 2
  • Monica Garza
    • 2
  • Melissa Ochoa-Perez
    • 2
  • Joseph W. Ditre
    • 3
  • Nubia A. Mayorga
    • 1
  • Michael J. Zvolensky
    • 1
    • 4
  1. 1.Department of PsychologyUniversity of HoustonHoustonUSA
  2. 2.Legacy Community Health CenterHoustonUSA
  3. 3.Department of PsychologySyracuse UniversitySyracuseUSA
  4. 4.Department of Behavioral SciencesUniversity of Texas MD Anderson Cancer CenterHoustonUSA

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