Chronic Pain and PTSD: Developing an Integrated Treatment Approach

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Chronic Pain and PTSD Developing an Integrated
Treatment Approach

• John D. Otis, Ph.D.
• VA Boston Healthcare System
• Boston, MA

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Presentation Overview

• Overview Chronic Pain and OEF/OIF Veterans
• The co-morbidity of Chronic Pain and PTSD
• Development of an Integrated Treatment for
  Chronic Pain and PTSD
• Questions Ideas

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Images of Pain
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What is Chronic Pain?

• Pain is defined as an unpleasant sensory and
  emotional experience associated with actual or
  potential tissue damage, or described in terms of
  such damage.
• Chronic pain Pain with a duration of 3 months
  or greater that is often associated with
  functional, psychological and social problems
  that can negatively impact a persons life.

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The Problem of Pain

• Pain is one of the most common complaints made by
  patients to primary care providers in the VA
  healthcare system (approximately 50 of
  patients).
• In a study of 1,800 OEF/OIF Veterans, 46.5
  reported some pain, with 59 of those exceeding
  the VA clinical threshold of 4 (0 to 10 scale)
  (Gironda et al., 2006).
• Pain is typically an adaptive reaction to an
  injury and gradually decreases over time with
  conservative treatment.
• However, for some people pain persists past the
  point where it is considered adaptive and
  contributes to negative mood, disability, and
  increased use of healthcare system resources.

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The Pain Cycle
Muscle atrophy weakness Weight loss/gain
Pain
Disability
Negative self-talk Poor sleep Missing work
Less active Decreased motivation Increased
isolation
Distress
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The Challenge of Pain

• Over time, negative thoughts and beliefs about
  pain, and behaviors related to pain can become
  very resistant to change.

• Thoughts
• My pain is going to kill me
• This is never going to end
• I'm worthless to my family
• Im disabled
• There is nothing I can do
• for myself
• I'm a bad father, husband,
• and provider

• Behaviors
• Staying in bed all day
• Sleeping all day
• Staying away from friends
• Decreasing activities that
• have the potential to
• increase pain
• Taking more medication
• than prescribed

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Cognitive Behavioral Therapy for Pain Management

• Research supports the efficacy of CBT for the
  treatment of chronic pain (Morley et al., 1999)
• Components of CBT for pain include
• Identifying inaccurate beliefs about pain
• Reconceptualizing pain as subject to personal
  control through the influence of thoughts,
  feelings and behaviors
• Teaching cognitive and behavioral coping skills
  (e.g., cognitive restructuring, activity pacing,
  etc.)
• Practice and consolidation of coping skills
  through imagery, rehearsal, and reinforcement of
  their appropriate use

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• Pain often results from injuries related to
  events such as occupational injuries, motor
  vehicle accidents, or military combat.
• This has led to a growing interest in the
  interaction between pain and Posttraumatic Stress
  Disorder (PTSD), as research and clinical
  practice indicate that they frequently co-occur
  and can interact in such a way to negatively
  impact the course of treatment for either
  disorder.

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The Co-morbidity of Chronic Pain and PTSD

• The prevalence of PTSD has been estimated to be
  between 20 to 34 in patients referred for the
  treatment of pain.
• The prevalence of pain has been estimated to be
  between 45 to 87 in patients referred for the
  treatment of PTSD.
• Question Data obtained from VA Boston Psychology
  Pain Management indicate that
• of patients assessed met criteria for
  PTSD based on PTSD Checklist (PCL) scores (n65).

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The Interaction between Chronic Pain and PTSD

• Patients with co-morbid pain and PTSD experience
  more intense pain, more emotional distress,
  higher levels of life interference, and greater
  disability than pain patients without PTSD.
• Due to the interaction of these conditions, these
  patients can also be more complex and challenging
  to treat.

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Clinical Examples

• When ever I'm laying in bed at night and my
  shoulder starts hurting, I start having thoughts
  of when I was shot.
• When I think about the day my vehicle was hit I
  can feel the pain in my back flare up right where
  I was hurt.
• I tried my PT exercises but the pain started
  increasing and I started thinking about what I
  saw and heard in Vietnam so I just said the heck
  with it and called it quits for the day.

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Potential Mechanisms

• Anxiety Sensitivity a fear of arousal-related
  sensations arising from the belief that they will
  have harmful consequences.
• Catastrophizing exaggerated beliefs and
  expectations that events will lead to negative
  outcomes.
• Both of these factors may increase the fear and
  avoidance of activities or thoughts associated
  with recovery.
• PAIN The avoidance of physical activities
• PTSD The avoidance of feared thoughts/situations

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A Need for Research

• Given the high rates of comorbidity between
  chronic pain and PTSD, and evidence suggesting
  that these two disorders may interact in some
  way, efforts to develop more effective treatments
  for this population are greatly needed.

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Efficacy of An Integrated CBT Approach to
Treating Chronic Pain and PTSD

• John D. Otis, Ph.D. and Terence M. Keane Ph.D.
• A VA Merit Review funded by the Rehabilitation,
• Research Development Service

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Acknowledgements

• Terence M. Keane, Ph.D., Co-PI
• Co-Investigators
• Robert Kerns, Ph.D.
• Candice Monson, Ph.D.
• Clara Lora, PsyD
• Sam Wan, MA
• Alex McDonald, MA
• Jillian Shipherd, Ph.D.
• Barbara Niles, Ph.D.

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Purpose

• Evaluate the efficacy of an integrated CBT
  approach to the treatment of co-morbid chronic
  pain and PTSD
• Examine potential mechanisms of action (e.g.,
  catastrophizing, and anxiety sensitivity) that
  might serve to have an impact on treatment outcome

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OEF/OIF Veterans

• More co-morbidity with OEF/OIF veterans when
  compared with other veterans because OEF/OIF
  veterans are surviving their wounds
• Pain and PTSD more likely to be associated with
  the same event

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Assessment Measures

• Pain
• PTSD
• Affective Distress
• Physical Functioning/Disability
• Catastrophizing anxiety sensitivity

12 sessions
Post- treatment
6-Month Follow-up
Pre- treatment
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Research Design

• Participants will be 136 veterans with a
  co-morbid diagnosis of chronic pain and PTSD
• Participants will be randomly assigned to 1 of 4
  treatment conditions
• CBT-Pain
• CBT-PTSD
• CBT-PTR
• Wait-List

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Treatment

• CBT-Pain and CBT-PTSD
• Treatment for participants in these conditions
  will follow a 12-session, individual, manualized
  treatment protocol.
• CBT-PTR
• Treatment will follow a 12-session, individual,
  manualized treatment protocol developed for this
  research study that will integrate empirically
  supported treatment components for both
  conditions.

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Treatment Components
CBT for Pain
CBT for PTSD

• Education re pain
• Relaxation training
• Cognitive restructuring
• Stress management
• Activity pacing
• Pleasant activity scheduling
• Anger management
• Sleep hygiene
• Relapse prevention

• Education re PTSD
• Cognitive restructuring
• Teach coping skills
• Social support
• Anger management sleep
• Exposure therapy
• Reprocessing the meaning of the event

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Study Development Issues

• The assessment/treatment length
• Substance use
• Relaxation training
• Exposure therapy vs. Cognitive Processing Therapy
  (CPT)
• Deciding on essential elements of treatment

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Integrated Treatment

• Session 1 Education on Chronic Pain and PTSD
• Session 2 Making Meaning of Pain and PTSD
• Session 3 Thoughts/Feelings related to Pain and
  PTSD
• Cognitive Errors
• Session 4 Cognitive Restructuring
• Session 5 Diaphragmatic Breathing and
  Progressive Muscle
• Relaxation
• Session 6 Avoidance and Interoceptive Exposure
• Session 7 Pacing and Pleasant Activities
• Session 8 Sleep Hygiene
• Session 9 Safety/Trust
• Session 10 Power/Control/Anger
• Session 11 Esteem/Intimacy
• Session 12 Relapse Prevention and Flare-up
  Planning

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Current Status

• Assessment protocol developed
• All treatment manuals have been developed and
  pilot tested
• Actively treating and recruiting study
  participants

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Questions and Ideas
Otis, J. D., Keane, T. M., Kerns, R. D. (2003).
An Examination of the relationship between
chronic pain and Posttraumatic Stress Disorder.
Journal of Rehabilitation, Research and
Development, 40(5), 397-406. Otis, J. D.,
Pincus, D. B., Keane, T. M. (in press).
Comorbid Chronic Pain and Posttraumatic Stress
Disorder across the Lifespan A Review of
Theoretical Models. In Young G., Kane, A.,
Nicholson K., (Eds). Causality Psychological
Knowledge and Evidence in Court. Kluwer Academic/
Plenum Press.