Do post-traumatic pain and post-traumatic stress symptomatology mutually maintain each other? A systematic review of cross-lagged studies

Abstract

After traumatic exposure, individuals are at risk of developing symptoms of both pain and post-traumatic stress disorder (PTSD). Theory and research suggest a complex and potentially mutually maintaining relationship between these symptomatologies. However, findings are inconsistent and the applied methods are not always well suited for testing mutual maintenance. Cross-lagged designs can provide valuable insights into such temporal associations, but there is a need for a systematic review to assist clinicians and researchers in understanding the nature of the relationship. Thus, the aim of this systematic review was to identify, critically appraise, and synthesize results from cross-lagged studies on pain and PTSD symptomatology to assess the evidence for longitudinal reciprocity and potential mediators. Systematic searches resulted in 7 eligible studies that were deemed of acceptable quality with moderate risk of bias using the cohort study checklist from Scottish Intercollegiate Guidelines Network. Furthermore, synthesis of significant pathways in the cross-lagged models showed inconsistent evidence of both bidirectional and unidirectional interaction patterns between pain and PTSD symptomatology across time, hence not uniformly supporting the theoretical framework of mutual maintenance. In addition, the synthesis suggested that hyperarousal and intrusion symptoms may be of particular importance in these cross-lagged relationships, while there was inconclusive evidence of catastrophizing as a mediator. In conclusion, the findings suggest an entangled, but not necessarily mutually maintaining relationship between pain and PTSD symptomatology. However, major variations in findings and methodologies complicated synthesis, prompting careful interpretation and heightening the likelihood that future high-quality studies will change these conclusions.

Military veterans with and without post-traumatic stress disorder: results from a chronic pain management programme

“…Additionally, at end of treatment the PTSD group when compared to the no PTSD group had made statistically significant reductions on the CORE-10 and on the IES-6 (see Table 5). However, there was substantial missing data at day 10 in both PTSD and No PTSD groups, 31 and 23, respectively, mainly due to administrative error [12], work [11], pain flare-up [8], and post-traumatic stress symptoms [19]. Figure 1 shows reliable changes [41] in confidence in activity despite pain (PSEQ) and pain catastrophising (PCS); those making reliable improvement far outnumbered those who reliably worsened, only a few of the latter for each outcome.…”

“…There is growing interest in the relationship between chronic pain and post-traumatic stress disorder (PTSD) and identifying effective treatments when these conditions present together. Psychological models proposed to explain the association of chronic pain and post-traumatic stress remain largely hypothetical [7][8][9]. The recognition of interaction between chronic pain and post-traumatic stress has generated recommendations for integrated treatment [10][11][12], for example, behavioural activation using a collaborative approach involving primary care, mental health, and other clinicians [12], Cognitive-Behavioural Therapy (CBT), interdisciplinary pain programmes, and exposure-based interventions [11].…”

Psychologische Psychotherapie bei persistierenden Schmerzen nach einer HWS-Distorsion

“…Bei komorbiden chronischen Schmerzpatienten scheinen vor allem Intrusionen und Hyperarousal in Zusammenhang mit dem Schmerz zu stehen [24]. Hyperarousal wird in engem Zusammenhang mit der erhöhten subjektiv wahrgenommenen Bedrohung gesehen, kann aber auch als eigenständiges Symptom bestehen [25].…”

“…Diese Faktoren machen die Diagnosestellung komorbider PTBS bei Schmerzen nach HWS-Distorsion komplex. Daher sollte die Diagnose durch einen psychologischen oder psychiatrischen Kliniker mit Erfahrung in der Schmerztherapie gestellt werden [24].…”

Somatic Experiencing® for patients with low back pain and comorbid posttraumatic stress symptoms – a randomised controlled trial

“…It is still debated whether PTSS and pain are simply co-occuring or mutually maintaining conditions (Otis, Keane, & Kerns, 2003 ; Ravn, Hartvigsen, Hansen, Sterling, & Andersen, 2018 ). A number of mutually maintaining mechanisms have been suggested (for a review of the theoretical frameworks and empirical studies, see Otis et al, 2003 and Ravn, Hartvigsen, et al, 2018 ). Factors such as catastrophising, hyperarousal and avoidance behaviours may maintain and exacerbate both pain and PTSS.…”