The impact of PTSD on functioning in patients seeking treatment for chronic pain and validation of the Posttraumatic Diagnostic Scale

Purpose: To assess the psychometric properties of a Swedish version of the Posttraumatic Diagnostic Scale (PDS); to investigate the prevalence of traumatic experiences, trauma types and posttraumatic stress disorder (PTSD) in a sample of patients seeking treatment for chronic pain; and to examine how indices of pain-related functioning vary with a history of traumatic exposure and PTSD diagnostic status. Methods: Participants were 463 consecutive patients with chronic pain referred for assessment at the Pain Rehabilitation Unit at Skåne University Hospital. Results: The translated version of the PDS demonstrated high levels of internal consistency and a factor structure similar to that reported in previous validation studies using samples identified because of trauma-exposure (not chronic pain), both of which provide preliminary support for the validity of this translated version. Based on their responses to the PDS, most patients (71.8 %) reported one or more traumatic events with 28.9% fulfilling criteria for a current PTSD diagnosis. The patients with PTSD also reported significantly higher levels of pain interference, kinesiophobia, anxiety and depression, as well as significantly lower levels of life control, compared to patients exposed to trauma and not fulfilling criteria for PTSD, and patients with no history of traumatic exposure. Conclusions: Consistent with previous research, a significant proportion of patients seeking treatment for chronic pain reported a history of traumatic exposure and nearly one-third of these met current criteria for PTSD according to a standardized self-report measure. The presence of PTSD was associated with multiple indictors of poorer functioning and greater treatment need and provides further evidence that routine screening of chronic pain patients for PTSD is warranted. Self-report measures like the PDS appear to be valid for use in chronic pain samples and offer a relative low-cost method for screening for PTSD

Predictors and mediators of outcome in CBT for chronic pain : The roles of psychological flexibility and PTSD

Chronic pain is a commonly occurring and debilitating condition, and among the costliest health problems for both the individual and society at large. Cognitive behavioral therapy (CBT) is the most widely-disseminated psychological treatment for chronic pain. Even though it is recommended and evidence-based, it yields quite modest improvements in pain-related functioning and accompanying symptoms of emotional distress. It is now generally acknowledged that further efforts are needed to improve the efficacy of CBT for chronic pain. Specifically, pain researchers have called for studies to identify mechanisms that underlie changes in treatment outcomes (mediators) and characteristics of the individual that predict improvements in these mechanisms and treatment overall (predictors and moderators). To address this call, the primary aim of this research program was to study whether changes in psychological flexibility mediated outcomes in a multi-disciplinary, group-based CBT program delivered at a regional specialist unit for pain rehabilitation. The secondary aim was to identify possible predictors of outcome by focusing on facets of psychological flexibility as well as the understudied influence of posttraumatic stress disorder (PTSD). This aim also included investigation of the relationships between PTSD, pain presentation, and psychological flexibility. With these two aims, we hoped to shed further light on the validity of the psychological flexibility model as an integrating, overarching model that can help define relevant treatment processes for adults presenting with chronic pain and psychiatric problems. Study I investigated whether pain-related acceptance, from the psychological flexibility model, and other variables posited as potential mediators in standard CBT mediated changes in pain-related outcomes measured at post-treatment and 12-month follow-up from the CBT program. The results highlighted the mediating role of pain-related acceptance across different indices of outcome.Study II evaluated the psychometric properties of the Swedish-language versions of the full length and shortened version of the Committed Action Questionnaire, as well as the generalizability of previous results related to committed action. The results supported the validity and reliability of the Swedish-language versions of the measure, the generalizability of earlier findings, and the relevance of committed action to health and functioning in individuals with chronic pain.Study III focused on the prevalence of traumatic experiences, trauma types, and PTSD in patients referred for treatment of chronic pain, and the relationship between PTSD and pain-related functioning prior to treatment. High rates of traumatic exposure and PTSD were found for chronic pain patients. The presence of PTSD in these patients was associated with worse clinical characteristics and an increased need for treatment.Study IV examined whether various processes from the psychological flexibility model mediated the relationship between PTSD and chronic pain. Results indicated that the relationship was mediated by pain-related acceptance, committed action, and cognitive fusion, where pain-related acceptance constituted the most influential mediator from the psychological flexibility model. Study V analysed whether indices of emotional distress (including PTSD) and different facets of psychological flexibility predicted pain-related outcomes at 12-month follow-up from the CBT program. Furthermore, it examined whether changes in processes from the psychological flexibility model mediated changes in pain-related outcomes. The only significant predictors of outcomes turned out to be psychological inflexibility and committed action. All available facets of psychological flexibility had mediating effects on treatment outcomes.Based on the results from these studies, theoretical integration within the CBT field may be facilitated by a process-focused approach including the psychological flexibility model. This model seems to be transdiagnostically and trans-situationally applicable in several ways. Its processes span problem areas with diverse backgrounds from the somatic field and chronic pain to the psychiatric field and PTSD, and appear useful not only to treatments specifically built around targeting psychological flexibility but also more broadly in CBT treatments

Treatment outcomes in group-based CBT for chronic pain: An examination of PTSD symptoms

Background: The relevance of PTSD symptoms to outcomes of Cognitive Behavioral Therapy (CBT) for chronic pain is unclear. This study examines whether (a) traumatic exposure or the severity of PTSD symptoms at pre‐treatment predict outcomes (pain intensity/interference) (b) participation in this treatment is associated with reduced PTSD symptoms, and (c) any observed changes in PTSD symptoms are mediated by changes in psychological mechanisms that have been shown to be of importance to PTSD and chronic pain. Methods: Participants were 159 chronic pain patients who were consecutively admitted for a multidisciplinary, group‐based CBT program at the Pain Rehabilitation Unit at Skåne University Hospital. A self‐report measure of traumatic exposure and PTSD symptoms was administered before and after treatment, and at a 12‐month follow‐up, along with measures of depression, anxiety, pain intensity, pain interference, psychological inflexibility, life control, and kinesiophobia. Results: Traumatic exposure and PTSD symptom severity did not predict pain intensity or interference at 12‐month follow‐up. There were no overall significant changes in PTSD symptom severity at post‐treatment or follow‐up, but 24.6% of the participants showed potential clinically significant change at follow‐up. Psychological inflexibility mediated the changes that occurred in PTSD symptoms during treatment. Conclusions: Neither traumatic exposure nor baseline symptoms of PTSD predicted the treatment outcomes examined here. Despite improvements in both comorbid depression and anxiety, participation in this pain‐focused CBT program was not associated with improvements in comorbid PTSD. To the extent that changes in PTSD symptoms did occur, these were mediated by changes in psychological inflexibility during treatment. Significance: Pain‐focused CBT programs yield clinically meaningful improvements in pain and comorbid symptoms of depression and anxiety, but may have little effect on comorbid PTSD. This raises the issue of whether current pain‐focused CBT programs can be modified to improve outcomes for comorbid conditions, perhaps by better targeting of psychological flexibility, and/or whether separate treatment of PTSD may be associated with improved pain outcomes

Prolonged exposure for pain and comorbid PTSD: A single-case experimental study of a treatment supplement to multiprofessional pain rehabilitation

It is unclear how to address PTSD in the context of chronic pain management. Here we examine the potential benefits of an addition of prolonged exposure (PE) therapy for PTSD for adults attending multidisciplinary CBT for chronic pain. Four adults seeking treatment for chronic pain from a specialized pain rehabilitation service were offered PE for PTSD using a replicated, randomized, single-case experimental phase design, prior to commencing a 5-week multidisciplinary CBT program for chronic pain. Pre-, post-, follow-up, and daily measures allowed examination of PTSD and pain outcomes, potential mediators, and the trajectory of these outcomes and potential mediators during the subsequent pain-focused CBT program. Visual inspection of the daily data demonstrated changes in all outcome variables and potential mediators during the PE phase. Changes came at different times and at different rates for the four participants, highlighting the individual nature of putative change mechanisms. Consistent with expectation, PE produced reliable change in the severity of PTSD symptoms and trauma-related beliefs for all four participants, either by the end of the PE phase or the PE follow-up, with these gains maintained by the end of the 5-week pain-focused CBT program. However, few reductions in pain intensity or pain interference were seen either during the PE phase or after. Although "disorder specific"approaches have dominated the conceptualising, study, and treatment of conditions like PTSD and chronic pain, such approaches may not be optimal. It may be better instead to approach cases in an individual and process-focused fashion

A Validation and Generality Study of the Committed Action Questionnaire in a Swedish Sample with Chronic Pain

Purpose Psychological flexibility is the theoretical model that underpins Acceptance Commitment Therapy (ACT). There is a growing body of evidence indicating that ACT is an effective treatment for chronic pain but one component of the model, committed action, has not been sufficiently researched. The purpose of this study is to validate Swedish-language versions of the full length Committed Action Questionnaire (CAQ; CAQ-18) and the shortened CAQ (CAQ-8), to examine the generality of previous results related to committed action and to further demonstrate the relevance of this construct to the functioning of patients with chronic pain. Method The study includes preliminary analyses of the reliability and validity of the CAQ. Participants were 462 consecutive referrals to the Pain Rehabilitation Unit at Skåne University Hospital. Results The Swedish-language versions of the CAQ (CAQ- 18 and CAQ-8) demonstrated high levels of internal consistency and satisfactory relationships with various indices of patient functioning and theoretically related concepts. Confirmatory factor analyses showed that the Swedish versions of the CAQ yielded similar two-factor models as found in the original validation studies. Hierarchical regression analyses identified the measures as significant contributors to explained variance in patient functioning. Conclusion The development, translation and further validation of the CAQ is an important step forward in evaluating the utility of the psychological flexibility model to the treatment of chronic pain. The CAQ can both assist researchers interested in mediators of chronic pain treatment and further enable research on change processes within the psychological flexibility model

Prolonged exposure for pain and comorbid PTSD : a single-case experimental study of a treatment supplement to multiprofessional pain rehabilitation

Objectives: It is unclear how to address PTSD in the context of chronic pain management. Here we examine the potential benefits of an addition of prolonged exposure (PE) therapy for PTSD for adults attending multidisciplinary CBT for chronic pain. Methods: Four adults seeking treatment for chronic pain from a specialized pain rehabilitation service were offered PE for PTSD using a replicated, randomized, single-case experimental phase design, prior to commencing a 5-week multidisciplinary CBT program for chronic pain. Pre-, post-, follow-up, and daily measures allowed examination of PTSD and pain outcomes, potential mediators, and the trajectory of these outcomes and potential mediators during the subsequent pain-focused CBT program. Results: Visual inspection of the daily data demonstrated changes in all outcome variables and potential mediators during the PE phase. Changes came at different times and at different rates for the four participants, highlighting the individual nature of putative change mechanisms. Consistent with expectation, PE produced reliable change in the severity of PTSD symptoms and trauma-related beliefs for all four participants, either by the end of the PE phase or the PE follow-up, with these gains maintained by the end of the 5-week pain-focused CBT program. However, few reductions in pain intensity or pain interference were seen either during the PE phase or after. Conclusions: Although "disorder specific" approaches have dominated the conceptualising, study, and treatment of conditions like PTSD and chronic pain, such approaches may not be optimal. It may be better instead to approach cases in an individual and process-focused fashion

Further validation of the Chronic Pain Values Inventory in a Swedish chronic pain sample

PurposeValue based action is an important process in the psychological flexibility model and is associated with daily functioning in people with chronic pain, but measures of it are not well-developed. The purpose of the present study was to examine the reliability and validity of a Swedish-language version of the Chronic Pain Values Inventory (CPVI) in a large sample of adults seeking treatment for chronic pain.Material and methodsA Swedish version of the CPVI was created and administered alongside other measures of psychological flexibility and pain-related functioning in a convenience sample of 232 patients admitted for treatment at the Pain Rehabilitation Unit at Skåne University Hospital between February 2014 and December 2015. Internal consistency of the CPVI was assessed as was its relationship to theoretically related facets from the psychological flexibility model. The utility of values-related processes in explaining variance in pain-related functioning was also examined by correlations and hierarchical regression analyses.ResultsOverall, this Swedish-language version of the CPVI was found to have satisfactory reliability and validity. The CPVI subscales yielded high levels of internal consistency. Evidence of construct validity in relation to other measures from the psychological flexibility model was observed as well as evidence of clinical utility in relation to measures of pain-related functioning.DiscussionThis brief self-report measure of values-based action seems to yield valid data in Swedish adults suffering from chronic pain. Values based processes appear important within evidence-based treatments for chronic pain, especially Acceptance and Commitment Therapy (ACT), and the CPVI may help assess these, particularly in predictor studies of pain-related functioning and analyses of therapeutic change processes or mechanisms

Acceptance : A factor to consider in persistent pain after neck trauma

Studies on the interaction between acceptance and pain-related processes after neck trauma are to our knowledge sparse and such treatment strategies are rarely incorporated in management and treatment of posttraumatic neck pain. Thus, the aim of the present study is to investigate how acceptance relates to persistent pain in patients after neck trauma, when controlling for the influence of other psychological factors, trauma characteristics and demographic variables. Consecutive patients with persistent pain and disability after neck trauma (n = 565) were assessed by a multi-professional team at a specialized pain rehabilitation clinic. Separate regression analyses were conducted with three outcomes: pain distribution, pain interference, and pain severity. Predictors were age, sex, education, time since trauma, type of trauma, anxiety, depression, and acceptance. Acceptance was the only factor associated with all outcomes, and patients with lower acceptance displayed more widespread pain and greater interference and severity of pain. The results also showed that higher depression was associated with worse pain interference and severity, whilst anxiety only mattered significantly for pain severity and not for pain interference. Female sex was related to more widespread pain and greater pain interference. Overall acceptance stood out as the most important factor for the different outcomes and lower acceptance was associated with more widespread pain distribution and greater pain interference and severity. The findings of this study add to a growing body of literature confirming that the development of chronicity after neck trauma should be understood as a multidimensional process, best described by a biopsychosocial model. The results also suggest that psychological factors and especially acceptance might be important processes with implications for enhanced recovery after neck trauma

A network analysis of clinical variables in chronic pain: a study from the Swedish quality registry for pain rehabilitation (SQRP)

Background. Efforts to identify specific variables that impact most on outcomes from interdisciplinary pain rehabilitation are challenged by the complexity of chronic pain. Methods to manage this complexity are needed. The purpose of the study was to determine the network structure entailed in a set of self-reported variables, examine change, and look at potential predictors of outcome, from a network perspective. Methods. In this study we apply network analysis to a large sample of people seeking interdisciplinary pain treatment (N = 2,241). Variables analyzed include pain intensity, pain interference, extent of pain, depression, anxiety, insomnia, and psychological variables from cognitive behavioral models of chronic pain. Results. We found that Acceptance, Pain Interference, and Depression were key, “central,” variables in the pretreatment network. Interestingly, there were few changes in the overall network configuration following treatment, specifically with respect to which variables appear most central relative to each other. On the other hand, Catastrophizing, Depression, Anxiety, and Pain Interference each became less central over time. Changes in Life Control, Acceptance, and Anxiety were most strongly related to changes in the remainder of the network as a whole. Finally, no network differences were found between treatment responders and non-responders. Conclusions. This study highlights potential future targets for pain treatment. Further application of a network approach to interdisciplinary pain rehabilitation data is recommended. Going forward, it may be better to next do this in a more comprehensive theoretically guided fashion, and ideographically, to detect unique individual differences in potential treatment processes