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Support for the mutual maintenance of pain and post-traumatic stress disorder symptoms

  • A. Liedl (a1) (a2), M. O'Donnell (a3) (a4) (a5), M. Creamer (a3) (a4), D. Silove (a6), A. McFarlane (a7), C. Knaevelsrud (a2) (a8) and R. A. Bryant (a6)...



Pain and post-traumatic stress disorder (PTSD) are frequently co-morbid in the aftermath of a traumatic event. Although several models attempt to explain the relationship between these two disorders, the mechanisms underlying the relationship remain unclear. The aim of this study was to investigate the relationship between each PTSD symptom cluster and pain over the course of post-traumatic adjustment.


In a longitudinal study, injury patients (n=824) were assessed within 1 week post-injury, and then at 3 and 12 months. Pain was measured using a 100-mm Visual Analogue Scale (VAS). PTSD symptoms were assessed using the Clinician-Administered PTSD Scale (CAPS). Structural equation modelling (SEM) was used to identify causal relationships between pain and PTSD.


In a saturated model we found that the relationship between acute pain and 12-month pain was mediated by arousal symptoms at 3 months. We also found that the relationship between baseline arousal and re-experiencing symptoms, and later 12-month arousal and re-experiencing symptoms, was mediated by 3-month pain levels. The final model showed a good fit [χ2=16.97, df=12, p>0.05, Comparative Fit Index (CFI)=0.999, root mean square error of approximation (RMSEA)=0.022].


These findings provide evidence of mutual maintenance between pain and PTSD.


Corresponding author

*Address for correspondence: A. Liedl, Treatment Centre for Torture Victims Berlin (bzfo), Research Department, Turmstrasse 21, 10559 Berlin, Germany. (Email:


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Andreski, P, Chilcoat, H, Breslau, N (1998). Post-traumatic stress disorder and somatization symptoms: a prospective study. Psychiatry Research 79, 131138.
Arbuckle, JL (2005). Amos™ 6.0 User's Guide. Amos Development Corporation: Spring House, PA.
Bair, MJ, Robinson, RL, Katon, W, Kroenke, K (2003). Depression and pain comorbidity: a literature review. Archives of Internal Medicine 163, 24332445.
Baker, SP, O'Neil, B, Haddon, W, Long, WB (1974). The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. Journal of Trauma 14, 187196.
Beesdo, K, Jacobi, F, Hoyer, J, Low, N, Höfler, M, Wittchen, H-U (2009). Pain associated with anxiety and depressive disorders in a nationally representative population sample. Social Psychiatry and Psychiatric Epidemiology. Published online: 10 April 2009. doi: 10.1007/s00127-009-0045-1.
Bentler, PM (1990). Comparative fit indexes in structural models. Psychological Bulletin 107, 238246.
Blake, DD, Weathers, FW, Nagy, LM, Kaloupek, DG, Charney, DS, Keane, TM (1998). Clinician-Administered PTSD Scale for DSM-IV. National Center for Posttraumatic Stress Disorder: Boston, MA.
Browne, MW, Cudeck, R (1993). Alternative ways of assessing model fit. In Testing Structural Equation Models (ed. Long, K. A. B. J. S.), pp. 136162. Sage: Newbury Park, CA.
Bryant, RA, Harvey, AG (1995). Processing threatening information in posttraumatic stress disorder. Journal of Abnormal Psychology 104, 537541.
Bryant, RA, Marosszeky, JE, Crooks, J, Baguley, I, Gurka, J (1999). Interaction of posttraumatic stress disorder and chronic pain following traumatic brain injury. Journal of Head Trauma Rehabilitation 14, 588594.
Burns, JW (2006). Arousal of negative emotions and symptom-specific reactivity in chronic low back pain patients. Emotion 6, 309319.
Campbell, DG, Felker, BL, Liu, CF, Yano, EM, Kirchner, JE, Chan, D, Rubenstein, LV, Chaney, EF (2007). Prevalence of depression–PTSD comorbidity: implications for clinical practice guidelines and primary care-based interventions. Journal of General Internal Medicine 22, 711718.
Clapp, JD, Beck, JG, Palyo, SA, Grant, DM (2008). An examination of the synergy of pain and PTSD on quality of life: additive or multiplicative effects? Pain 138, 301309.
Cook, AJ, Brawer, PA, Vowles, KE (2005). The fear-avoidance model of chronic pain: validation and age analysis using structural equation modeling. Pain 21, 195206.
Creamer, M, Burgess, P, McFarlane, AC (2001). Post-traumatic stress disorder: findings from the Australian National Survey of Mental Health and Well-being. Psychological Medicine 31, 12371247.
de Leeuw, R, Schmidt, JE, Carlson, CR (2005). Traumatic stressors and post-traumatic stress disorder symptoms in headache patients. Headache 45, 13651374.
Dirkzwager, AJE, Van Der Velden, PG, Grievink, L, Yzermans, CJ (2007). Disaster-related posttraumatic stress disorder and physical health. Psychosomatic Medicine 69, 435440.
Finney, SJ, DiStefano, C (2006). Non-normal and categorical data in structural equation modeling. In Structural Equation Modeling: A Second Course (ed. Hancock and, G. R.Mueller, R. O.), pp. 269314. Information Age Publishing: Greenwich, CT.
Harvey, AG, Bryant, RA, Rapee, RM (1996). Preconscious processing of threat in posttraumatic stress disorder. Cognitive Therapy and Research 20, 613623.
Heim, C, Ehlert, U, Hellhammer, DH (2000). The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders. Psychoneuroendocrinology 25, 135.
Jenewein, J, Moergeli, H, Wittmann, L, Büchi, S, Kraemer, B, Schnyder, U (2009). Development of chronic pain following severe accidental injury. Results of a 3-year follow-up study. Journal of Psychosomatic Research 66, 119126.
Jensen, MP, Karoly, P, Braver, S (1986). The measurement of clinical pain intensity: a comparison of six methods. Pain 27, 117126.
Kessler, RC, Sonnega, A, Bromet, E, Hughes, M, Nelson, CB (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry 52, 10481060.
Korte, SM, Koolhaas, JM, Wingfield, JC, McEwen, BS (2005). The Darwinian concept of stress: benefits of allostasis and costs of allostatic load and the trade-offs in health and disease. Neuroscience and Biobehavioral Reviews 29, 338.
Leeuw, M, Goossens, MEJB, Linton, SJ, Crombez, G, Boersma, K, Vlaeyen, JWS (2007). The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. Journal of Behavioral Medicine 30, 7794.
Lethem, J, Slade, P, Troup, J, Bentley, G (1983). Outline of a fear avoidance model of exaggerated pain perception – I. Behaviour Research and Therapy 21, 401408.
Liedl, A, Knaevelsrud, C (2008). Chronic pain and PTSD: the Perpetual Avoidance Model and its treatment implications. Torture 18, 6976.
McBeth, J, Silman, AJ, Gupta, A, Chiu, YH, Ray, D, Morriss, R, Dickens, C, King, Y, Macfarlane, GJ (2007). Moderation of psychosocial risk factors through dysfunction of the hypothalamic-pituitary-adrenal stress axis in the onset of chronic widespread musculoskeletal pain. Arthritis and Rheumatism 56, 360371.
McEwen, BS (2000). The neurobiology of stress: from serendipity to clinical relevance. Brain Research 886, 172189.
McFarlane, AC (2007). Stress-related musculoskeletal pain. Best Practice and Research in Clinical Rheumatology 21, 549565.
McFarlane, AC, Ellis, N, Barton, C, Browne, D, Van Hooff, M (2008). The conundrum of medically unexplained symptoms: questions to consider. Psychosomatics 49, 369377.
Merskey, H, Bogduk, N (1994). Classification of Chronic Pain. IASP Task Force on Taxonomy: Seattle.
Moores, KA, Clark, CR, McFarlane, AC, Brown, GC, Puce, A, Taylor, DJ (2008). Abnormal recruitment of working memory updating networks during maintenance of trauma-neutral information in post-traumatic stress disorder. Psychiatry Research 163, 156170.
Mueller, J, Karl, A, Denke, C, Mathier, F, Dittmann, J, Rohleder, N, Knaevelsrud, C (2009). Chronic pain in survivors of war and torture with PTSD – clinical relevance and preliminary findings on the feasibility of CBT-biofeedback. Cognitive Behaviour Therapy. Published online: 12 August 2009. doi: 10.1080/16506070902815024.
Norman, SB, Stein, MB, Dimsdale, JE, Hoyt, DB (2008). Pain in the aftermath of trauma is a risk factor for post-traumatic stress disorder. Psychological Medicine 38, 533542.
Norton, P, Asmundson, G (2003). Amending the fear-avoidance model of chronic pain: what is the role of physiological arousal? Behavior Therapy 34, 1730.
O'Donnell, M, Creamer, M, Pattison, P, Atkin, C (2004). Psychiatric morbidity following injury. American Journal of Psychiatry 161, 507514.
O'Donnell, ML, Bryant, RA, Creamer, M, Carty, J (2008). Mental health following traumatic injury: toward a health system model of early psychological intervention. Clinical Psychology Review 28, 387406.
Otis, JD, Keane, TM, Kerns, RD (2003). An examination of the relationship between chronic pain and post-traumatic stress disorder. Journal of Rehabilitation Research and Development 40, 397405.
Pillemer, S, Bradley, L, Crofford, L, Moldofsky, H, Chrousos, GP (1997). The neuroscience and endocrinology of fibromyalgia. Arthritis and Rheumatism 40, 19281939.
Roberts, NP, Kitchiner, NJ, Kenardy, J, Bisson, JI (2009). Systematic review and meta-analysis of multiple-session early interventions following traumatic events. American Journal of Psychiatry 166, 293301.
Roelofs, J, Peters, ML, Vlaeyen, JW (2002). Selective attention for pain-related information in healthy individuals: the role of pain and fear. European Journal of Pain 6, 331339.
Roth, RS, Geisser, ME, Bates, R (2008). The relation of post-traumatic stress symptoms to depression and pain in patients with accident-related chronic pain. Journal of Pain 9, 588596.
Rubacka, JM, Schmeidler, J, Nomura, Y, Luthra, R, Rajendran, K, Abramovitz, R, Chemtob, CM (2008). The relationship between PTSD arousal symptoms and depression among mothers exposed to the World Trade Center attacks. Journal of Nervous and Mental Disease 196, 504507.
Sareen, J, Cox, BJ, Stein, MB, Afifi, TO, Fleet, C, Asmundson, GJG (2007). Physical and mental comorbidity, disability, and suicidal behavior associated with posttraumatic stress disorder in a large community sample. Psychosomatic Medicine 69, 242248.
Schermelleh-Engel, K, Moosbrugger, H, Mueller, H (2003). Evaluating the fit of structural equation models: tests of significance and descriptive goodness-of-fit measures. Methods of Psychological Research Online 8, 2374.
Sharp, TJ, Harvey, AG (2001). Chronic pain and posttraumatic stress disorder: mutual maintenance? Clinical Psychology Review 21, 857877.
Shipherd, JC, Keyes, M, Jovanovic, T, Ready, DJ, Baltzell, D, Worley, V, Gordon-Brown, V, Hayslett, C, Duncan, E (2007). Veterans seeking treatment for posttraumatic stress disorder: what about comorbid chronic pain? Journal of Rehabilitation Research and Development 44, 153165.
Staud, R, Craggs, JG, Robinson, ME, Perlstein, WM, Price, DD (2007). Brain activity related to temporal summation of C-fiber evoked pain. Pain 129, 130142.
Villano, CL, Rosenblum, A, Magura, S, Fong, C, Cleland, C, Betzler, TF (2007). Prevalence and correlates of posttraumatic stress disorder and chronic severe pain in psychiatric outpatients. Journal of Rehabilitation Research and Development 44, 167177.
Vlaeyen, J, Linton, S (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 85, 317332.
Vlaeyen, JWS, Kole-Snijders, AMJ, Boeren, RGB, van Eek, H (1995). Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain 62, 363372.
Wall, PD, Melzack, R (1999). Textbook of Pain. Churchill Livingstone: Edinburgh.
Weathers, FW, Keane, TM, Davidson, J (2001). Clinician-administered PTSD scale: a review of the first ten years of research. Depression and Anxiety 13, 132156.
Whalley, MG, Farmer, E, Brewin, CR (2007). Pain flashbacks following the July 7th 2005 London bombings. Pain 132, 332336.
Zatzick, DF, Jurkovich, GJ, Gentilello, L, Wisner, D, Rivara, FP (2002). Posttraumatic stress, problem drinking, and functional outcomes after injury. Archives of Surgery 137, 200205.


Support for the mutual maintenance of pain and post-traumatic stress disorder symptoms

  • A. Liedl (a1) (a2), M. O'Donnell (a3) (a4) (a5), M. Creamer (a3) (a4), D. Silove (a6), A. McFarlane (a7), C. Knaevelsrud (a2) (a8) and R. A. Bryant (a6)...


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