Chronic Pain and PTSD: Developing an Integrated Treatment Approach John D. Otis, Ph.D. VA Boston Healthcare System Boston, MA

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

Images of Pain

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 person’s life.

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.

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

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 I’m 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

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

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.

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 (n=65). 50

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.

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.”

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

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. A Need for Research

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

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.

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

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

Assessment Measures Pain PTSD Affective Distress Physical Functioning/Disability Catastrophizing & anxiety sensitivity Post- treatment 6-Month Follow-up 12 sessions Pre- treatment

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 1.CBT-Pain 2.CBT-PTSD 3.CBT-PTR 4.Wait-List

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.

Treatment Components 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 CBT for PainCBT for PTSD

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

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

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

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), 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.