Chronic Pain and PTSD: Evolving Views on Their Comorbidity

Abstract

PurposeThis paper presents a literature review of post-traumatic stress disorder (PTSD) and its link to chronic pain.Design and Methods
Twenty-four papers are reviewed (included research and reviews), with the goal of improving and updating our understanding on this issue and its theoretical and clinical repercussions.FindingsThe tight interdependence of symptoms that can be observed in both PTSD and chronic pain syndromes lends support to the idea that these disorders both constitute a reactive disorder.Practice ImplicationsVarious forms of therapy and treatment focus on PTSD, but chronic pain symptoms must also be assessed.

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Chronic Pain and PTSD: Evolving Views on Their Comorbidity
Marie-Jo Brennstuhl, PhD, Cyril Tarquinio, Phd, Pr., and Sebastien Montel, PhD, Pr.
Marie-Jo Brennstuhl, PhD, is Doctor of Psychology, Psychologist Laboratory APEMAC EA 4360, University of Lorraine, Metz, France; Cyril Tarquinio,
PhD, Pr., is Professor, Laboratory APEMAC EA4360, University of Lorraine, Metz, France; and Sebastien Montel, PhD, Pr., is Professor, Laboratory LPN
EA2027, University of Paris 8, Saint-Denis, France.
Search terms:
Chronic pain, clinical practice, comorbidity,
PTSD, review
Author contact:
mjo.b@live.fr, with a copy to the Editor:
gpearson@uchc.edu
Conflict of Interest Statement
The authors report no actual or potential
conflicts of interest. No external or intramural
funding was received.
First Received February 17, 2014; Final Revision
received September 27, 2014; Accepted for
publication October 23, 2014.
doi: 10.1111/ppc.12093
PURPOSE: This paper presents a literature review of post-traumatic stress disorder
(PTSD) and its link to chronic pain.
DESIGN AND METHODS: Twenty-four papers are reviewed (included research
and reviews), with the goal of improving and updating our understanding on this
issue and its theoretical and clinical repercussions.
FINDINGS: The tight interdependence of symptoms that can be observed in both
PTSD and chronic pain syndromes lends support to the idea that these disorders
both constitute a reactive disorder.
PRACTICE IMPLICATIONS: Various forms of therapy and treatment focus on
PTSD, but chronic pain symptoms must also be assessed.
Over 50 years ago, Beecher (1959) paved the way toward a
new understanding of pain by putting an end to the mind-
body dichotomy and adopting a biopsychosocial view of
pain. Today, pain is understood in terms of four basic com-
ponents: sensory, cognitive, behavioral, and emotional. The
complexity of pain treatment lies in the need to take a global
approach to the individual and his/her pathology and to call
upon pluridisciplinary practices in considering post-
traumatic stress disorder (PTSD) and chronic pain as reac-
tive disorders.
The International Association for the Study of Pain (IASP)
defines pain as “an unpleasant sensory and emotional experi-
ence associated with actual or potential tissue damage, or
described in terms of such damage” (Merskey & Bogduk,
1994). Pain that persists beyond 3–6 months and does not
respond to standard treatment is called chronic.
Along with theoretical and scientific advancements in
treating and understanding pain, the field of trauma has seen
an upsurge of interest within the scientific and clinical com-
munity. The term “war neurosis”(also called shell shock) has
been supplanted by “post-traumatic stress disorder,” the
name generally used today. On the basis of DSM-IV-R crite-
ria, published by the American Psychiatric Association
(2000), this syndrome belongs to the set of anxiety disorders.
It is characterized by specific symptoms that appear following
a traumatic event in which the subject comes face-to-face
with death. Intrusive memories and reviviscence appear, asso-
ciated with avoidance, dulled emotions, and neurovegetative
hyperactivity. The symptoms must last longer than a month
following the event, and must significantly alter the individu-
al’s social activity. The domain of psychotrauma has been
expanded to include other stressful life experiences such as
chronic illness, mourning, microtrauma, and pain. An inter-
esting clinical case published by Grande, Loeser, Ozuna,
Ashleigh, and Samii (2004) showed how pain exacerbation
and PTSD can be intermingled. Whalley, Farmer, and Brewin
(2007) reported another case where flashbacks of the trauma
caused the person to experience pain.
Two pioneering articles have provided the guidelines for
future studies (Asmundson, Coons, Taylor, & Klatz, 2002;
Sharp & Harvey, 2001). In their 2001 review, Sharp and
Harvey were the first to examine publications pertaining to
the comorbidity of PTSD and chronic pain, noticing a real
lack of research in this area. In terms of prevalence, they noted
the presence of chronic pain in 20–80% of trauma cases, and
PTSD in 10–50% of chronic pain cases. These initial results
thus supplied some preliminary evidence of a comorbidity
link between the two syndromes.
Based on these findings, Sharp and Harvey proposed a
series of seven processes likely to account for the mutual
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maintenance of PTSD and chronic pain. The first is
“attentional biases,” where painful sensations remind the
patient of the trauma on a recurring basis. The second,
“anxiety sensitivity,” is seen as being capable of sustaining
PTSD/chronic pain comorbidity through the interpretation
of sensations. In other words, PTSD-linked anxiety contrib-
utes to maintaining the individual’s beliefs that the pain is
harmful, thereby worrying the sufferer even more. The third
process concerns “persistent reminders of the trauma.”Here,
chronic pain is seen as a reviviscence of the trauma (as in
flashbacks), which sustains the connection between the
physical sensation and the trauma. The fourth process,
“avoidant coping style” or escape coping, has to do not only
with the chronic pain sufferer’s inability to carry out certain
physical activities, which triggers a deconditioning process,
but also the avoidance behavior characteristic of PTSD.
“Depression and reduced levels of behavioral activity” is the
fifth mutual-maintenance factor responsible for sustaining
incapacitation on the chronic pain side and trauma avoidance
on the PTSD side. In sixth position, we find “pain perception,”
which is intensified by anxiety and increases the patient’s level
of perceived pain, emotional distress, and disability. Lastly,
because the “cognitive resources” needed to manage chronic
pain and PTSD are depleted, there are few capacities left for
developing more adaptive strategies. All of these factors point
out the highly interdependent nature of PTSD and chronic
pain, each syndrome contributing to maintaining or even
aggravating the symptoms of the other (Sharp & Harvey,
2001, pp. 862–863).
Similarly, Asmundson et al. (2002) published a review a
year later and proposed a model for understanding the
PTSD/pain link based on vulnerability and the role of
anxiety. In the model, anxiety sensitivity increases the indi-
vidual’s alertness during the stressful event. This, in turn,
makes the person even more predisposed to developing
PTSD by way of awareness of the threat—and also the
risk—of chronic pain due to bodily injury. However, unlike
Sharp and Harvey, who regard anxiety sensitivity as a factor
that maintains the PTSD/chronic pain association,
Asmundson et al. see it as a predisposition to the onset of the
two syndromes and their comorbidity. Making the distinc-
tion between “etiological vulnerability” and “maintenance
factor” is nonetheless fundamental.
Is the link between PTSD and pain the result of a
comorbidity, a cause-and-effect relation, or aggravation
factors? Is pain a forgotten symptom in the nosology of
PTSD? According to Sharp and Harvey (2001), it is a
comorbidity relation, with chronic pain and PTSD being
mutually maintained by various factors including patholo-
gies like depression and anxiety. Should these pathologies be
considered as maintenance factors, as the authors suggest, or
are they comorbid disorders too? For Asmundson et al.
(2002), it is more a problem of developing a description of an
etiological vulnerability that can explain the onset and
comorbidity of chronic pain and PTSD. But even this would
not explain why the two disorders develop in parallel,not how
they are mutually maintained.
The research conducted in the years that followed fur-
thered these early models (Beck & Clapp, 2011), but the ques-
tion of the link remains a predominant one. Globally, we can
subdivide the studies into several categories: some tend to see
a comorbidity link between diagnoses of PTSD and chronic
pain; others look for mediators—such as anxiety or
depression—likely to account for the persistence of this
comorbidity. Still others focus on the complex etiology
between trauma and certain painful pathologies such as
fibromyalgia.
Aims and Methods
In this paper,comorbidity of chronic pain and PTSD was ana-
lyzed by reviewing the studies published following Sharp and
Harvey (2001) and Asmundson et al.’s (2002) original work.
Beyond a comorbidity link, are these two syndromes interwo-
ven in a way that is more complex than mere symptom
cohabitation? The etiology of the traumatic experience seems
to provide a fruitful avenue of research where pain appears as
a reactive manifestation that is PTSD-like but lies at the
somatic level.
Papers were selected through the following process. Only
studies (included research, reviews, and case studies) pub-
lished between 2000 and 2013 were considered for review
given advancements made around the theories proposed by
Sharp and Harvey (2001) and Asmundson et al. (2002). The
databases PsycINFO, PubMed, and ScienceDirect were
queried using the keywords “chronic pain” and “PTSD.” This
first query yielded 960 articles (Figure 1).
Only the adult population was included. The focus on
persistent pain called “chronic,” without a direct link to a
physical deterioration, suggests the need to seek a psycho-
logical understanding of the problem. Accordingly, papers
referring to physical illnesses with a large impact on the
experience of pain were excluded. Papers about acute pain
were eliminated if they involved a chronic illness or pallia-
tive treatment. Furthermore, eliminated papers were dealing
with PTSD and chronic pain accompanied by other symp-
toms, without an identified link mentioned (other than the
presence of or an increase or decrease in symptoms).
Although very useful in other cases, these papers were not
helpful in addressing the question of comorbidity between
these two syndromes.
Table 1 gives the results of the analysis according to
retained criteria. Studies were heterogeneous as to the popu-
lations, type of pain, type of trauma, and sample size.
However, all of them attempted to gain insight into the
comorbidity link between chronic pain and PTSD from one
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of three perspectives: pain as a cause of the development of
PTSD, PTSD as a cause of the development of chronic pain,
and various comorbidities linked to the maintenance of
chronic pain and PTSD.
A total of 24 research papers comprised the review.All pro-
posed a particular understanding of the link between chronic
pain and PTSD.Table 2 was organized around five criteria for
analysis: source (authors’ names, publication date and
journal, discipline or department, and country), study aims,
topic addressed, sample,and methodology and results.
Results
The first step in the analysis was to develop an overview of
current views on the link between chronic pain and PTSD,
reviewing prevalence and measurement tools. Differing
points of view and contrasting explanatory theories were
evaluated. Is pain an aggravation factor or cause of the onset
of PTSD, or is it the onset of PTSD that causes the painful syn-
drome to become chronic? Finally, how do secondary
disorders like anxiety and depression maintain the
comorbidity of chronic pain and PTSD?
Chronic Pain and PTSD: Prevalence and Measures
Recent epidemiological studies offer some new information
about the prevalenceof comorbid chronic pain andPTSD. The
National Comorbidity Replication Survey reported that 7.3%
of individuals with chronic lower back pain meet the criteria
for PTSD (VonKorff et al., 2005). Similarly, the Canadian
Community Health Survey noted a 7.7% prevalence rate of
PTSD among fibromyalgia patients, and a rate as high as 46%
among persons with chronic lower back pain (Sareen et al.,
2007). Shipherd et al. (2007) found a chronic pain prevalence
rate of 66% (including lower back pain and osteoarthritis)
among veterans suffering from PTSD. Other studies have
looked at the percentage of chronic pain sufferers (especially
fibromyalgia) among PTSD patients;in a study by Amital et al.
(2006) on men, fibromyalgia was found in 45% of the PTSD
patients, 5%of the depression patients,and 0% of the controls.
Literature search
Databases : PudMed, PsycINFO,
ScienceDirect
Search results combined (n = 960)
Articles screened on basis of title
and abstract
Included (n = 32)
Included (n = 24)
Manuscript review and application
of inclusion criteria
Excluded (n = 928)
Referring to physical illnesses : 434
Acute pain : 228
Palliative type of treatment : 138
PTSD, chronic pain and other
symptoms (link not mentioned) : 128
Excluded (n = 8)
Not found : 2
Not usable to answer research
questions : 6
Follow-up
of link evolution (n = 8)
Pain → PTSD
(n = 7)
PTSD → Pain
(n = 5)
Comorbid
disorders (n = 4)
Figure 1. Literature Selection
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To date, no questionnaires have been developed to directly
measure the link between PTSD and chronic pain, not even
ones that measure their respective symptoms on the same
scale. Coffey, Gudmundsdottir, Beck, Palyo, and Miller
(2006) conducted an empirical study to explore this question.
For a group of 229 survivors of road accidents, the Impact
Event Scale and the PTSD Symptom Scale-Self-Report proved
to be good indicators of the impact of traumatic events on
chronic pain sufferers. Likewise, Poundja, Fikretoglu, Guay,
and Brunet (2007) showed that the Brief Pain Inventory
turned out to be a valid inventory for measuring pain among
veterans who had a traumatic war event.
Table 1. Main Characteristics of the Chronic
Pain/Trauma Comorbidity Studies Selected
Characteristics Breakdown of characteristics
Number of
articles selected
Types of pain All types of pain 16
Fibromyalgia 4
Diffuse pain 2
Lower back pain 3
Osteoarthritis 1
Burns 1
Trauma All types of PTSD 11
War 4
Road accidents 4
Childhood abuse 4
Burns 1
Topic of study Follow-up of link evolution 9
Pain →PTSD 7
PTSD →pain 5
Comorbid disorders 4
Population Persons who had a road accident 4
Veterans 4
Fibromyalgia patients 3
General population 4
Chronic pain sufferers 4
Persons who suffered from childhood violence 3
Anxiety-depression patients 2
Persons who had burns 1
Twins 1
Sample size Less than 50 1
50–99 5
100–149 4
150–499 2
500–999 1
1,000–1,999 4
2,000–3,000 1
5,000–10,000 2
Over 10,000 1
Over 35,000 1
Discipline or
department
Psychology 5
Psychiatry and human behavior 10
Physical medicine and rehabilitation 1
Veterans department 1
Physiotherapy department 2
Research department 2
Health 2
Country Australia 2
Canada 3
United States 14
Israel 2
Netherlands 2
Switzerland 1
PTSD, post-traumatic stress disorder.
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Table 2. Overview of Studies and Methodological Details
Authors Study aims Sample and methodology
Amital et al. (2006) Explore comorbidity of PTSD and fibromyalgia Sample: 124 men: 55 with PTSD, 20 with major depression, and 49 controls
Tools:SHQ, Sheehan Disability Scale, SF-36 (quality of life assessment), CAPS, HDRS,
FMS tenderness assessment
Arguelles et al. (2006) Explore the role of genetic factors in comorbidity of PTSD
and diffuse pain
Sample: 1,024 monozygotic twins, 828 dizygotic twins
Tools:IES and CWP
Clapp et al. (2008) Exploreeffects of chronic pain and PTSD comorbidity on
quality of life
Sample: 142 survivors of road accidents suffering from PTSD and chronic pain
Tools:WHYMPI, PSS-SR, QOLI
Coffey et al. (2006) Comparison of two PTSD assessment scales: IES and
PSS-SR
Sample: 229 survivors of road accidents, 43% of whom met PTSD criteria
Tools:IES and PSS-SR questionnaires
Defrin et al. (2008) Explore perception of pain among subjects suffering
from PTSD
Sample: 32 PTSD patients, 29 patients suffering from anxiety disorder, 20 controls
Tools:Diagnosis with DSM-IV-R, and scale from 0 to 10 assessing perception of pain
from stimuli
Gerrits et al. (2012) Longitudinal study on the impact of pain among patients
suffering from anxiety-depression disorders
Sample: 1,209 participants with anxiety disorders and/or depression followed up for
2 years
Tools:Chronic Pain Grade for pain, and CIDI for anxiety-depression disorders
Haviland et al. (2010) Explore the relationships between major life events,
traumatic experiences, and fibromyalgia diagnosis
Sample: 10,424 respondents (two-thirds women and one-third men)
Tools:Questionnaire on fibromyalgia symptoms, and presence of various types of
stressors or traumatic experiences
Jakupcak et al. (2006) Determine the link between anxiety sensitivity and
depression in order to understand somatic complaints
of veterans suffering from PTSD
Sample: 45 veterans suffering from PTSD
Tools:Self-reported ratings of anxiety sensitivity and depression
Jenewein et al. (2009) Longitudinal study on the onset of chronic pain and
comorbid disorders following road accidents involving
severe injuries
Sample: 90 individuals seriously injured in a road accident, 1-, 6-, 12-, and 36-month
follow-ups
Tools:CAPS for PTSD, SCL-90-R for psychological complaints, HAD, SOC for resilience
and coping skills
Lee (2010) Explore the link between childhood abuse,
neuroendocrine development and differences, stress
reactivity, and fibromyalgia diagnosis
Review of the literature
Mayou and Bryant (2001) Longitudinal study of consequences of traffic accidents 3
months and 1 year later
Sample: 1,148 individuals aged 17–69 having been in a road accident
Tools:Medical file, PSS-SR, and self-reports
McWilliams et al. (2003) Explore comorbidity links between mood disorders,
anxiety disorders, and chronic pain in a large cohort
Sample: 5,877 participants representative of national population
Tools:CIDI, self-reporting of pain
Otis et al. (2010) Study of the comorbid link between PTSD and chronic
pain.
Sample: 149 veterans participating in a pain-management program
Tools:PCL-M, BDI, MPQ, and WHYMPI
Poundja et al. (2006) Evaluate implications and role of depression in PTSD/pain
comorbidity
Sample: 130 veterans evaluated and treated for PTSD
Tools:Evaluation of PTSD, pain, and depression
Raphael and Spatz
Widom (2011)
Longitudinal study of the link between childhood abuse,
PTSD, and appearance of chronic pain 30 years later
Sample: 458 adults abused during childhood, 349 adult controls
Tools:DIS, different categories of abuse, and self-reporting of pain
Roth et al. (2008) Assess implications and role of depression in
PTSD/chronic pain comorbidity
Sample: Patients reporting symptoms of chronic pain
Tools:Assessment of PTSD, depression, and pain
Sachs-Ericsson et al. (2007) Explore links between childhood abuse, depression, and
chronic pain
Sample: 1,727 persons (National Comorbidity Survey)
Tools:Questions about type of abuse, pain, and health problems. CIDI for depression.
Sareen et al. (2007) Address comorbidities, disabilities, and suicidal behaviors
among patients suffering from PTSD.
Sample: 36,984 persons over age 15
Tools:Various mental disorders tested on CIDI, and measures of quality of life,
disabilities, and suicidal behavior
Shipherd et al. (2007) Evaluation of PTSD treatment among veterans Sample: 85 veterans treated for PTSD
Tools:Assessment of pain and symptoms of PTSD before and after treatment
Sterling et al. (2005) Prospective study of factors affecting development and
maintenance of chronic pain and disability. Six-month
follow-up of diffuse pain.
Sample: 76 persons suffering from diffuse pain
Tools:Initial assessment: motor functions, physiological responses, and psychological
disturbances (including IES). Neck Disability Index scores after 6 months.
Sterling and Kenardy (2006) Explore differences in sensitivity and reaction of central
nervous system among patients suffering from diffuse
pain with or without a post-traumatic reaction
Sample: 66 patients suffering from diffuse pain
Tools:Assessment of initial sensitivity, physiological response of nervous system, and
PTSD symptoms
Van Loey et al. (2003) Longitudinal study of predictive factors of PTSD onset
after severe burns
Sample: 301 persons hospitalized for burns, 66% exhibiting PTSD 3 weeks after
incident
Tools:Self-reporting of peritraumatic mental state, pain-related anxiety, and
post-trauma symptoms
VonKorff et al. (2005) Assessment of comorbidity links between lower back or
neck pain and psychological disorders
Sample: 5,692 adults from general population
Tools:Self-reporting of pain and CIDI for comorbid disorders
Zatzick et al. (2007) Study of link between physical injury and onset of PTSD
symptoms
Sample: 2,931 survivors of severe injuries, 3- and 12-month follow-ups
Tools:Evaluation of medical file and administration of PCL (PTSD CheckList) after 12
months
BDI, Beck Depression Inventory; CAPS, Clinician-Administered PTSD Scale; CBT, cognitive behavioral therapy; CIDI, Composite International Diagnosis Interview; CWP, Chronic Widespread
Pain; DIS, Mental Health Diagnosis Interview Schedule; HAD, Anxiety and Depression; HDRS, Hamilton Depression Rating Scale; IES, Impact Event Scale; MPQ, McGill Pain Questionnaire;
PCL-M, PTSD Check List-Military; PSS-SR, PTSD Symptom Scale-Self-Report; PTSD, post-traumatic stress disorder; QOLI, Quality of Life Inventory; SCL-90-R; 90-Item Revised Symptom Check-
list; SHQ, Sleep History Questionnaire; SOC, Sense of Coherence Scale; WHYMPI, West Haven-Yale Multidimensional Pain Inventory.
Chronic Pain and PTSD: Evolving Views on Their Comorbidity
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The potential roles of the family and genetic factors in
comorbid PTSD and diffuse pain were explored by Arguelles
et al. (2006) but the results were not conclusive. The authors
tested a large sample of monozygotic (n=1,042) and dizy-
gotic (n=828) twins. Although the two groups did not differ
significantly,there was a strong correlation between the diag-
nosis of PTSD and the presence of diffuse pain.
These studies suggest that measuring comorbidity between
chronic pain and PTSD is a difficult undertaking and involves
two contradictory approaches. On the one side, the preva-
lence of chronic pain is measured among PTSD patients; on
the other side, the prevalence of PTSD is measured among
chronic pain patients. The lack of syndrome-specific tools
complicates these measures even more.
Chronic Pain and PTSD: How Are They Linked?
Longitudinal studies have attempted to answer this question
by exploring the long-term link between chronic pain and
PTSD. In one study, 23% of individuals exhibited PTSD
symptoms 3 months after an accident, but this figure dropped
to 17% after 1 year (Mayou & Bryant, 2001). In the case of
injury, 7% of the injured individuals said that 3–12 months
later,they were still not back to normal. From the standpoint
of psychological rehabilitation, the severity of the injury
(along with the health problems it entailed) seemed to be a
significant predictor of PTSD after 1 year, when the preva-
lence of PTSD declines. A similar study by Zatzick et al.
(2007) but with more severely injured patients showed that
23% of the accident survivors were diagnosed with PTSD
after a year.One of the factors associated with PTSD was pain
severity, notably after 3 months, with symptoms of one or the
other evolving in parallel. Lastly, studies by Sterling and col-
leagues have looked more specifically at the changing trajec-
tories of pain and PTSD, here again, following a road
accident. In 2006, Sterling and Kenardy found evidence of an
association between initial sensitivity to pain and PTSD
symptoms 6 months after the accident. Pain severity might
play a significant role in post-trauma symptoms.
Unlike the above studies, Sterling, Jull, Vicenzino, Kenardy,
and Darnell’s (2005) study —one of an abundance of studies
on road accidents—showed that the initial symptoms of
trauma are predictors of a future incapacitation linked to
chronic pain. More recently, a 36-month follow-up of road
accidents resulting in serious injuries found not only that 44%
of the individuals were still suffering from pain after 36
months. They had more symptoms of PTSD, depression,
anxiety, disability, and medical leaves of absence from work
than those who were no longer enduring pain (Jenewein et al.,
2009).
These longitudinal studies have brought out a tight link
between pain and PTSD, and seem to show that the initially
perceived strength of injury-related pain is a good predictor
of the development of PTSD, just as the onset of PTSD
appears to predict the development of chronic pain. This
reciprocal interdependence is consistent with Sharp and
Harvey (2001) and Asmundson et al.’s (2002) initial theories
on the common factors mentioned above.
Chronic Pain, PTSD,and Other Comorbid Disorders
As a whole, pain appears to be comorbid with a number of
disorders. Although there is no doubt—whether in research
or clinical practice—about the existence of such links, the
nature of these intermingled connections is still a current
question. A recent study showed that while pain is strongly
correlated with anxiety-depression disorders, it is likely to
make these disorders more serious and lead to their chronic-
ity (Gerrits et al., 2012).
Anxiety disorders seem to play an important role in the
comorbidity of chronic pain and PTSD, as previously
described by Sharp and Harvey (2001) and Asmundson et al.
(2002). Jakupcaket al. (2006) supported these theor ies bysug-
gesting that anxiety sensitivity is a maintenance factor of
PTSD/chronic pain comorbidity. Among the various anxiety
disorders, panic disorder and PTSD were found to have
the highest degree of comorbidity with chronic pain
(McWilliams, Cox, & Enns, 2003). The presence of several
anxiety disorders was significantly associated with greater dis-
ability. Pain- or trauma-linked anxiety has also been shown to
be a good predictor of the severity and chronicity of painful
trauma-related disorders (Van Loey, Maas, Faber, & Taal,
2003). Van Loey et al.’s (2003) longitudinal study on 301
patients indicated that peritraumatic dissociation, pain-
related anxiety, injury severity, and gender were significant
predictors of PTSD severity 1 year later. In another study,
PTSD sufferers experienced more chronic pain, more severe
pain, and pain in more areas of the body than did persons with
asecondary anxietydisorder (or personsin the controlgroup).
Persons with PTSD may also exhibit greater sensitivity to
painful stimuli (Defrin et al., 2008).
Jakupcak et al. (2006) highlighted the role of depression in
maintaining PTSD/chronic pain comorbidity among veter-
ans. This was confirmed by several other studies (Otis et al.,
2010; Poundja, Fikretoglu, & Brunet, 2006). In their study,
Roth, Geisser, and Bates (2008) proposed a model linking
these different symptoms: PTSD is thought to be directly
associated with depression whereas depression would affect
both the pain’s intensity,and more indirectly,the individual’s
route toward disability. Future longitudinal studies are
needed to confirm these preliminary results.
In a literature review, Bob (2008) explored the links
between pain, dissociation, and self-representation, increas-
ing an understanding of pain from the neurophysiological
standpoint of dissociation. In this view, pain is regarded as an
unconscious modification of one’s self-representation within
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an episode of dissociation, which frequently occurs along
with the traumatic event. During the event, a somatic self-
identity would be created and dissociated from the subliminal
self-representation. The dissociative dimension is another
new angle for understanding trauma (Van der Hart,
Nijenhuis, & Steele, 2010).
PTSD, then, is likely linked to chronic pain. However,
certain types of traumas or events seem to be more likely than
others to trigger this reciprocal interdependence. In 2007,
Sachs-Ericsson, Kendall-Tackett, and Hernandez looked at
the connection between abuse in childhood and chronic pain
in adulthood. They found a greater proportion of health
problems, notably more pain and depression,among persons
reporting childhood abuse. Depression was strongly linked to
pain but was not found to be the mediating factor between
childhood abuse and the onset of pain. Lee (2010) explored
the relationship between childhood abuse, stress reactivity,
and neurobiological abnormalities. His review of the litera-
ture pointed out a significant association between childhood
abuse and a fibromyalgia diagnosis in adulthood. However,
he noted that childhood abuse may be an etiological factor
of fibromyalgia, given that abuse can lead to abnormal
neuroendocrine development, thereby increasing the stress
reactivity potentially related to the onset of fibromyalgia. Pre-
cisely in the case of fibromyalgia, a study on a very large
cohort (Haviland, Morton, Oda, & Fraser, 2010) showed that
a diagnosis of fibromyalgia was closely tied to two types of
trauma: sexual aggression and abuse, and physical aggression
and abuse. Psychological violence, neglect, and major life
events were not associated with fibromyalgia.
A retrospective studycovering a period of 30 years (Raphael
& Spatz Widom, 2011) pointedout some associations between
childhood abuse, PTSD, and pain in adulthood. Despite the
patients’ difficulty retrieving memories over such a long
period, childhood abuse was nonetheless found to be weakly
linked to a risk of adulthood pain. PTSD, on the other hand,
had higher correlations with childhood abuse and the risk of
adulthood pain. The combination of childhood abuse and
PTSD incurred a highly significant risk of chronic pain in
adulthood. PTSD, then, seems to be a mediator between trau-
matic experiences and the onset of chronic pain.
The importance of investigating this question becomes
quite clear when we consider the implications of these diverse
comorbidities on a patient’s quality of life (Clapp, Beck,
Palyo, & Grant, 2008). The association of PTSD and chronic
pain seems to have a greater impact on the quality of life of
persons who have had road accidents than each of these disor-
ders taken separately.
Discussion
Although there is strong evidence that PTSD and chronic
pain are linked, the nature of this complex link remains ill
defined. It is difficult to draw a straight line from the cause to
the effect in explaining the onset of one or the other of these
two syndromes. Depending on the population studied and
the disorder initially assessed, pain can contribute to the onset
of PTSD and also maintain it; the same holds true for PTSD,
which can act both as a triggering factor and a maintenance
factor of chronic pain. Investigators in this field have also
demonstrated the critical role of anxiety-depression disor-
ders as mediators of this comorbidity. No matter the nature of
the link, PTSD/chronic pain comorbidity seems to occupy a
place of its own in clinical practice.
It seems that DSM-V acknowledges the important part
played by pain in the new PTSD criteria proposed. Indeed,
criterion A (event exposure) has been extended to include
exposure to an actual or threatened severe injury (to oneself
or to others). Furthermore, criterion C now includes
reviviscence of the event and physical sensations (American
Psychiatric Association, 2013).
Although the criteria for PTSD are precise and it is recog-
nized as a potentially chronic disorder if not treated (Riggs,
Rothbaum, & Foa, 1995), this is not true of chronic pain. In
addition to the IASP definition (Merskey & Bogduk, 1994),
this syndrome has a number of nosological descriptions with
imprecise criteria such as “a pain disorder associated with
both psychological factors and a general medical condition.”
But chronic pain can take on many diverse forms. Some
aspects of the heterogeneity of its etiology and maintenance
have been addressed here. Again, the new DSM-V seems to
both broaden and deepen our understanding of pain by pro-
posing that it should be seen as a “complex somatic syndrome
disorder” or as a specificity of a“somatic syndrome disorder.”
Furthermore, DSM-V differentiates diagnostically between a
pain disorder and adjustment disorders, which belong to the
set of anxiety disorders. Thus, the connection between pain
disorders and anxiety disorders is beginning to emerge, and
the road to understanding PTSD/chronic pain comorbidity
seems to be widening as new nosological definitions are
acquired.
Conclusion
Does this make it legitimate to consider chronic pain occur-
ring in PTSD as a reactive kind of pain? If so, should treat-
ment for patients with post-traumatic stress be aimed at
making the pain disappear? The articles selected and studied
in the present review, although diverse if not contradictory,
have one basic thing in common: the trauma.Across all popu-
lations, types of pain, and PTSD studied, the common factor
that overarches this link lies at the level of the trauma or trau-
matic event that caused the individual to develop PTSD,
chronic pain, or even other comorbid disorders. It would
seem, then, that to gain insight into the complex interdepen-
dence of these disorders, one should start from the traumatic
Chronic Pain and PTSD: Evolving Views on Their Comorbidity
7Perspectives in Psychiatric Care •• (2014) ••–••
© 2014 Wiley Periodicals, Inc.

event. In this approach,one would see chronic pain as a reac-
tive response of the same order as PTSD, but with the two
having different response modes. Within one and the same
model of the development of PTSD following a traumatic
event, chronic pain would be another possible response to the
trauma. Accordingly, the question of the link between PTSD
and chronic pain would no longer be posed in terms of cause
and effect along an array of possible responses to the trauma.
An individual would react in one way or the other, depending
on his/her own particular mode of functioning. In this view,
PTSD and chronic pain are situated on the same level.Associ-
ated comorbid disorders such as depression and generalized
anxiety would come into the picture as symptom-worsening
conditions.
Vulnerability to the development of a reactive disorder
such as chronic pain or PTSD is thought to be related not only
to anxiety sensitivity (Asmundson et al., 2002; Jakupcak
et al., 2006) but also to traumatic life events experienced
during childhood (Haviland et al., 2010; Lee, 2010; Raphael &
Spatz Widom, 2011; Sachs-Ericsson, Kendall-Tackett, &
Hernandez, 2007). The pediatric population is having a dif-
ferent vulnerability given their changing development. In
adulthood, a traumatic event is going to upset the individual’s
life. Different modes of response are then possible, two of
which are PTSD and/or chronic pain.Worsened by comorbid
disorders such as depression (Jakupcak et al., 2006; Otis et al.,
2010; Poundja et al., 2006; Roth et al., 2008) or anxiety
(Defrin et al., 2008; Van Loey et al., 2003), the pain would
become chronic. The comorbid symptomatology of PTSD
and chronic pain as a reaction to trauma is the principal idea
set forth by Sharp and Harvey (2001). The tight interdepen-
dence of symptoms that can be observed in both PTSD and
chronic pain syndromes lends support to the idea that these
disorders should be situated on the same level, that of a reac-
tive disorder.
But why, then, couldn’t we contend that this is one and the
same reactive disorder? What differences can be found
between the two syndromes? A key factor for gaining insight
into this question is the temporal course of the reaction, that is,
whether it bears heavily on the individual’s mode of function-
ing, with a greater or lesser tendency toward somatization.
Indeed, various longitudinal studies have pointed out a
sequence of steps leading up to PTSD and chronic pain. While
the pain felt right after the accident or traumatic event is an
aggravating or even a predictive factor of the onset of PTSD,
PTSD turns out to be an aggravating or even predictive factor
of the transition fromacute pain to chronic pain.The temporal
dimension thus seems to have some explanatory power in
accounting for the complex interaction of these disorders,
with PTSD being an indicator of a quasi-immediate trauma
and chronic pain an indicator of an older and perhaps deeper
trauma. Indeed, we consider that PTSD is a reaction, which
appears a few months following the traumatic event, in agree-
ment with the criteria of DSM-IV-R, while the chronic pain
would have remained unsettled,and which would go on much
longer.
Implications for Nursing Practice
The comorbidity between PTSD and chronic pain raises
questions about effective treatment. Although we already
know of some effective therapies for PTSD, such as eye
movement desensitization and reprocessing and cognitive
behavioral therapy (CBT), few studies have looked into the
effectiveness of joint therapy for PTSD and chronic pain.
Therapy programs now in use, particularly CBT, focus
largely on the trauma itself, in the hope of decreasing pain
(regarded therein as a comorbid or reactive disorder) via
psychoeducation on pain and PTSD, relaxation sessions,
and sessions involving trauma exposure/desensitization
(Asmundson & Hadjistavropolous, 2006). Individuals have
exhibited a significant decrease not only in PTSD symptoms
but also in chronic pain, suggesting that PTSD treatment
can have a significant impact on pain (Beck, Coffey, Foy,
Keane, & Blanchard, 2009; Shipherd et al., 2007).
Given the current challenges for nursing practice in treat-
ing patients with PTSD and chronic pain, it seems crucial to
find the most effective clinical management. The various
forms of therapy and treatment mentioned above focus on
PTSD,but also assess any additional effects on chronic pain. It
can be hypothesized that treating chronic pain might have a
beneficial impact on PTSD symptoms. Owing to the high
comorbidity between chronic pain and PTSD, therapy that
includes treatment of both syndromes would be a better,
more effective choice. The studies reviewed here point out
some worthwhile avenues of research and show that these
critical issues are still open for debate.
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