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The traumatized body: Long-term PTSD and its implications for the orientation towards bodily signals
Abstract
Orientation to bodily signals is defined as the way somatic sensations are attended, perceived and interpreted. Research suggests that trauma exposure, particularly the pathological reaction to trauma (i.e., PTSD), is associated with catastrophic and frightful orientation to bodily signals. However, little is known regarding the long-term ramifications of trauma exposure and PTSD for orientation to bodily signals. Less is known regarding which PTSD symptom cluster manifests in the 'somatic route' through which orientation to bodily signals is altered. The current study examined the long-term implications of trauma and PTSD trajectories on orientation to bodily signals. Fifty-nine ex-prisoners of war (ex-POWs) and 44 controls were assessed for PTSD along three time-points (18, 30 and 35 years post-war). Orientation to bodily signals (pain catastrophizing and anxiety sensitivity-physical concerns) was assessed at T3. Participants with a chronic PTSD trajectory had higher pain catastrophizing compared to participants with no PTSD. PTSD symptom severity at T2 and T3 mediated the association between captivity and orientation. Among PTSD symptom clusters, hyperarousal at two time-points and intrusion at three time-point mediated the association between captivity and orientation. These findings allude to the cardinal role of long-term PTSD in the subjective experience of the body following trauma.
... Although less studied, theoretical explanations have been proposed for the experience of the body following exposure to traumatic events, mainly referring to the understanding that "the body keeps the score" (Van der Kolk, 2015). Specifically, PTSD may alter an individual's interpretation of the body as a safe entity by disrupting the basic constellation of their orientation toward their body (Tsur, Defrin, et al., 2018;Van der Kolk, 2015). Potential mechanisms by which interpretation of bodily signals may be altered following trauma can be viewed through the lens of the psychophysiology of PTSD (Dunlop & Wong, 2019). ...
... Specifically, the activation of the hypothalamic-pituitary-adrenal 1 Bob Shapell School of Social Work, Tel Aviv University, Israel (HPA) axis and sympathetic-adrenal-medullary system (Heim & Nemeroff, 2009) entail significant bodily sensations that instigate the sense of the traumatic event repeatedly reoccurring ( Van der Kolk, 1994). This may be especially relevant for the hyperarousal PTSD cluster (Tsur, Defrin, et al., 2018). As such, stress-related somatic signals could be categorized as threatening stimuli and interpreted as catastrophic and frightful. ...
... These theoretical explanations suggest that, for individuals exposed to trauma and especially those who suffer from PTSD, the body may become the stage for reexperiencing pain and suffering (Tsur et al., 2020;Tsur, Shahar, et al., 2017), referred to as the "somatic memory" of trauma (Levine, 1997;Van der Kolk, 2015). As a result, bodily sensations, such as heart palpitations or headaches, whether related to illness or not, might be construed as a potential danger to the self, interpreted as catastrophic and frightful sensations (Tsur, Defrin, et al., 2018). ...
Theoretical literature suggests that trauma and (PTSD) may instigate changes in the interpretation of bodily signals. Some findings support these inquiries, revealing that exposure to traumatic events and PTSD are associated with pain catastrophizing, body vigilance, fear of pain, and other manifestations of bodily perceptions and interpretations. However, these findings are not integrated into an inclusive empirically based conceptualization, thus leading to a limited comprehension of this phenomenon. This systematic literature review was conducted to synthesize the existing literature referring to orientation to bodily signals. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the review included a final of 48 manuscripts that addressed orientation to bodily signals among participants (aged 18 and above) and its potential associations with PTSD. The review revealed that most studies assessed one orientation manifestation, which was tested for its link to PTSD. The majority of the manuscripts were cross-sectional and included participants who faced combat, vehicle accidents, or various types of traumas. Only five manuscripts focused on interpersonal trauma and abuse. Most manuscripts reported significant correlations, revealing that trauma and PTSD are associated with a negative, catastrophic and frightful interpretation of bodily signals. These findings emphasize the need to encapsulate the various manifestations of orientation to bodily signals under a unified construct, as proposed by the term post-traumatic orientation to bodily signals. Further research is needed to illuminate the circumstances and processes by which trauma is implicated in post-traumatic orientation to bodily signals.
... Unfortunately, trauma in general, and child maltreatment in particular, experienced by the mother, the daughter, or both, may affect this unique bond in various detrimental domains (Pickreign Stronach et al., 2011;Reijman et al., 2017). One such derivative is the subjective experience of the body, or the orientation towards bodily signals (Tsur, Defrin, Lahav, & Solomon, 2018;Tsur, Shahar, role in explaining the association between trauma and posttraumatic orientation to bodily signals. Such findings imply that PTSD is associated with a catastrophic orientation to bodily signals (e.g., Kleiman, Clarke, & Katz, 2011;López-Martínez, Ramírez-Maestre, & Esteve, 2014), and anxiety sensitivity (e.g., Bernstein, Zvolensky, Feldner, Lewis, & Leen-Feldner, 2005). ...
... Example for items include; "I worry all the time about whether the pain will end," I feel I can't stand it anymore," "I become afraid that the pain will get worse." Studies supported the scale's validity (Sullivan et al., 1995) as well as for the Hebrew version (Tsur et al., 2018;. Cronbach's alpha for the current sample was high; 0.91 for the mothers, and 0.9 for the daughters, indicating high reliability. ...
... Participants were asked to rate whether they experienced the statements presented on a 5-point Likert scale. Studies supported the scale's validity (e.g., Peterson & Heilbronner, 1987) as well as the Hebrew version (Tsur et al., 2018). Cronbach's alpha for the current sample was high; 0.94 for the mothers, and 0.91 for the daughters, indicating high reliability. ...
Background
Orientation to bodily signals reflects the ways in which individuals interpret their bodily sensations. Such orientation is formed within early interpersonal context. Findings reveal that trauma may result in catastrophic and fearful orientation towards bodily signals. However, not much is known regarding the link between trauma and orientation towards the body as manifested within a family intergenerational context.
Objective
This study examines the link between child maltreatment, complex posttraumatic stress symptoms (CPTS symptoms), and a posttraumatic orientation to bodily signals among dyads of mothers and their young adult daughters.
Participants and setting
194 mother-daughter dyads (mothers’ mean age = 56, SD = 6.3; daughters’ mean age = 26, SD = 3.03) completed self-reported questionnaires, assessing child maltreatment (CTQ), CPTS symptoms (ITQ), and orientation to bodily signals (pain catastrophizing, anxiety sensitivity-physical, body vigilance).
Results
Orientation to bodily signals was associated with child maltreatment, through the mediation of CPTS symptoms among mothers (indirect effects between 0.13–0.28; p > 0.021) and daughters (indirect effects between 0.21–0.11; p > 0.032). Mothers’ child maltreatment was associated with daughters’ child maltreatment (effect = 0.35; p < 0.001), and mothers’ orientation to bodily signals was associated with daughters’ orientation (effects between 0.19-0.27; p < 0.016). Daughters’ orientation to bodily signals was partially associated with mothers’ child maltreatment through mothers’ CPTS symptoms and orientation to body (indirect effect = 0.064; p = 0.023).
Conclusions
Child maltreatment is implicated in posttraumatic orientation towards bodily signals. Such secondary processes may be intergenerationally transmitted.
... Orientation towards bodily signal reflects the ways in which somatic signals are acknowledged, perceived, and interpreted by the individual (Mehling et al., 2009;Shahar and Lerman, 2013;Sullivan et al., 1995). Thus, it is suggested that trauma in general, and PTSD in particular, leads to a catastrophic and frightful orientation towards bodily signals (Tsur et al., 2018;Van Der Kolk, 2014), which in turn, may intensify chronic pain (Sharp and Harvey, 2001;Tsur et al., 2017a) and potentially pain perception and modulation (Defrin et al., 2014;Ginzburg et al., 2015). Initial findings support this idea, revealing higher catastrophic and fearful orientations to bodily signals among individuals with PTSD (Kleiman et al., 2011;Lõpez-Martínez et al., 2014;Tsur et al., 2018;Viana et al., 2016) and chronic pain (Sterling and Chadwick, 2010;Vlaeyen and Linton, 2000). ...
... Thus, it is suggested that trauma in general, and PTSD in particular, leads to a catastrophic and frightful orientation towards bodily signals (Tsur et al., 2018;Van Der Kolk, 2014), which in turn, may intensify chronic pain (Sharp and Harvey, 2001;Tsur et al., 2017a) and potentially pain perception and modulation (Defrin et al., 2014;Ginzburg et al., 2015). Initial findings support this idea, revealing higher catastrophic and fearful orientations to bodily signals among individuals with PTSD (Kleiman et al., 2011;Lõpez-Martínez et al., 2014;Tsur et al., 2018;Viana et al., 2016) and chronic pain (Sterling and Chadwick, 2010;Vlaeyen and Linton, 2000). Different findings also point to a link between catastrophic pain orientation and dysfunctional pain perception (Nir and Yarnitsky, 2015;Weissman-Fogel et al., 2008). ...
... In congruence with this line of thought, it has been suggested that trauma and PTSD may demolish the basic trust in the body as a safe entity (Van Der Kolk, 2014). Especially when traumatic experiences involve physical agony, such as in torture, this may be imprinted in the body for many years and even a lifetime (Pieritz et al., 2015;Tsur et al., 2018). PTSD may also affect the basic orientation towards the body, experienced as ongoing implicit trauma reminders (Rothschield, 2003). ...
Objective:
Individuals exposed to trauma, especially those who develop posttraumatic stress disorder (PTSD), are at a higher risk of suffering from chronic pain as well as altered pain perception and modulation. However, the underlying mechanisms of these processes are yet to be established. Recent findings have indicated that trauma survivors tend to personify chronic pain that is developed after the exposure, in a way that resonates with the traumatic experience. The aim of this study was to test whether pain personification plays a significant role in explaining the long-term links between trauma, PTSD and pain.
Methods:
This study is part of a large-scale longitudinal study on ex-prisoners of war (ex-POWs) from the 1973 Yom-Kippur war, who were followed over 35 years after the war. Fifty-nine ex-POWs who were exposed to torture and 44 matched combatants were assessed for PTSD at 18, 30, and 35 post-war. Quantitative somatosensory testing of heat-pain threshold, pain tolerance, conditioned pain modulation (CPM), and temporal summation of pain (TSP), as well as torturing personification, were assessed at 35 years after the war.
Results:
Sequential mediation analyses revealed that the associations between torture and heat pain threshold, as well as pain tolerance were mediated by PTSD at several time-points (-1.43<indirect effect < 1.47). Torturing personification significantly mediated the associations between torture, PTSD, CPM and TSP (-0.16 < indirect effect).
Conclusions:
These findings point to the effect of trauma on the subjective orientation towards bodily signals as a key factor in dysfunctional pain modulation.
... The current sample consisted of individuals who were exposed to trauma. Findings indeed demonstrated that trauma may be implicated in life-long health deteriorations (Beristianos et al., 2014;O'Donovan et al., 2015) and alterations in the way physical symptoms are perceived (Tsur et al., 2018). Such alterations may occur via bodily dissociation, characterized by avoidance of internal experiences (Nijenhuis et al., 1998;Price and Thompson, 2007), or from a tendency to perceive bodily symptoms as catastrophic, frightening, and threatening (Tsur et al., 2018;Tsur et al., 2017). ...
... Findings indeed demonstrated that trauma may be implicated in life-long health deteriorations (Beristianos et al., 2014;O'Donovan et al., 2015) and alterations in the way physical symptoms are perceived (Tsur et al., 2018). Such alterations may occur via bodily dissociation, characterized by avoidance of internal experiences (Nijenhuis et al., 1998;Price and Thompson, 2007), or from a tendency to perceive bodily symptoms as catastrophic, frightening, and threatening (Tsur et al., 2018;Tsur et al., 2017). Therefore, as war veterans become older, thereby facing more objective health concerns and possible premature aging processes (Lohr et al., 2015;Solomon et al., 2017a,b), their perception of these physical changes may be affected by their previous traumatic experiences. ...
... The detrimental effects of trauma on subjective physical health have been well established. Recent findings have demonstrated that the experience of trauma is deeply engraved in the basic perception and orientation towards somatic symptoms (Tsur et al., 2018). The findings of this study revealed a unique and complex pattern of influences between somatic and interpersonal subjective experiences among war veterans. ...
Rationale:
Poor subjective physical health and loneliness are among the most detrimental ramifications of trauma. Indeed, substantial research has examined the link between subjective physical health and loneliness, mainly focusing on how loneliness leads to poorer physical health. However, the effects of poor subjective physical health on loneliness, as well as the reciprocal effects of these two factors, have scarcely been examined. Even less is known regarding the course of these mutual effects among individuals who have been exposed to trauma.
Objective:
The current investigation examines the reciprocal effects of subjective physical health and loneliness among a group of war veterans over four decades.
Methods:
Two-hundred and seventy-four Israeli veterans from the 1973 Yom- Kippur War reported self-rated health (SRH), somatization and loneliness at 1991 (T1), 2003 (T2), 2008 (T3) and 2015 (T4). An autoregressive cross-lagged (ARCL) modeling strategy was employed to test the bidirectional relationship between subjective health and loneliness.
Results:
The results showed that from T1 to T2, loneliness predicted subjective physical health. However, from T2 to T3, and from T3 to T4, subjective physical health predicted loneliness. PTSD moderated the association between loneliness and subjective physical health.
Conclusion:
The findings show a novel pattern of influences, demonstrating that the reciprocal effects of subjective physical health and loneliness change over time. The findings imply that subjective health and interpersonal experiences are inherently connected.
... Internalization and neuroticism are proposed to link PTSD, depression, and generalized anxiety disorder (GAD; Flory and Yehuda, 2015;Reardon et al., 2007). Additionally, physical anxiety sensitivity, bodily catastrophizing, and fear of negative emotions have been linked to PTSD, panic, and somatic complaints comorbidity (Tsur et al., 2018). Finally, the PTSD numbing subscale correlates with depression, the hyperarousal subscale correlates with GAD, and both subscales correlate to suicidality and aggression (Hellmuth et al., 2012;Price and van Stolk-Cooke, 2015). ...
... Mejía et al.Price et al. (2019) findings on GAD and depression. Additionally, the correlation between anxiety and somatic complaints might be explained by physical anxiety sensitivity, body catastrophizing, or suppressionTsur et al., 2018). We identified that the anxiety and the PTSD hyperarousal association found in previous studies was not present in ours(Hellmuth et al., 2012;M. ...
... Furthermore, the available literature also documented long-term PTSD (a chronic PTSD trajectory; Bonanno & Mancini, 2012), i.e., PTSD symptoms experienced for an extended period, for instance, 5 to 8 years following a traumatic event (Yule et al., 2000). Other studies indicated that long-term PTSD can also be observed even more than 30 years after the trauma, especially in the case of war-related trauma (Tsur et al., 2018). Nevertheless, as previous research suggested, there is a high variability regarding trauma responses, including the onset of PTSD and its unique long-term trajectories (Bonanno & Mancini, 2012), depending on a mix of risk and protective factors, in addition to individual differences, which can be considered on a resilience/resistance approach. ...
... In our study, we could not differentiate between samples exposed to these different traumatic experiences, because all these are included in the broader categories of maltreatment (e.g., abuse and neglect) or adverse childhood experiences (i.e., abuse, neglect, family dysfunctions). However, we know from previous studies that long-term PTSD is significantly related to higher physical impairment and catastrophic orientation (Tsur et al., 2018), in addition to a reduced quality of life (Holbrook et al., 2002). Thus, for a deeper understanding of how long-term PTSD is related to quality of life in the context of different childhood traumatic experiences, future studies should analyze the differential role of various trauma events in shaping future emotional outcomes. ...
This meta-analysis aimed to evaluate the relation between posttraumatic stress symptoms and quality of life in samples of participants exposed to childhood traumatic experiences. To test these relations, we conducted a systematic review of the literature on PTSD symptoms and quality of life. We identified 16 eligible studies that we included in the meta-analysis. Based on previous literature, we hypothesized that: (1) there is a negative relation between PTSD symptoms and quality of life; (2) the relation between PTSD symptoms and quality of life differs based on the type of childhood trauma and the type of trauma exposure; (3) the relation between PTSD symptoms and quality of life differs based on the dimensions of quality of life; (4) the relation between PTSD symptoms and quality of life vary according to gender, age, the region where the studies were conducted, the type of PTSD symptomatology measurement, and quality of life. The quantitative analysis was conducted using meta-analytic techniques. Results sustained the fact that there is a negative relation between PTSD symptoms and quality of life. Moreover, the relation between PTSD symptoms and quality of life depends on the type of trauma, gender, age, region where the studies were conducted, type of measure for PTSD symptoms, and quality of life. The theoretical and practical implications of these results are discussed.
... A growing body of knowledge suggests that other factors are involved in such processes, pertaining to the way individuals perceive, interpret and attend to their bodily sensations following trauma. That is, findings imply that individuals who have experienced persistent interpersonal trauma tend to develop a posttraumatic orientation to bodily signals (Tsur, Defrin, Lahav, & Solomon, 2018). Such orientation is characterized by the tendency to perceive normal bodily sensations, such as hunger, temperature, and pain, as catastrophic and frightful. ...
... Posttraumatic orientation to bodily signals is suspected to evolve due to the shattering of trust in one's own body as a safe entity, combined with the reexperiencing of intrusive somatic sensations referring to the traumatic incident (Levine, 1997;van der Kolk, 2014). Such catastrophic and frightful orientation has been shown to play a significant role in the etiology and coping with various debilitating physical morbidities, including chronic pain (Burns et al., 2015a(Burns et al., , 2015b, as well as irritable bowel syndrome (Sherwin et al., 2017), asthma (Avallone et al., 2012), and premature aging (Tsur et al., 2018). ...
Background
Child maltreatment (CM) studies have contributed considerably to our understanding of the phenomenon epidemiology and consequences. However, the concept of children’s pain has been surprisingly understudied in CM studies.
Objective
The current study examined pain from the unique perspectives of children as conveyed in forensic interviews following parental physical abuse.
Participants and settings: The sample consisted of 35 forensic interviews with Israeli children (21 girls) aged 4-14.
Results
Thematic analysis of the interviews indicated the complex perception of pain by the children, in which while highlighted the intensive pain they endured during abuse, they also muted and minimized this pain in their descriptions. This tendency of the children to mute their pain is not surprising given their reality, which is manifested in complicated interactions with both the forensic interviewers and significant others in their lives.
Conclusions
The discussion focuses on the association between muted pain experiences and the nature of traumatic experiences. Moreover, delving into the unique family dynamic described by the children advances our understanding of the way pain is embedded in the children’s interactions with their surroundings; the family, the perpetrator, and the forensic interviewer. Potential links between peritraumatic pain in child abuse and posttraumatic chronic pain are also discussed.
... Individuals exposed to childhood trauma were shown to exhibit higher risk of revictimization later in life (for review: [39]). Lifetime exposure to traumatic events can negatively affect an individual's body perception, being associated with symptoms of posttraumatic stress such as catastrophic and frightful orientation towards bodily signals [40]. ...
Objective
Inflammatory bowel diseases (IBD) are accompanied by symptoms that can vastly affect patients’ representations of their bodies. The aim of this study was to investigate alterations in body evaluation and body ownership in IBD and their link to interoceptive sensibility, gastrointestinal-specific anxiety, and history of childhood maltreatment.
Methods
Body evaluation and ownership was assessed in 41 clinically remitted patients with IBD and 44 healthy controls (HC) using a topographical self-report method. Interoceptive sensibility, gastrointestinal-specific anxiety and a history of childhood maltreatment were assessed via self-report questionnaires.
Results
Patients reporting higher interoceptive sensibility perceived their bodies in a more positive manner. Higher gastrointestinal-specific anxiety was linked to a more negative body evaluation particularly of the abdomen in patients with IBD. Childhood maltreatment severity strengthened the positive association between interoceptive sensibility and body ownership only in those patients reporting higher trauma load.
Conclusion
Altered body representations of areas associated with abdominal pain are linked to higher symptom-specific anxiety and lower levels of interoceptive sensibility in IBD. Particularly in patients with a history of childhood maltreatment, higher levels of interoceptive sensibility might have a beneficial effect on the patients’ sense of body ownership.
... Sensitivity to pain may adaptively increase in post-attack safer situations, in which attention can be given to the wounds, or when threat potential is sustained and unpredictable, such that pain can hinder risk-taking foraging. Furthermore, the long-term PTSD was associated with a higher catastrophic and frightful orientation to bodily signals [48]. These findings can explain why patients with PTSD also exhibited higher scores of selfreported "orofacial pain in the past six months" and the "average pain in the past six months" (Table 4). ...
Objective
The present study aimed to investigate the association between self-reported awake/sleep bruxism, and orofacial pain with post-traumatic stress disorder (PTSD).
Methods
A case–control study with a convenience sample was designed. Participants were recruited from a university-based Trauma Ambulatory. The diagnosis of PTSD was established through a clinical interview and the Structured Clinical Interview (SCID-I/P). Thirty-eight PTSD patients and 38 controls completed the Research Diagnostic Criteria for Temporomandibular Disorders Axis-II to categorize awake/sleep bruxism and orofacial pain. Following this, we performed a short clinical examination of the temporomandibular joint and extraoral muscles.
Results
Adjusted logistic regression analysis showed that awake bruxism was associated with PTSD (OR = 3.38, 95% CI = 1.01–11.27, p = 0.047). Sleep bruxism was not associated with any covariate included in the model. In a Poisson regression model, PTSD (IRR = 3.01, 95% CI = 1.38–6.55, p = 0.005) and the muscle pain/discomfort (IRR = 5.12, 95% CI = 2.80–9.36, p < 0.001) were significant predictors for current orofacial pain.
Conclusions
PTSD was associated with self-reported awake bruxism and low-intensity orofacial pain. These conditions were frequent outcomes in patients previously exposed to traumatic events.
Clinical relevance
We suggest including a two-question screening for bruxism in psychiatry/psychology interviews to improve under-identification and to prevent harmful consequences at the orofacial level.
... A large body of empirical research has since shown how the experience of one's own body can be significantly hampered by experiences of traumatic events 46,47 and how body-oriented therapy can help trauma survivors in dealing with PTSD (for a metanalysis, see 48 ). Theoretical explanations of this process have usually focused on a deterioration in the orientation toward body signals in the aftermath of PTSD symptoms that can result in applying a catastrophic or alien orientation toward the body and experiencing one's body as detached from one's self [49][50][51] . Importantly, similar negative bodily experiences have been observed among offspring of Holocaust survivors 8 and children of refugee families 14 , showing that the intergenerational effects of trauma emerge in multidimensional rather than singular psychosocial outcomes 11 . ...
The main aim of this study was to investigate the long-lasting influences of World War II (WWII) trauma in a national sample of Poles, based on Danieli’s (1998) survivors’ post-trauma adaptational styles (fighter, numb, victim) and their link with current post-traumatic stress disorder (PTSD) symptoms and embodiment level among participants. We also sought to investigate whether the level of knowledge about WWII trauma among ancestors could moderate that association. The study was conducted among a representative sample of 1598 adult Poles obtained from an external company. Participants filled out the Danieli Inventory of Multigenerational Legacies of Trauma, the knowledge about traumatic World War II experiences in the family questionnaire, the Posttraumatic Diagnostic Scale-5, and the Experience of Embodiment Scale. We observed a positive relationship between all survivors’ post-trauma adaptational styles and current levels of PTSD symptoms among participants. In addition, PTSD level mediated the relationships between those adaptational styles and embodiment intensity; that mediation was additionally moderated by a lack of knowledge about WWII trauma among ancestors in our participants. Our study adds to the literature on intergenerational trauma by highlighting the importance of evaluating embodiment in understanding the mechanisms of trauma transmission. Furthermore, it highlights the moderating effect of knowledge of family history in this mechanism and the need to share family histories with subsequent generations.
... The copyright holder for this preprint this version posted September 4, 2023. ; https://doi.org/10.1101/2023.09.03.23294937 doi: medRxiv preprint frightful orientation to bodily signals [55]. These findings can explain why patients with PTSD also exhibited higher scores of self-reported "orofacial pain in the past six months" and the "average pain in the past six months" (Table 4). ...
Objective: The present study aimed to investigate the association between self-reported awake/sleep bruxism, and orofacial pain with post-traumatic stress disorder (PTSD). Methods: Participants were recruited from a university-based Trauma Ambulatory. The diagnosis of PTSD was established through a clinical interview and the Structured Clinical Interview (SCID-I/P). Thirty-eight PTSD patients and 38 controls completed the Research Diagnostic Criteria for Temporomandibular Disorders Axis-II to categorize awake/sleep bruxism and orofacial pain. Following this, we performed a short clinical examination of the temporomandibular joint and extraoral muscles.
Results: Adjusted logistic regression analysis showed that awake bruxism was associated with PTSD (OR = 3.38, 95% CI = 1.01-11.27, p = 0.047). Sleep bruxism was not associated with any covariate included in the model. In a Poisson regression model, PTSD (IRR = 3.01, 95% CI = 1.38-6.55, p = 0.005) and the muscle pain/ discomfort (IRR = 5.12, 95% CI = 2.80-9.36, p < 0.001) were significant predictors for current orofacial pain.
Conclusions: PTSD was associated with self-reported awake bruxism and low-intensity orofacial pain. These conditions were frequent outcomes in patients previously exposed to traumatic events.
... Catastrophic and fearful orientation refers to an amplified negative perception of bodily signals associated with the tendency to ruminate upon, magnify, and feel helpless when facing adverse bodily sensations (McNally, 2002). Body vigilance is high in order to monitor interoceptive bodily signals and perturbations in search of illness signs (Zvolensky and Forsyth, 2002;Pieritz et al., 2015;Tsur et al., 2017Tsur et al., , 2018. This tendency increases psychosomatic symptoms (Lamela and Figueiredo, 2013) and body shame (Talmon and Ginzburg, 2018). ...
Trauma-related disorders are debilitating psychiatric conditions that influence people who have directly or indirectly witnessed adversities. Dramatic brain/body transformations and altered person's relationship with self, others, and the world occur when experiencing multiple types of traumas. In turn, these unfortunate modifications may contribute to predisposition to trauma-related vulnerability conditions, such as externalizing (aggression, delinquency, and conduct disorders) problems. This mini-review analyzes the relations between traumatic experiences (encoded as implicit and embodied procedural memories) and bodily self, sense of safety for the own body, and relationship with others, also in the presence of externalizing conducts. Furthermore, an emerging research area is also considered, highlighting principles and techniques of body-oriented and sensorimotor therapies designed to remodel bodily self-aspects in the presence of trauma, discussing their potential application with individuals showing externalizing problems.
... Somatic difficulties are thought to contribute to the high economic cost of military service for veterans returning from service (Eekhout et al., 2016). Somatization has also been suggested to hamper traditional PTSD treatment success (Hale et al., 2019) and predict poorer long-term chronic PTSD outcomes, specifically in an Israeli veteran population (Tsur et al., 2018). The somatic experience of trauma, such as through physical reactions to trauma reminders or long-term bodily distress is believed to be involved in over and under sensitive arousal states and these physiological reactions may obscure cognitive processing of trauma (van der Kolk & Najavits, 2013). ...
To this date, the prevalence of posttraumatic stress disorder (PTSD) and associated psychological symptom profiles amongst non-combatant community-based veterans in Israel has not been studied. Data were analysed from a web-based survey of veterans via a market research platform during September 2021 and included 522 non-combat (e.g. intelligence, office-based or education corps) veterans and 534 combat (e.g. front-line infantry) veterans. The survey assessed PTSD, depression, anxiety and somatic symptoms in addition to the prevalence of self-reported aggression. A two-way multivariate analysis of covariance indicated that higher PTSD and somatic symptoms were prevalent for those exposed to combat experiences even when not in a combatant role. A logistic regression indicated that of those who did not self-define as aggressive prior to service, those exposed to combat were three times more likely to be aggressive following their service than veterans not exposed to combat. This effect was not demonstrated for combat soldiers compared to non-combat soldiers. Results indicate that mental health outreach would be better targeted towards those who have been exposed to combat-type experiences during their service even in non-combat units. The current study highlights the effect of combat exposure on secondary PTSD symptoms; aggression and somatization.
... One striking aspect of PTSD trauma memories is their firm grounding in sensory-motor representations (Van der Kolk & Fisler, 1995), such as flashbacks accompanied by re-experiencing of pain (for a report of one such individual, see Whalley et al., 2007). One study found that the somatosensory-motor network (SMN), comprised of the pre-and postcentral gyri (primary motor cortex and somatosensory cortex, respectively), the primary sensory cortices, and the supplementary motor area (SMA), undergoes a within-network decrease in functional connectivity in those with PTSD, especially in the somatosensory cortex (Shang et al., 2014), which is consistent with catastrophic, fearful orientation to somatic signals in PTSD (Tsur et al., 2018). Conversely, hyperconnectivity between the posterior DMN and SMN in PTSD is consistent with symptoms such as involuntary re-experiencing of, vivid sensory-motor imprints of the original traumatic memory (Kearney et al., 2023). ...
Background:
Post-traumatic stress disorder can be viewed as a memory disorder, with trauma-related flashbacks being a core symptom. Given the central role of the hippocampus in autobiographical memory, surprisingly, there is mixed evidence concerning altered hippocampal functional connectivity in PTSD. We shed light on this discrepancy by considering the distinct roles of the anterior versus posterior hippocampus and examine how this distinction may map onto whole-brain resting-state functional connectivity patterns among those with and without PTSD.
Methods:
We first assessed whole-brain between-group differences in the functional connectivity profiles of the anterior and posterior hippocampus within a publicly available data set of resting-state fMRI data from 31 male Vietnam war veterans diagnosed with PTSD (mean age = 67.6 years, sd = 2.3) and 29 age-matched combat-exposed male controls (age = 69.1 years, sd = 3.5). Next, the connectivity patterns of each subject within the PTSD group were correlated with their PTSD symptom scores. Finally, the between-group differences in whole-brain functional connectivity profiles discovered for the anterior and posterior hippocampal seeds were used to prescribe post-hoc ROIs, which were then used to perform ROI-to-ROI functional connectivity and graph-theoretic analyses.
Results:
The PTSD group showed increased functional connectivity of the anterior hippocampus with affective brain regions (anterior/posterior insula, orbitofrontal cortex, temporal pole) and decreased functional connectivity of the anterior/posterior hippocampus with regions involved in processing bodily self-consciousness (supramarginal gyrus). Notably, decreased anterior hippocampus connectivity with the posterior cingulate cortex/precuneus was associated with increased PTSD symptom severity. The left anterior hippocampus also emerged as a central locus of abnormal functional connectivity, with graph-theoretic measures suggestive of a more central hub-like role for this region in those with PTSD compared to trauma-exposed controls.
Conclusions:
Our results highlight that the anterior hippocampus plays a critical role in the neurocircuitry underlying PTSD and underscore the importance of the differential roles of hippocampal sub-regions in serving as biomarkers of PTSD. Future studies should investigate whether the differential patterns of functional connectivity stemming from hippocampal sub-regions is observed in PTSD populations other than older war veterans.
... According to this model, many aspects of healthy behaviour and cognition rely upon interactions within and between these core networks [27]. Functional, organizational and dynamic abnormalities within and signals in PTSD [46]. Taking the above evidence into account, it is reasonable to hypothesize that PTSD involves abnormal connectivity between the hippocampus and SMN. ...
Background: Post-traumatic stress disorder can be viewed as a memory disorder, with trauma-related flashbacks being a core symptom. Given the central role of the hippocampus in autobiographical memory, surprisingly, there is mixed evidence concerning altered hippocampal functional connectivity in PTSD. We shed light on this discrepancy by considering the distinct roles of the anterior versus posterior hippocampus and examine how this distinction may map onto whole-brain resting-state functional connectivity patterns among those with and without PTSD.
Methods: We first assessed whole-brain between-group differences in the functional connectivity profiles of the anterior and posterior hippocampus within a publicly available data set of resting-state fMRI data from n =31 male Vietnam War veterans diagnosed with PTSD and n =29 age-matched combat-exposed male controls. Next, the connectivity patterns of each subject within the PTSD group were correlated with their PTSD symptom scores. Finally, the between-group differences
in whole-brain functional connectivity profiles discovered for the anterior and posterior hippocampal seeds were used to prescribe post-hoc ROIs, which were then used to perform ROI-to-ROI functional connectivity and graph-theoretic analyses.
Results: The PTSD group showed increased functional connectivity of the anterior hippocampus with affective brain regions (anterior/posterior insula, orbitofrontal cortex, temporal pole) and decreased functional connectivity of the anterior/posterior hippocampus with regions involved in processing bodily self-consciousness (supramarginal gyrus). Notably, decreased anterior hippocampus connectivity with the posterior cingulate cortex /precuneus was associated with increased PTSD symptom severity. The left anterior hippocampus also emerged as a central locus of abnormal functional connectivity, with graph-theoretic measures suggestive of a more central hub-like role in those with PTSD compared to trauma-exposed controls.
Conclusions: Our results highlight that the anterior hippocampus plays a critical role in the neurocircuitry underlying PTSD and underscore the importance of the differential roles of hippocampal sub-regions in serving as biomarkers of PTSD.
... With respect to the COVID-19 pandemic, the risk for psychiatric disorders appears to be significantly increased by loneliness (Tso and Park, 2020;Park et al., 2020). Moreover, the impact of existing PTSD symptomatology on perceived stress was mediated by loneliness (Jeftić et al., 2021): individuals might experience post-traumatic stress reactions (e.g., trauma-related fear and heightened physiological arousal) when triggered by traumatic reminders like lockdown and severe restrictions (Tsur et al., 2018). ...
The present study investigated psychosocial predictors of psychosis-risk, depression, anxiety, and stress in Croatia during the COVID-19 pandemic. Given Croatia's recent transgenerational war trauma and the relative lack of available prodromal data, this study presents a unique opportunity to examine the impact of loneliness and other psychosocial factors on psychosis-risk and mental health in this population. 404 Croatian participants completed an anonymous online survey of physical and mental health questions. 48 participants met the criteria for elevated psychosis-risk on prodromal questionnaire (PQ-16). Loneliness had a significant impact on psychosis-risk. Exposure to trauma was associated with psychosis-risk and loneliness, while domestic abuse/violence was associated only with the distress surrounding psychotic-like symptoms. COVID concern was also associated with psychosis-risk. Lastly, the associations between psychosis-risk and depression, anxiety, and stress were robust. These findings highlight the important role of loneliness in psychosis-proneness in Croatia. Depression, anxiety, and stress were also closely related to elevated psychosis-risk. Loneliness is a highly salient issue for individuals with psychosis and it is important to target loneliness within a multi-faceted psychosocial intervention for those at risk for schizophrenia.
... This would allow the investigation of a potential dose-response relationship between RSS and the magnitude/severity of experienced stressors. In doing so, future studies could examine the impact of traumatic stressors, as it is well documented that traumata can lead to altered body access (e.g., Levine, 2010;Tsur et al., 2018;van der Kolk, 2014). Second, the present convenience sample showed good health conditions. ...
Background: Stress is a ubiquitous phenomenon in modern societies and is often accompanied by somatic sensations and symptoms, such as tension and nausea. Despite the inherent somatic component of stress, research on coping with stress has previously neglected to consider how somatic stress responses (i.e., somatic stress) may affect stress-coping behavior. Aim: To address this gap in the literature, this study introduces the concept of reactions to somatic stress (RSS). It also provides the first psychometric evaluation of the Reactions to Somatic Stress Questionnaire (RSSQ), a novel 16-item questionnaire that assesses hampering and facilitating RSS. Method: The RSSQ and a battery of questionnaires on related constructs were administered via an online survey to N = 265 participants from the general population. Results: Exploratory (n = 133) and confirmatory (n = 132) factor analyses yielded two dimensions of the RSSQ: Hampering RSS (RSS-H) and facilitating RSS (RSS-F). Both subscales showed good internal consistency (α = .81–.89). Correlations with body awareness, emotion regulation skills, and beliefs about stress indicated medium to high convergent and discriminant validity. The RSS-H and RSS-F scores significantly predicted maladaptive and adaptive coping behavior, respectively. This association remained stable after controlling for subjective stress and related measures. Limitations: Generalization of the obtained results is limited to healthy individuals. Conclusion: The study supports the theoretical assumptions underlying the RSS concept. The RSSQ suggests a promising way to assess reactions to somatic stress as they relate to coping with stress. The RSSQ could be used for clinical and health psychological testing or interdisciplinary research.
... Posttraumatic stress disorder (PTSD) is a chronic condition that affects approximately 7-10% of individuals exposed to a traumatic event (Kessler et al., 2005;Pietrzak et al., 2011). This leads to long-term and wide-ranging negative consequences for health, occupational, and social functioning (Bramsen & Van der Ploeg, 1999;Goenjian et al., 2000;Kessler et al., 1995;Kovac et al., 2015;Moriarty et al., 2021;Solomon et al., 2021;Tsur et al., 2018). Since 1980, when PTSD was first introduced in the classification of mental disorders (American Psychiatric Association, 1980), the nosology of PTSD has been widely debated (Friedman et al., 2016;Yufik & Simms, 2010). ...
Person-centered analyses may be applied to identify latent homogeneous subgroups of posttraumatic stress disorder (PTSD) symptoms. The evidence suggests three to five class/profile solutions that are distinct in a quantitative and/or qualitative way. This study aimed to examine the evidence for different profiles of PTSD symptoms among a Polish sample exposed to road accidents and floods and to verify different predictors of profile membership: demographic and trauma-related variables, temperamental traits according to Jan Strelau's Regulative Theory of Temperament, and cognitive factors. Data from 572 participants, aged between 18 and 85 years were included. The latent profile analysis indicated five profiles: low symptom; intermediate symptom with higher negative affect; intermediate symptom with low negative affect, higher avoidance, and anxiety; elevated symptom; and high symptom. Multinomial logistic regression analysis revealed significant predictors of profile membership: temperamental trait – emotional reactivity, trauma exposure aspect - physical injuries, and three cognitive strategies of affect regulation: minimizing importance, thought suppression/mental distraction, and mental disengagement. Profiles differing not only in symptom severity, but also in the intensity of specific symptom clusters were obtained. Their diversity may be related to pre-, peri-, and post-traumatic factors of temperamental, trauma-related, and cognitive nature.
... Chronic pain and posttraumatic stress disorder (PTSD) co-occur at striking frequency[1, 83,90,93] but mechanisms explaining this comorbidity are poorly understood [66]. Re-experiencing the traumatic event as recurrent, involuntary, and intrusive distressing memories is a core symptom of PTSD [4]. ...
Psychological trauma is typically accompanied by physical pain, and posttraumatic stress disorder (PTSD) often co-occurs with chronic pain. Clinical reports suggest that pain after trauma may be part of a re-experiencing symptomatology. Classical conditioning can underlie visual re-experiencing since intrusions can occur as conditioned responses (CRs) to trauma-related cues. If individuals also experience pain to cues previously paired with, but not anymore inflicting nociceptive stimulation (CSs), conditioning could also explain re-experiencing of pain. Sixty-five participants underwent classical conditioning, where painful electrocutaneous stimulation and aversive film-clips served as unconditioned stimuli (USs) in a 2(pain/no pain)×2(aversive/neutral film) design. CSs were neutral pictures depicting contextual details from the films. One day later, participants were re-exposed to CSs during a memory-triggering-task (MTT). We assessed pain-CRs by self-report and an fMRI-based marker of nociceptive pain, the neurologic pain signature (NPS); and recorded spontaneous daily-life pain-intrusions with an e-diary. During conditioning, pain-signaling CSs elicited more self-reported-pain and NPS-responses than no-pain-signaling CSs. Possibly because the aversive-film masked differences in participants' responses to pain-signaling vs. no-pain-signaling CSs, pain-CRs during acquisition only emerged within the neutral-film condition. When participants were re-exposed to CSs during MTT, self-reported-pain-CRs during the neutral-film condition and, though more uncertain, NPS-CRs during the aversive-film condition persisted. Importantly, participants with stronger pain-CRs showed a greater probability and severity of experiencing spontaneous pain intrusions during daily-life. Our data support that pain can emerge as a CR with emotional and sensory components. Classical conditioning presents a possible mechanism explaining pain-intrusions, and more broadly, pain experienced without nociceptive input.
... This means that even after many years of the trauma, survivors may relive their experience as vivid as when the trauma first occurred. Furthermore, reminders may trigger re-experiencing of the past trauma, activating trauma-related fear and hyperarousal (Tsur et al., 2018). Especially individuals with posttraumatic stress disorder (PTSD) might experience heightened physiological arousal due to traumatic reminders without any direct recollection of the event (Ehlers & Clark, 2000;van der Kolk, 2000;Zoellner et al., 2020). ...
In order to gain a better understanding of what happens during the COVID-19 pandemic to those who were previously traumatized, this study investigated perceived stress and severity of PTSD symptoms during the COVID-19 pandemic in people who experienced the 1992-1995 war in Bosnia and Herzegovina. It was also examined how reminders of past trauma and loneliness instigated by the COVID-19 crisis relate to current stress and PTSD symptoms. The sample consisted of 123 participants (74.8% women). Participants responded to assessments of sociodemographic characteristics, exposure to COVID- related information, concerns over disease, severity of exposure to war, frequency and intensity of war trauma reminders, loneliness, stress, and severity of PTSD symptoms. Data was collected as part of [edited out for blind review] Global Survey. Results showed that in a population previously exposed to the effects of war, severity of PTSD symptoms was positively related to perceived stress, and loneliness during the pandemic significantly mediated this relationship. Intensity of exposure to war trauma reminders was associated with higher levels of PTSD symptom severity. Higher severity of PTSD symptoms was related to forced displacement during the war. Moreover, higher stress was related to increased concerns over disease. To conclude, those exposed to war may be more affected by the global COVID-19 pandemic and preventive measures that accompany it, while loneliness mediates the effects of PTSD and perceived stress in this population.
... Nonetheless, they have consistently found that pain anxiety is higher among participants with PTSD compared to controls. For example, Tsur, Defrin, Lahav, and Solomon (2018) found that former prisoners of war exhibited significantly higher pain catastrophizing (which is consistent with the cognitive anxiety component of pain anxiety) than veterans who had not experienced captivity. In addition, participants on a chronic PTSD trajectory exhibited significantly higher pain catastrophizing than participants without PTSD. ...
Background
Pain anxiety has been associated with more severe posttraumatic stress disorder (PTSD) symptoms. However, the unique role of individual domains of pain anxiety has yet to be explored in the prediction of PTSD severity. This study examined whether specific pain anxiety domains (i.e., cognitive anxiety, escape/avoidance, fear of pain, and physiological anxiety) predict both concurrent and downstream PTSD symptoms above and beyond other PTSD risk factors.
Method
Participants were 63 survivors of traumatic events with moderate to high baseline pain treated in the emergency department and assessed for PTSD symptoms and pain anxiety at 3- and 12-months.
Results
Three-month pain anxiety domains of fear of pain and physiological anxiety (inversely related) significantly predicted concurrent 3-month PTSD symptoms above and beyond other established PTSD risk factors (i.e., sex, age, pain, and trauma type). However, only 3-month fear of pain significantly predicted 12-month PTSD symptoms.
Conclusions
Findings highlight the relevance of specific pain anxiety domains in concurrent and future PTSD symptoms and suggest the importance of evaluating pain anxiety among patients with PTSD. Interventions focused on increasing willingness to experience and tolerate fear of pain may help mitigate this risk, thereby improving outcomes for individuals with acute PTSD symptoms.
... Chronic pain and posttraumatic stress disorder (PTSD) cooccur at striking frequency, 1,83,90,93 but mechanisms explaining this comorbidity are poorly understood. 66 Re-experiencing the traumatic event as recurrent, involuntary, and intrusive distressing memories is a core symptom of PTSD. 4 Of interest, patients with PTSD re-experience the traumatic event not only as distressing visual intrusions (eg, the perpetrator's face) but also often (eg, 49% of patients with PTSD 53 ) as painful sensations. ...
Psychological trauma is typically accompanied by physical pain, and posttraumatic stress disorder (PTSD) often co-occurs with chronic pain. Clinical reports suggest that pain in the aftermath of trauma may be part of a re-experiencing symptomatology. Previously, we demonstrated that classical conditioning can underlie visual re-experiencing since intrusions appear to occur as conditioned responses (CRs) to trauma-related cues. Possibly, classical conditioning also plays a role in re-experiencing of pain. However, this hypothesis has so far remained untested. Sixty-five participants underwent classical conditioning, where painful electrical stimulation and highly aversive film-clips served as unconditioned stimuli (USs) in a 2 (pain/no pain) x 2 (aversive/neutral film) design. Conditioned stimuli (CSs) were neutral pictures depicting contextual details from the films. One day later, participants were re-exposed to CSs during a memory-triggering-task (MTT). Pain-CRs were assessed by self-report and an fMRI-based marker of nociceptive pain, the neurologic pain signature (NPS).During conditioning, pain-signaling CSs elicited more self-reported pain and NPS responses than no-pain-signaling CSs. Self-reported pain-CRs but not NPS CRs recurred 24h later when participants were re-exposed to CSs during MTT. Both during acquisition and MTT, the aversive affective film-context blurred the difference in participants´ pain-reports to pain-signaling and no-pain-signaling CSs.Our data support the hypothesis that pain can emerge as a classically conditioned response. Pain as a CR to pain-signaling cues could represent an instance of pain re-experiencing in PTSD. Possibly, this mechanism may perpetuate pain beyond tissue healing and thereby explain the comorbidity between chronic pain and PTSD.
... CSA and other forms of child maltreatment leave their traces on the subjective experience of self and body. Particularly, it has been postulated that "the body keeps the score" (van der Kolk, 2015), and that trauma may result in post-traumatic orientation to bodily signals (Tsur, 2020;Tsur et al., 2018). Experiences of pain related to CSA may correspond with the essential experience of uncontrollable, invasive, interpersonal manifestations of abuse (Tsur et al., 2017). ...
The literature on child sexual abuse (CSA) has contributed significantly to the understanding of its characteristics, epidemiology, and consequences. Considerably less attention has been dedicated, however, to the subjective experiences of the abused children, and more specifically to their experiences of pain. The current study explored the way children perceive and describe pain during and shortly following incidents of sexual abuse. The sample was comprised of 35 transcripts of forensic interviews following alleged CSA. Thematic analysis of the children’s narratives identified three themes: (a) pain during the abusive incidents, described using words indicating its intensity and quality; (b) pain shortly after the abusive incidents, including weeks later, and (c) pain as embedded within the complex dynamic with perpetrator. The children struggled to localize the pain, mainly using words such as “inside” and “deep.” Moreover, they testified that in the course of the abusive incidents, they were often silenced when trying to communicate their pain to the perpetrators. The children’s narratives provided us with a unique opportunity to learn about the pain not only during the abusive incidents but also following it. Additionally, children described suffering from pain in areas that were not directly injured during the CSA incidents, mainly referring to the head, abdomen and legs. The discussion addresses the potential intervening factors in peritraumatic CSA pain, as well as its potential links with chronic post-traumatic physical and mental morbidity. This study illuminates the necessity to address the complicated links between short- and long-term physical, emotional, cognitive, and interpersonal manifestations of CSA.
... Few reports examine the course of chronic pain and chronic PTSD. In a longitudinal study of Israeli prisoners of war, Tsur, Defrin, Lahav & Solomon (2018) measured PTSD and pain symptoms at three times over the course of 35 years, along with pain catastrophizing and anxiety sensitivity. The authors suggest that hyperarousal symptoms (e.g., hypervigilance) may be particularly important in sustaining the link between PTSD symptoms and maladaptive reactions to somatic signals (e.g., pain). ...
Chronic pain and chronic PTSD are often comorbid sequelae in patients who have experienced life-threatening experiences such as combat, assaults, or motor vehicle accidents, presenting lifelong challenges for patients and for medical management in all settings. This article briefly reviews four models for exploring the interrelationships of chronic pain and chronic PTSD. The article presents a longitudinal case study, documented over 10 years, of a patient with chronic back pain, and delayed-onset chronic PTSD related to sexual trauma experienced as a young adult. Data from the case study are examined for evidence in support of the chronic pain/chronic PTSD models. There is evidence to support all four models, with considerable evidence supporting the Mutual Maintenance Model (Sharp & Harvey, in Clinical Psychology Review 21(6): 857-77, 2001). Data show significant recovery over time from both conditions with improvements in function, work, and relationships, in response to Psychodynamic Therapy (PDT), Cognitive Behavioral Therapy (CBT), and hypnotic interventions, physical therapy, and pilates-based exercise. Notably, both chronic conditions were addressed simultaneously, with providers working collaboratively and sharing information through the patient. Emphasis is on non-pharmaceutical rehabilitative trauma-informed and patient-centered approaches to care.
... Particularly, individuals who were exposed to CA may react to health-related threats with elevated fear and anxiety as well (Hein & Monk, 2017;Van der Kolk, 2015). Such understanding arises from findings showing that individuals who were exposed to interpersonal trauma tend to perceive bodily signals as catastrophic and frightening, presumably indicating dreadful consequences (Sansone et al., 2013;Tsur et al., 2018). Furthermore, findings reveal that CA is often implicated in elevated levels of health anxiety in adulthood (Reiser, McMillan, Wright, & Asmundson, 2014). ...
Background
The COVID-19 pandemic exposes individuals not only to health-related risks, but also to psychosocial fear and acute stress. Previous studies reveal that individuals who experienced child abuse (CA), especially those who suffer from complex posttraumatic stress disorder (CPTSD), are at a higher risk of reacting with fear and stress when faced with stressful life-events.
Objective
To test whether exposure to CA is implicated in a higher risk of COVID-19-related fear and acute stress, and whether CPTSD intervenes in such processes.
Participants and settings
A convenience sample of 837 adults participated in the study during the first peak of COVID-19 in Israel.
Methods
Participants completed self-report questionnaires, assessing child physical, sexual and emotional abuse, CPTSD (ITQ), COVID-19-related acute stress disorder (COVID-19 ASD; ASDS) and fear of COVID-19.
Results
Bivariate analyses showed that participants who experienced CA were higher than participants who did not experience CA in COVID-19 ASD (p = .032), but not in fear of COVID-19 (p = .65). Mediation analyses demonstrated two significant paths: in the first, CA was associated with elevated fear of COVID-19 (effect = .061, .059; p < 0.05) and COVID-19 ASD (effect = .14, .084; p < 0.05) through the mediation of CPTSD; in the second path, when controlling for the mediation of CPTSD, CA was associated with reduced fear of COVID-19 (effect = −.15; p = 0.001), and COVID-19 ASD (effect = −.12; p = 0.024).
Conclusions
The findings reveal a complex pattern, indicating that CPTSD may be a risk factor for elevated levels of COVID-19 distress among individuals who experienced CA. However, some CA survivors may express reduced COVID-19 distress.
... A growing body of knowledge reveals that interpersonal trauma is not merely implicated in the functioning of the body, but also in the ways in which traumatized individuals perceive, interpret, and experience their bodily signals (van der Kolk, 2015). Such findings reveal that individuals who were exposed to interpersonal trauma tend to perceive bodily signals as catastrophic and frightening, potentially indicating serious dreadful conditions and consequences (Tsur et al., 2018). Stemming from these understandings, and combined with the illness personification theory (Schattner et al., 2008;Shahar & Lerman, 2013), a new research arena has emerged, which sheds light on the ways in which individuals who experienced trauma personify their bodily signals. ...
Child abuse has been shown to increase the risk for chronic pain. The illness personification theory implies that individuals tend to ascribe humanlike characteristics to chronic pain, and that this personification is embedded in the way they cope with their chronic condition. Recent findings demonstrate that individuals who experienced interpersonal violence tend to personify chronic pain in a way that resonates with past abusive experience. Although findings prevail to the link between trauma and the experience of the body, the personification of chronic pain among individuals who experienced child abuse has not been examined before. This article includes two studies that tested whether child abuse is implicated in abusive chronic pain personification in a young adult female sample (Study 1) and among females who experienced child abuse (Study 2). In both studies, self-report measures of child abuse, posttraumatic stress (PTS) symptoms, complex posttraumatic symptoms (disturbances of self-organization [DSO]), and abusive chronic pain personification were administered. Structural equation modeling was utilized to assess the hypotheses. The findings of the two studies showed a significant association between child abuse and pain personification. Whereas PTS symptoms did not mediate this link (Study 1), DSO symptoms mediated this association (Study 2). The findings of these studies support the understanding that the experience of interpersonal violence is engraved in the experience of the body, as reflected in abusive chronic pain personification. Disturbances in self-organization seem to underlie this process, thus pertaining to the link between the experience of the body, self, and interpersonal trauma.
... Both PTSD and pain are characterized by the awareness of such somatic symptoms enduring beyond the acute stage. The ongoing experience of these symptoms, particularly outside the context of an actual life-or injury-threatening event, may induce misgivings or even fear of one's somatic symptoms (Tsao et al., 2009;Tsur, Defrin, Lahav, & Solomon, 2018;Van der Kolk, 2014;Vervoort, Goubert, Eccleston, Bijttebier, & Crombez, 2005;Vlaeyen & Linton, 2000). The model of somatosensory amplification, developed initially for hypochondriasis (Barsky, 1992;Barsky & Wyshak, 1990;Barsky, Goodson, Lane, & Cleary, 1988), posits that, particularly under stress, individuals may experience ambiguous somatic symptoms more intensely, which commands their attention and ultimately reinforces misperceptions. ...
Objective:
Posttraumatic stress disorder (PTSD) is associated with somatic and cognitive changes, which may be magnified when accompanied by persistent pain. The mechanisms of somatic sensation processing may extend to cognitive symptoms, revealing a potential generalization of impairment across cognitive and somatic domains in PTSD. We hypothesized that somatic burden would mediate relationships between PTSD, pain, and perceived cognitive impairment.
Methods:
Two samples-360 trauma-exposed college students and 268 mechanical Turk users-completed self-report measures.
Results:
Both samples revealed similar findings. There was a significant indirect effect of PTSD and pain on perceived cognitive problems through somatic burden. There remained a direct effect of PTSD symptoms. These findings indicate that in trauma-exposed samples with pain, somatic burden rather than pain severity accounts for perceived cognitive problems.
Conclusion:
High somatic burden may reflect an underlying appraisal about somatic cues, which extend in part to interpretation of cognitive cues.
... Thereby, witnessing a traumatic injury of a close relative may render the fragility of the physical body, thus impeding the sense of confidence and security of somatic integrity and functioning. Corresponding with the distrust in one's body that often accompanies PTS symptoms (Van Der Kolk, 2014), relatives may develop what is considered as posttraumatic orientation to bodily signals (Tsur, Defrin, Lahav, & Solomon, 2018). This, in turn, may affect their perception of personal physical and mental health (Tsur, Defrin, & Ginzburg, 2017). ...
Severe Traumatic brain injury (sTBI) often instigates widespread long-lasting disability and is accompanied by extensive rehabilitation. Unsurprisingly, sTBI also holds malignant consequences for patients' close relatives. The burden caused by the injury and its severity explains some of the ramifications for the relatives. Additionally, some findings demonstrate that patients with sTBI and their relatives develop posttraumatic stress (PTS) symptoms. However, although the link between PTS symptoms and physical and mental health is well-documented in literature, the effect of PTS symptoms on relatives of patients with sTBI has barely been examined. This study examines the influence of PTS symptoms of patients with sTBI and their relatives on the physical and mental health and functioning of the relatives. Patients who sustained a severe sTBI (Abbreviated Injury Scale of the head region > 3) and close relatives were included in a multi-center, prospective cohort study (TRAST-MI). One-hundred patients and their relatives were assessed at 2, 6, and 12 months post injury. Outcome variables included health-related quality of life (SF-12) as well as emotional, cognitive, interpersonal, and total functioning (PCRS). Relatives' physical health was predicted by relatives' PTS symptoms (Slope=-1.76; p = .043), and mental health was predicted by both patients' (Slope=-2.77; p = .034) and relatives' (Slope=-6.59; p < .001) PTS symptoms. Functioning level was only predicted by patients' PTS symptoms (Slope=-.25; p< .001). The findings emphasize that TBI should be considered a comprehensive traumatic experience reaching further than mere physical damage to the brain and its direct consequences, affecting the injured individual and close relatives.
... Post-Traumatic Stress Disorder is described as a complex pathological reaction to trauma wherein traumatic experiences may compromise feelings of safety in the affected person's own body or environment (Tsur et al., 2018). Trauma occurring during childhood can lead to disrupted neurological development which can have long-term impacts on cognitive function (Mueller and McCullough, 2017). ...
The use of horses in equine-assisted activities may be stressful to the animals. This study hypothesised that horses exposed to humans with PTSD would display more signs of stress than with ‘neurotypical’ humans. After 5 minutes of baseline observation, 17 therapy horses (16.4±3.6 years) were individually subjected for 2 minutes in a round pen to each of four humans clinically diagnosed with Post Traumatic Stress Disorder (PTSD). A professional acting coach then instructed four neurotypical humans matched physically to the PTSD humans in emulating the physical movements of their paired PTSD subject, after which the neurotypical humans were tested in the same manner. Heart rate (HR; bpm) and behavioral observations indicative of stress in the horse (gait, head height, ear position, distance from the human, latency of approach to the human, vocalisations and chewing) were collected every 5 seconds throughout each trial and analysed using a repeated measures GLM with Sidak’s multiple comparisons between treatments and time periods. Horse behaviors did not differ between PTSD and neurotypical humans (F1,21864=2.63, P>0.1). However, a post-hoc analysis showed that horses approached quicker (F1,54=6.2, P<0.001), stood closer (F1,3756=9.14, P<0.01), and oriented their ears (F1,3704=13.07, P<0.0003) more toward humans who were experienced with horses (N=4). Horse HR was lower when paired with inexperienced humans (N=4; F1,21531=16.9, P<0.0001). Horses do not appear to respond differently to humans with PTSD than to those without, but they were more attentive to humans with more horse experience. Understanding horse responses can lead to improved welfare and horse and human safety.
Keywords: equine-assisted activities; PTSD; behavior; heart rate
... Post-Traumatic Stress Disorder is described as a complex pathological reaction to trauma wherein traumatic experiences may compromise feelings of safety in the affected person's own body or environment (Tsur et al., 2018). Trauma occurring during childhood can lead to disrupted neurological development which can have long-term impacts on cognitive function (Mueller and McCullough, 2017). ...
Recent studies have indicated that CM (child maltreatment) may influence individuals' perception of their bodies, often resulting in a posttraumatic orientation to bodily signals (OBS). Given the intricate relationship between bodily and interpersonal experiences, it is hypothesized that posttraumatic OBS may be intergenerationally transmitted. However, knowledge regarding this phenomenon, and its underlying mechanisms, remains limited. Two studies tested (a) the link between CM and posttraumatic OBS, mediated by posttraumatic stress (PTS) symptoms and attachment security, and (b) the intergenerational transmission of a posttraumatic OBS following CM among dyads of parents and their young adult offspring. The first study included 445 young adults (mean age = 352, SD = 10.2), and the second study included 393 dyads (parents’ mean age = 58, SD = 5.91; offspring's mean age = 27, SD = 3.91). The participants completed self-reported questionnaires. Study 1 found that posttraumatic OBS was associated with CM, through the mediation of PTS symptoms (indirect effect = 0.15, p = .005), and insecure attachment (indirect effects between 0.132 and 1.44, p < .006). The second study found two pathways of intergenerational transmission. The first pathway showed indirect paths between parents’ CM exposure and offspring’s posttraumatic OBS, through parents’ reaction to CM (PTS symptoms, anxious attachment, and avoidant attachment) and posttraumatic OBS (indirect effects between 0.006 and 0.013, p < .039). The second pathway revealed indirect links between parents’ CM exposure and offspring’s posttraumatic OBS, through parents’ and offspring’s reaction to CM (indirect effects between 0.006 and 0.56, p < .015). The study’s findings add empirical evidence that posttraumatic OBS is a significant implication of CM. The second study illuminates the intergenerational transmission of a posttraumatic OBS following parental CM exposure, uncovering PTS symptoms, and insecure attachment styles as potential underlying mechanisms.
Background
PTSD is associated with greater incidence of chronic pain. Pain catastrophizing often accounts for this association. Less is known about these relationships during the acute phase (1–2 months) following orthopedic traumatic injuries. We sought to understand which orthopedic traumatic injury-related PTSD symptoms were associated with acute pain and physical dysfunction and whether pain catastrophizing accounted for these associations.
Methods
This secondary analysis uses baseline data from a multisite randomized controlled trial of an intervention for individuals with heightened pain catastrophizing or pain anxiety following acute orthopedic injury. We used partial correlations to examine associations between PTSD symptom clusters (re-experiencing, avoidance, negative alterations in cognitions and mood, and hyperarousal) and pain outcomes (pain intensity and physical dysfunction) controlling for pain catastrophizing. We used hierarchical regressions to evaluate unique associations between PTSD clusters and pain outcomes. In exploratory analysis, we examined the indirect effects of PTSD symptoms on pain outcomes through catastrophizing.
Results
Hierarchical linear regressions indicated that hyperarousal was uniquely associated with greater pain intensity with activity (β = 0.39, p < 0.001, ΔR2 =0.06) and physical dysfunction (β = 0.22, p = 0.04 ΔR2 =0.02). PTSD symptoms were still associated with pain with activity even with pain catastrophizing included in the models, and catastrophizing did not have a significant indirect effect on the relationship between PTSD and physical dysfunction (b=0.06, SEBoot=0.04, 95% CIBoot = [-0.003, 0.14]). Pain catastrophizing did largely account for the association between re-experiencing, avoidance, and negative alterations in cognitions and mood symptoms and pain at rest.
Conclusions
Pain catastrophizing interventions may be best suited for limiting the impact of PTSD symptoms on pain at rest, but catastrophizing alone may not fully explain the relationship between PTSD symptoms and physical dysfunction after acute orthopedic injury. To prevent the negative association of PTSD symptoms, especially hyperarousal, on physical outcomes in acute pain populations, interventions may require more than solely targeting pain catastrophizing.
Chronic pain is highly comorbid with posttraumatic stress disorder (PTSD), a disorder characterized by avoidance, hypervigilance, negative cognitions and affect, and intrusive symptoms (e.g., flashbacks), particularly among military personnel and those who are more vulnerable at developing this comorbid condition. This chapter describes the evolution of understanding pain from unidimensional Cartesian models to more complex models that culminated in the predominant contemporary biopsychosocial model, which accurately acknowledges that the experience of pain cannot be explained solely through the physical experience and that the physical experience is affected by factors seemingly unrelated to one's physical pain. This chapter also discusses two predominant theories that explain the chronic pain and PTSD comorbidity: the shared vulnerability model and the mutual maintenance model. The shared vulnerability model posits that anxiety sensitivity and genetic predispositions (particularly as they relate to the hypothalamic-pituitary-adrenal axis and stress response) make it more likely that certain individuals will develop this comorbidity. Similarly, the mutual maintenance model highlights seven different cognitive and emotional processes that form a shared mechanism of comorbidity: attentional biases, anxiety sensitivity, reminders of the traumatic experiences, avoidance, negative affect and decreased physical activity, negative perceptions of illness, and the inability to use effective coping strategies. This chapter examines the current state of these theories, discusses the existing treatments for comorbid pain and PTSD (both pharmacologic and nonpharmacologic), and offers suggestions on future directions for research and clinical care that may guide ongoing efforts to effectively treat these complex patient populations (e.g., a focus on patient identity).
Experiences of childhood abuse may have detrimental effects on the psychopathological and psychophysiological level. Evidence from previous studies mainly supports the notion that CA-exposed individuals show higher psychopathological impairment, such as intrusive experiences, dissociation, impaired general functioning, as well as reduced satisfaction with QoL and sexuality, as compared to individuals who have not been exposed to CA. On a psychophysiological level, this impairment is reflected by elevated HR and reduced HRV levels. Additionally, altered pain sensitivity has been associated with a history of CA. As a major limitation, the majority of these studies did not assess or control for effects of mental disorders (i.e., PTSD), preventing from disentangling effects of trauma and a PTSD diagnosis. Another branch of research has explicitly assessed these variables in individuals with PTSD related to CA and other kind of PTE and has found comparable results in the respective variables. However, up to this point, there is a research gap of studies on CA-exposed individuals both with and without PTSD that may disentangle the effects of the mere exposure to CA per se against the effects of a consequential PTSD diagnosis. The aim of this dissertation was to examine a broad range of relevant psychopathological and psychophysiological sequelae of childhood abuse in women without mental disorders in order to disentangle the effects of trauma and psychopathology. For this purpose, two studies were conducted in order to focus on relevant psychopathological and psychophysiological aspects that are known to be impaired after experiencing CA and in patients with PTSD related to CA. These relevant aspects encompassed a broad range of general and PTSD-specific psychopathology, general functioning, quality of life, and satisfaction with sexuality. Additionally, stress responsiveness was examined at the subjective and psychophysiological level in response to experimentally induced stress. Furthermore, pain sensitivity at baseline as well as in response to stress were examined. These features were examined in HTEW as compared to HC women without a history of CA and female patients with PTSD related to experiences of CA. In study I, HTEW showed a high level of functioning and a very low level of pathological impairment that was comparable to the level of healthy controls. The results of study I in this dissertation suggest that PTE exposure per se does not necessarily have to go along with the development of psychopathology or impaired quality of life, sexuality, self-esteem, or guilt cognitions. Results of the present study rather suggest an association of PTSD and impairment in the reported variables. In the second study, the most distinct and clinically meaningful effects between HTEW and PTSD-patients were observed concerning subjective stress parameters. With regard to subjective ratings of stress and dissociation, HTEW were clearly different from PTSD-patients while resembling the group of HC. With respect to the psychophysiological parameters (HR and HRV) and pain sensitivity, the picture was less clear: Although HTEW differed significantly from PTSD-patients with respect to HR and HRV, differences were not as pronounced as for the subjective ratings. With respect to pain sensitivity in response to experimentally induced stress, comparisons of HTEW and PTSD-patients only approached significance. In comparison to HC, HTEW differed significantly for HR, HRV, and pain sensitivity. On a descriptive level, HR, HRV and pain sensitivity levels of HTEW were located in between levels of HC and of PTSD-patients. Results of the second study of this dissertation reveal that differences between HTEW and PTSD-patients in baseline stress levels as well as stress responses were most distinct in subjective as compared to psychophysiological readouts. This may imply that subjective stress rating and dissociation may be seen as diagnostic correlates of PTSD rather than being related to experiences of CA per se. Results of the objective stress indicators draw a less clear picture: Although HTEW differed significantly from PTSD-patients and HC with respect to HR and HRV, differences between HTEW and PTSD-patients were not as pronounced as for the subjective indicators of stress. Taken together, based on recent advances in this field as well as results of our own work, it is proposed that psychopathology in form of a PTSD diagnosis seems to contribute to more general psychopathology (i.e., intrusions and dissociation), impaired general functioning, reduced QoL and satisfaction with sexuality, impaired baseline stress levels as well as stress responsiveness on a subjective as well as psychophysiological level. However, results of study II also suggest that one cannot exclude an additional role of CA on psychophysiological stress responses as well as pain sensitivity as the data also indicates that a small proportion of altered stress response may relate to experiences of CA per se. The contribution of this dissertation is an increased knowledge on the sequelae of CA apart from developing PTSD. Improved knowledge on the sequelae of CA may help identifying novel diagnostic markers to detect individuals who are at risk of developing PTSD. An early detection of vulnerability to PTSD in turn would help prevent developing a full-blown PTSD, as preventive programs could be called into action at an earlier stage. Furthermore, the recognition of these mechanisms and sequelae can help improve treatment planning in terms of potential accompanying symptoms that are not entailed as diagnostic criteria of PTSD (i.e., reduced self-esteem, reduced satisfaction with QoL and sexuality). Furthermore, results of this dissertation suggest that good self-esteem, absence of guilt cognitions, as well as the process of disclosure seem to be important in withstanding adversities unscathed. With potentially important implications for treatment, these findings highlight the importance of routinely inquiring about CA as well as educating and training support-providers and society about sexual and physical assault. Training programs should encompass how to respond to disclosure of CA in more supportive ways. Furthermore, the implementation of prevention programs focused on developing and supporting the adolescent’s sense of being a good and worthy person should be encouraged.
Objective:
Studies suggest that torture survivors often suffer long-term chronic pain and increased pain perception. However, it is unclear whether the actual experience of torture, or rather the subsequent posttraumatic stress disorder (PTSD), explains these pain problems. Furthermore, while catastrophic and fearful orientations to pain have been suggested to play a significant role in the association between trauma and pain, the underlying mechanisms remain unclear. This study examined whether chronic pain and pain perception among torture survivors are associated with torture experience or PTSD and whether catastrophic and fearful orientations mediate or moderate these associations.
Methods:
Fifty-nine ex-prisoners of war who underwent torture and 44 matched veterans participated in this study. Pain perception was evaluated by assessing pain-threshold, and reactivity to experimental suprathreshold noxious stimuli. Participants completed self-administered questionnaires assessing PTSD, chronic pain, pain catastrophizing, and fear of pain.
Results:
While chronic pain was associated with PTSD (.44<β<.49; p<.002), increased pain perception was correlated with torture (.33<β<.65; p<.05). Pain catastrophizing was found to mediate the association between PTSD and chronic pain (β=.18, .19; p<.05). Fear of pain moderated the association between torture and pain perception (β=.41, .42; p<.017).
Conclusions:
The findings suggest that chronic pain is contingent upon the psychological toll of torture, i.e. PTSD. This study also indicates that PTSD exacerbates catastrophic orientation, which in turn may amplify chronic pain. Reactivity to experimental noxious stimuli was related to prior experiences of torture, which enhances perceived pain intensity when interacting with a fearful pain orientation. These findings highlight the significance of orientation to bodily experiences following trauma.
Objective: Youth with posttraumatic stress disorder (PTSD) symptoms have significant difficulties regulating affective experiences; as a result, many engage in nonadaptive coping behaviors including deliberate self-harm (DSH). To identify youth with PTSD symptoms who may be most at risk for DSH, this study examined anxiety sensitivity (AS) as a moderator of the relationship between PTSD symptoms and DSH in a diverse sample of psychiatric inpatient youth with a history of potentially traumatic events (PTE). Method: Participants (N = 50; 52.0% female; Mage = 15.1 years, SD = .51; 44% White) completed a test battery that included measures of DSH frequency, depression, AS and PTSD symptomatology. Results: The proposed model accounted for 53.6% of variance in DSH, with PTSD symptoms being a significant predictor (sr² = .11). The interaction of PTSD symptoms and AS accounted for an additional 4.5% of variance above and beyond covariates and main effects. Simple slopes revealed that the association between PTSD symptoms and DSH was significant for individuals scoring high (b = .25, SE = .06; t(50) = 3.83, p < .01) but not low (b = .03, SE = .10; t(50) = 0.30, p = .765) on the AS. Conclusions: Findings are consistent with theoretical and empirical work suggesting that DSH may be used to reduce emotional distress in the presence of maladaptive cognitive and emotional processes.
Posttraumatic stress disorder (PTSD) is a common reaction to traumatic events. Many people recover in the ensuing months, but in a significant subgroup the symptoms persist, often for years. A cognitive model of persistence of PTSD is proposed. It is suggested that PTSD becomes persistent when individuals process the trauma in a way that leads to a sense of serious, current threat. The sense of threat arises as a consequence of: (1) excessively negative appraisals of the trauma and/or ist sequelae and (2) a disturbance of autobiographical memory characterised by poor elaboration and contextualisation, strong associative memory and strong perceptual priming. Change in the negative appraisals and the trauma memory are prevented by a series of problematic behavioural and cognitive strategies. The model is consistent with the main clinical features of PTSD, helps explain several apparently puzzling phenomena and provides a framework for treatment by identifying three key targets for change. Recent studies provided preliminary support for several aspects of the model.
Childhood adversity has frequently been related to a wide range of psychosomatic complaints in adulthood. The present study examined the relationship between different forms of childhood adversity and laboratory measures of pain. Heat pain tolerance and perceived heat pain intensity were measured in a community-based sample of 62 women (aged 20–64 years). Participants completed the Childhood Trauma Questionnaire (CTQ), which assesses five forms of childhood adversity: physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect. Somatic symptoms, depressive symptoms, and pain catastrophizing were assessed as potential mediators. Bivariate analyses indicated that emotional abuse but no other forms of childhood adversity were significantly related to decreased heat pain tolerance (r=−0.27; P<0.05). Accordingly, multiple regression analyses revealed that only emotional abuse was a significant predictor of heat pain tolerance (β=−0.62; P=0.034) when entering all CTQ subscales simultaneously. Although emotional abuse was also related to somatic symptoms, depressive symptoms, and pain catastrophizing, none of these variables mediated the relationship between childhood adversity and laboratory pain (P>0.1). No significant associations were found between any forms of childhood adversity and heat pain intensity. Our findings indicate that the severity of emotional childhood abuse is associated with decreased pain tolerance, an affective component of pain, but not with heat pain intensity, which has been described as a sensory component of pain.
Significance
These findings indicate that the combination of shorter leukocyte telomeres with high telomerase activity is associated with stress-related impairment of function at both the biological and psychological levels. Slow poststress recovery in cardiovascular activity in inflammatory responses and reduced stress responsivity in blood pressure and cortisol are indicative of a state of heightened allostatic load. Older men with the shorter telomere/high telomerase phenotype also show impoverished resources for dealing with stress, including low levels of social support and optimism and higher levels of hostility. The integrated approach taken in this study advances our understanding of the cellular substrate of stress-related processes and documents the dynamic interplay between social environmental exposures and the mechanisms underlying chromosomal integrity.
We propose the term illness personification (ILL-PERF) as an organizing theme
shedding light on the ways individuals live with, under, and outside of chronic physical
illness. Drawing from multiple theoretical sources—object relations theory, social–
cognitive theory, existential phenomenology and neuroscience—as well as from our
own research program on chronic pain and systemic lupus erothemathosis (LSE), we
argue that individual differences in the tendency to ascribe human characteristics to
physical illness play an important risk/resilience role in illness-related disability and
emotional distress. We then describe the way ILL-PERF might be incorporated into
extant—and integrative—treatments of chronic physical illness.
Pain catastrophizing is a well-known concept in the pain literature and has been recognized as one of the most powerful psychological determinants of negative outcomes for pain problems. However, relatively little effort has been put into developing its theoretical underpinnings. More specifically, the intrinsic function of catastrophizing is not explicitly dealt with in contemporary theoretical models. The aim of this article is to add to existing models by proposing a development of the conceptualization of catastrophizing that stresses its function as an emotion regulator. We argue that catastrophizing can be conceptualized as a form of negative repetitive thinking, which is abstract, intrusive, and difficult to disengage from. It has been argued that repetitive negative thinking is a form of ineffective problem solving that functions to downregulate negative affect and that it can be regarded as an avoidant coping strategy because it impedes processing of emotional and somatic responses. Thus, in our conceptualization, catastrophizing is proposed to be a form of problem-solving behavior that functions to reduce negative emotion triggered by pain, and other related stimuli. Furthermore, we argue that catastrophizing is preferably regarded as a process where cognitions, emotions, and overt behavior are intertwined and not viewed as separate entities. To underscore the latter, we suggest the term catastrophic worry. Our intention with this development of the conceptualization is to give rise to new ideas for research and clinical practice and to revitalize discussions about the theoretical framework around pain-related catastrophizing.
Pain catastrophising has been broadly defined as an exaggerated negative orientation to actual or anticipated pain comprising elements of rumination, magnification, and helplessness. Hundreds of studies have documented associations between pain catastrophising and adverse pain outcomes, including heightened pain intensity, mental health problems, and disability. This article contrasts different conceptual models that have been advanced to explain how pain catastrophising might impact on pain outcomes. It is argued that traditional "intrapersonal" models of pain catastrophising are overly simplistic and lacking in explanatory power. Research is reviewed showing that interpersonal variables and social context are central determinants of the relation between pain catastrophising and pain outcomes. Discussion addresses the clinical implications of research showing that interpersonal factors underlie the relation between pain catastrophising and adverse pain outcomes. Discussion also addresses the implications of research on the interpersonal dimensions of pain catastrophising for theories of the psychology of pain.
In Study 1, the Pain Catastrophizing Scale (PCS) was administered to 425 undergraduates. Analyses yielded a three component solution comprising (a) rumination, (b) magnification, and (c) helplessness. In Study 2, 30 undergraduate participants were classified as catastrophizers (n = 15) or noncatastrophizers (n = 15) on the basis of their PCS scores and participated in an cold pressor procedure. Catastrophizers reported significantly more negative pain-related thoughts, greater emotional distress, and greater pain intensity than noncatastrophizers. Study 3 examined the relation between PCS scores, negative pain-related thoughts, and distress in 28 individuals undergoing an aversive electrodiagnostic medical procedure. Catastrophizers reported more negative pain-related thoughts, more emotional distress, and more pain than noncatastrophizers. Study 4 examined the relation between the PCS and measures of depression, trait anxiety, negative affectivity, and fear of pain. Analyses revealed moderate correlations among these measures, but only the PCS contributed significant unique variance to the prediction of pain intensity.
Empirically supported psychosocial treatments for posttraumatic stress disorder (PTSD) all entail some form of trauma-related exposure therapy. Although these treatments are often useful, none are effective for all patients. Even those who respond are often left with residual symptoms. A better understanding of the causes of PTSD may lead to more effective treatments. The present article reviews the nascent but steadily growing research on the role of anxiety sensitivity (fear of arousal-related sensations) in PTSD. Available research suggests that anxiety sensitivity may play an important role and that treatments that directly target anxiety sensitivity (such as interoceptive exposure) may improve outcome, particularly if these treatments are implemented before commencing trauma-related exposure therapy.
This paper describes the development of a multidimensional self-report measure of interoceptive body awareness. The systematic mixed-methods process involved reviewing the current literature, specifying a multidimensional conceptual framework, evaluating prior instruments, developing items, and analyzing focus group responses to scale items by instructors and patients of body awareness-enhancing therapies. Following refinement by cognitive testing, items were field-tested in students and instructors of mind-body approaches. Final item selection was achieved by submitting the field test data to an iterative process using multiple validation methods, including exploratory cluster and confirmatory factor analyses, comparison between known groups, and correlations with established measures of related constructs. The resulting 32-item multidimensional instrument assesses eight concepts. The psychometric properties of these final scales suggest that the Multidimensional Assessment of Interoceptive Awareness (MAIA) may serve as a starting point for research and further collaborative refinement.
The formal acceptance of posttraumatic stress disorder (PTSD) as a legitimate diagnostic category in the 1980 Diagnostic and Statistical Manual of Mental Disorders stimulated a torrent of research on psychological trauma. Not surprisingly, PTSD and its treatment had dominated that research. Another common approach has been to measure the average impact of different potentially traumatic events, as well as the factors that inform that impact. In this article, we consider the limitations of these perspectives and argue for a broader theoretical approach that takes into account the natural heterogeneity of trauma reactions over time. To that end, we review recent attempts to identify prototypical patterns or trajectories of trauma reaction that include chronic dysfunction, but also delayed reactions, recovery, and psychological resilience. We consider the advantages but also the limitations and ongoing controversies associated with this approach. Finally, we introduce promising new research that uses relative sophisticated advances in latent growth mixture modeling as a means of empirically mapping the heterogeneity of trauma responses and consider some of the implications of this approach for existing trauma theories. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
A recent cross-sectional study of National Guard troops found that pain and pain catastrophizing were prevalent and highly correlated with posttraumatic stress disorder (PTSD). At issue in the present study was whether pain and catastrophizing before military deployment could account for individual differences in PTSD symptoms after deployment. An anonymous survey was administered to a population sample of New Jersey National Guard troops before they were sent overseas and again when they returned home (1year later). The survey included a validated PTSD screening questionnaire, numerical ratings of pain intensity, and a measure of pain catastrophizing. A cohort of 922 National Guard members completed the survey before and after deployment. An uncontrolled analysis indicated that pain and catastrophizing before deployment were significantly but modestly associated with PTSD symptoms after deployment (accounting for 4.5% and 1.3% of the variance, respectively). A hierarchical regression model that controlled for sex, preexisting PTSD symptoms, and recent combat found that pain but not pain catastrophizing explained variance in postdeployment PTSD. The size of the effect, however, was negligible (0.8%, p<.01). Consistent with previous research, a cross-sectional analysis revealed that postdeployment pain and catastrophizing successfully accounted for unique variance in postdeployment PTSD. The failure of longitudinal predictors in the present study, therefore, cannot be attributed to insensitive screening instruments. These findings offer little or no support for the hypothesis that predeployment pain and catastrophizing can account for individual differences in PTSD after exposure to combat trauma.
Although war captivity is a potent pathogen for psychiatric illness, little is known about the long-term trajectories of post-traumatic stress disorder (PTSD) among ex-prisoners of wars (ex-POWs). This study aimed to assess the long-term trajectories of PTSD and their predictors following war captivity. One hundred and sixty four Israeli ex-POWs and 185 comparable combatants from the 1973 Yom Kippur War were followed over 35 years, with three follow-ups (1991, 2003, 2008). Ex-POWs reported higher PTSD rates than controls at all three assessments. Four trajectories of PTSD were identified: chronic PTSD, delayed PTSD, recovery and resilience. The majority of POWs reported delayed PTSD, while the majority of controls were classified as resilient. While PTSD rates remained relatively stable over time among controls, a steep increase in rates was observed among POWs between 1991 and 2003, followed by stabilization in rates between 2003 and 2008. Finally, subjective experience of captivity was the variable that best distinguished between the resilience and PTSD groups of ex-POWs, followed by participation in previous wars and negative life events during childhood. War captivity carries long-lasting psychiatric implications, even decades after release. Aging processes, as well as unique stressors that exist in Israel, may account for the elevated PTSD rates found here.
Forty-one DSM-III-R hypochondriacs and seventy-five randomly chosen patients were obtained from a medical outpatient clinic, and completed a psychiatric diagnostic interview and a ten-item self-report questionnaire, the Somatosensory Amplification Scale (SSAS); The SSAS asks the respondent how much s/he is bothered by various uncomfortable visceral and somatic sensations, most of which are not the pathological symptoms of serious diseases. SSAS scores were normally distributed, and had acceptable test-retest reliability and internal consistency. They were not related to sociodemographic characteristics, or to aggregate medical morbidity. Amplification was significantly higher in the DSM-III-R hypochondriacs than in the comparison sample, and was significantly correlated with the degree of hypochondriacal symptomatology within each sample. In the comparison sample, it was also significantly associated with depressive and anxiety disorders, but not with antisocial personality or substance abuse. The association between the amplification scale and DSM-III-R hypochondriasis remained highly significant after controlling for these concurrent psychiatric disorders.
The present article addresses two related developments in the psychology of pain, and integrates them into a coherent framework to better understand the relationship between pain and trauma. The first is an emerging conceptualization regarding the nature of the hierarchical organization of major pain-related anxiety constructs. The second is the theoretical rationale and empirical evidence linking pain and symptoms of post-traumatic stress disorder.
To explore the underlying hierarchical factor structure of commonly used pain-related anxiety measures including the Pain Anxiety Symptoms Scale (PASS-20), the Pain Catastrophizing Scale (PCS), and the Anxiety Sensitivity Index (ASI); and to relate this structure to post-traumatic stress disorder in patients scheduled for major surgery.
Measures were completed by 444 patients scheduled to undergo major surgery. Exploratory factor analysis and subsequent higherorder analysis using the Schmid-Leiman transformation were conducted to investigate the underlying factor structure of the ASI, the PCS and the PASS-20.
Twenty items from the ASI, the PASS-20 and the PCS loaded exclusively on one higher-order factor. The authors suggest the term 'sensitivity to pain traumatization' (SPT) for the underlying construct based in part on the strong, significant positive correlation between SPT scores and scores on the Post-traumatic Stress Disorder Checklist - Civilian Version. Finally, the total SPT score was significantly higher for patients with a history of pain than for those without a history of pain, both before surgery and one year after surgery. SPT describes the propensity to develop anxiety-related somatic, cognitive, emotional and behavioural responses to pain that resemble features of a traumatic stress reaction. Together, the results of the present study provide preliminary evidence for the construct validity of SPT.
There is a substantial literature relating the personality trait anxiety sensitivity (AS; tendency to fear anxiety-related sensations) and its lower order dimensions to the mood and anxiety (i.e., internalizing) disorders. However, particularly given the disorders' high comorbidity rates, it remains unclear whether AS is broadly related to these disorders or if it shows a pattern of differential relations. Meta-analyses of the concurrent relations of AS with the internalizing disorders were conducted based on 117 studies and 792 effect sizes. Mean Anxiety Sensitivity Index scores by diagnostic group and AS-symptom correlations both indicated that AS is most strongly related to panic, generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD). More specific analyses were also conducted on (a) AS correlations with symptom dimensions within individual disorders and (b) correlations between lower order AS components and symptoms. The meta-analytic correlation matrix for higher order AS-disorder relations was submitted to path analysis, modeling latent Distress disorders and Fear disorders that control for much of the shared variance among the disorders. Results of the path analysis indicated that AS is broadly related to these disorders but that agoraphobia, GAD, panic, and PTSD have the strongest associations. In addition, AS was more strongly related to the latent distress disorders than the fear disorders. Because of the contemporaneous assessment of AS and internalizing disorders in these studies, the results should not be taken to mean that AS has a stronger casual association with certain disorders. Implications for concurrent AS-internalizing relations, interpretations of the AS construct, and structural models of personality and psychopathology are discussed.
This study examined the relationships among anxiety sensitivity (AS), catastrophizing, somatization and pain in 240 non-clinical children (121 girls; mean age = 12.7 years). Children with pain problems (n = 81; 33.8%) reported greater AS and catastrophizing (ps < .01) relative to children without pain problems. AS but not catastrophizing was significantly associated with current pain. However, both AS and catastrophizing were significantly associated with somatization. AS and catastrophizing represent related but partially distinct cognitive constructs that may be targeted by interventions aimed at alleviating pain and somatization in children.
A growing body of work suggests that obese adults are less likely to adhere to exercise than normal-weight adults because they experience greater levels of discomfort and distress during exercise sessions. The present study introduces and provides a preliminary test of the hypothesis that the distress experienced during exercise among persons with elevated body mass index is particularly high among those who fear somatic arousal (i.e. elevated anxiety sensitivity [AS]). Young adults were randomly assigned to complete 20 min of treadmill exercise (at 70% of their age-adjusted predicted maximum heart rate) or 20 min of rest. Body mass, AS, and negative affect were measured at baseline, and fear was measured at 4-min intervals during the experimental phase. Consistent with the authors' hypothesis, there was a significant Exercise x BMI x ASI interaction (sr(2) = .08), suggesting that the greatest fear levels during exercise were observed among participants with high body mass, but only if they also had elevated AS. These findings offer a new approach for identifying specific vulnerable individuals and have clear clinical implications, given that the amplification factor of AS can be modified with clinical intervention.
Heightened body awareness can be adaptive and maladaptive. Improving body awareness has been suggested as an approach for treating patients with conditions such as chronic pain, obesity and post-traumatic stress disorder. We assessed the psychometric quality of selected self-report measures and examined their items for underlying definitions of the construct.
PubMed, PsychINFO, HaPI, Embase, Digital Dissertations Database.
Abstracts were screened; potentially relevant instruments were obtained and systematically reviewed. Instruments were excluded if they exclusively measured anxiety, covered emotions without related physical sensations, used observer ratings only, or were unobtainable. We restricted our study to the proprioceptive and interoceptive channels of body awareness. The psychometric properties of each scale were rated using a structured evaluation according to the method of McDowell. Following a working definition of the multi-dimensional construct, an inter-disciplinary team systematically examined the items of existing body awareness instruments, identified the dimensions queried and used an iterative qualitative process to refine the dimensions of the construct.
From 1,825 abstracts, 39 instruments were screened. 12 were included for psychometric evaluation. Only two were rated as high standard for reliability, four for validity. Four domains of body awareness with 11 sub-domains emerged. Neither a single nor a compilation of several instruments covered all dimensions. Key domains that might potentially differentiate adaptive and maladaptive aspects of body awareness were missing in the reviewed instruments.
Existing self-report instruments do not address important domains of the construct of body awareness, are unable to discern between adaptive and maladaptive aspects of body awareness, or exhibit other psychometric limitations. Restricting the construct to its proprio- and interoceptive channels, we explore the current understanding of the multi-dimensional construct and suggest next steps for further research.
We studied the role of somatosensory amplification, as measured by a self-report questionnaire, in symptomatology, overall discomfort, and disability in 115 patients with upper-respiratory-tract infections who visited an adult medical walk-in clinic. Multiple regression analyses indicated that amplification was a statistically significant predictor of the patients' localized but not systemic symptoms, of reported overall discomfort, and of their social and vocational disability. These relationships held true while controlling for differences in medical morbidity and sociodemographic characteristics. Amplification was closely related to, but distinct from, three measures of dysphoria: depression, anxiety, and hostility. The tendency to amplify a broad range of bodily sensations may therefore be an important factor in experiencing, reporting, and functioning with an acute and relatively mild medical illness.
Fifty‐two women who served during the Vietnam era were assessed for war‐zone exposure, traumatic life events, posttraumatic stress disorder (PTSD), and self‐reported health status. Symptoms of PTSD were examined as mediators in the relationship between traumatic exposure and subsequent reports of health problems. Results showed that PTSD symptoms accounted significantly for variance in health problems reported by women with prior traumatic stressor exposure. When the cardinal symptom domains of PTSD (reexperiencing, numbing, avoidance, hyperarousal) were analyzed separately, the symptom cluster representing hyperarousal accounted uniquely for the variance associated with health complaints, beyond that contributed by other symptom clusters. Discussion of the results focuses on mechanisms underlying the relationship between specific symptoms of PTSD and self‐reported health. Implications for intervention within the medical system are also considered.
Respiratory problems and posttraumatic stress disorder (PTSD) are the signature health consequences associated with the September 11, 2001 (9/11), World Trade Center disaster and frequently co-occur. The reasons for this comorbidity, however, remain unknown. Anxiety sensitivity is a transdiagnostic trait that is associated with both PTSD and respiratory symptoms. The present study explored whether anxiety sensitivity could explain the experience of respiratory symptoms in trauma-exposed smokers with PTSD symptoms. Participants (N = 135; Mage = 49.18 years, SD = 10.01) were 9/11-exposed daily smokers. Cross-sectional self-report measures were used to assess PTSD symptoms, anxiety sensitivity, and respiratory symptoms. After controlling for covariates and PTSD symptoms, anxiety sensitivity accounted for significant additional variance in respiratory symptoms (ΔR(2) = .04 to .08). This effect was specific to the somatic concerns dimension (β = .29, p = .020); somatic concerns contributed significantly to accounting for the overlap between PTSD and respiratory symptoms, b = 0.03, 95% CI [0.01, 0.07]. These findings suggest that the somatic dimension of anxiety sensitivity is important in understanding respiratory symptoms in individuals with PTSD symptoms. These findings also suggest that it may be critical to address anxiety sensitivity when treating patients with comorbid respiratory problems and PTSD.
Confirmatory factor analysis was used to compare 6 models of posttraumatic Stress disorder (PTSD) symptoms, ranging from I to 4 factors, in a sample of 3,695 deployed Gulf War veterans (N = 1,896) and nondeployed controls (N = 1,799). The 4 correlated factors-intrusions, avoidance, hyperarousal; and dysphoria-provided the best fit. The dysphoria factor combined traditional markers of numbing and hyperarousal. Model superiority was cross-validated in multiple subsamples, including a subset of deployed participants who were exposed to traumatic combat stressors. Moreover, convergent and discriminant validity correlations suggested that intrusions may be relatively specific to PTSD, whereas dysphoria may represent a nonspecific component of many disorders. Results are discussed in the context of hierarchical models of anxiety and depression.
Background:
Knowledge about the course of recovery after whiplash injury is important. Most valuable is identification of prognostic factors that may be reversed by intervention. The mutual maintenance model outlines how post-traumatic stress symptoms (PTSS) and pain may be mutually maintained by attention bias, fear, negative affect and avoidance behaviours. In a similar vein, the fear-avoidance model describes how pain-catastrophizing (PCS), fear-avoidance beliefs (FA) and depression may result in persistent pain. These mechanisms still need to be investigated longitudinally in a whiplash cohort.
Methods:
A longitudinal cohort design was used to assess patients for pain intensity and psychological distress after whiplash injury. Consecutive patients were all contacted within 3 weeks after their whiplash injury (n = 198). Follow-up questionnaires were sent 3 and 6 months post-injury. Latent Growth Mixture Modelling was used to identify distinct trajectories of recovery from pain.
Results:
Five distinct trajectories were identified. Six months post-injury, 64.6% could be classified as recovered and 35.4% as non-recovered. The non-recovered (the medium stable, high stable and very high stable trajectories) displayed significantly higher levels of PTSS, PCS, FA and depression at all time points compared to the recovered trajectories. Importantly, PCS and FA mediated the effect of PTSS on pain intensity.
Conclusions:
The present study adds important knowledge about the development of psychological distress and pain after whiplash injury. The finding, that PCS and FA mediated the effect of PTSS on pain intensity is a novel finding with important implications for prevention and management of whiplash-associated disorders. WHAT DOES THIS STUDY ADD?: The study confirms the mechanisms as outlined in the fear-avoidance model and the mutual maintenance model. The study adds important knowledge of pain-catastrophizing and fear-avoidance beliefs as mediating mechanisms in the effect of post-traumatic stress on pain intensity. Hence, cognitive behavioural techniques targeting avoidance behaviour and catastrophizing may be beneficial preventing the development of chronic pain.
Objective:
War captivity includes a unique constellation of simultaneous somatic and interpersonal assaults. This raises questions about the link between attachment and somatic complaints among ex-prisoners of war (ex-POWs). Although the attachment literature assumes that attachment affects somatic complaints and not vice versa, to date no empirical studies assess the association between the two variables over time. In this article we prospectively examine the association between attachment and somatic complaints over time among ex-POWs and comparable veterans.
Method:
The current study included two groups of male Israeli veterans of the 1973 Yom Kippur War: ex-POWs and comparable veterans who were not taken captive. Both groups were assessed via self-report measures at three times: T1 (1991), T2 (2003), and T3 (2008)-18, 30, and 35 years after the war, respectively.
Results:
Ex-POWs reported higher levels of somatic complaints and attachment insecurities. These levels increased over time compared to combatant veterans. Moreover, while there was a unidirectional influence of somatic complaints on attachment security over time among combatant veterans, this relationship was bidirectional among ex-POWs.
Conclusions:
The present study suggests that the combined physical and interpersonal assaults experienced during captivity have adverse effects on combatants and on attachment security, even three decades later. More important, in ex-POWs the relationship between these domains appears to be interactive and mutual, with one reinforcing the other, and vice versa.
Posttraumatic stress disorder (PTSD) and chronic pain often co-occur and exacerbate each other. Elucidating the mechanism of this co-occurrence therefore has clinical importance. Previously, PTSD patients with chronic pain were found to demonstrate a unique, paradoxical pain profile: hyper-responsiveness together with hyposensitivity to pain. Our aim was to examine whether two seemingly paradoxical facets of PTSD - anxiety and dissociation - underlie this paradoxical profile. PTSD patients (n=32) and healthy controls (n=43) underwent psychophysical testing and completed questionnaires. PTSD patients had higher pain thresholds and higher pain ratings to suprathreshold stimuli than controls. Pain thresholds were positively associated with dissociation levels and negatively associated with anxiety sensitivity levels. Experimental pain ratings were positively associated with anxiety sensitivity and negatively related to dissociation levels. Chronic pain intensity was associated with anxiety, anxiety sensitivity and pain catastrophizing. It appears that reduced conscious attention towards incoming stimuli, resulting from dissociation, causes delayed response in pain threshold measurement while biases towards threatening stimuli and decreased inhibition, possibly due to elevated anxiety, are responsible for the intensification of experimental and chronic pain. The paradoxical facets of PTSD and their particular influences over pain perception seem to reinforce the coexistence of PTSD and chronic pain, and should be considered when treating traumatized individuals.
This article provides new information regarding the underlying mechanism of the coexistence of PTSD and chronic pain. This knowledge could potentially help to provide better management of PTSD and chronic pain among individuals in the aftermath of trauma.
Copyright © 2015 American Pain Society. Published by Elsevier Inc. All rights reserved.
To evaluate the prevalence of DSM-5 posttraumatic stress disorder (PTSD) and factor structure of PTSD symptomatology in a nationally representative sample of US veterans and examine how PTSD symptom clusters are related to depression, anxiety, suicidal ideation, hostility, physical and mental health-related functioning, and quality of life.
Data were analyzed from the National Health and Resilience in Veterans Study, a nationally representative survey of 1,484 US veterans conducted from September through October 2013. Confirmatory factor analyses were conducted to evaluate the factor structure of PTSD symptoms, and structural equation models were constructed to examine the association between PTSD symptom clusters and external correlates.
12.0% of veterans screened positive for lifetime PTSD and 5.2% for past-month PTSD. A 5-factor dysphoric arousal model and a newly proposed 6-factor model both fit the data significantly better than the 4-factor model of DSM-5. The 6-factor model fit the data best in the full sample, as well as in subsamples of female veterans and veterans with lifetime PTSD. The emotional numbing symptom cluster was more strongly related to depression (P < .001) and worse mental health-related functioning (P < .001) than other symptom clusters, while the externalizing behavior symptom cluster was more strongly related to hostility (P < .001).
A total of 5.2% of US veterans screened positive for past-month DSM-5 PTSD. A 6-factor model of DSM-5 PTSD symptoms, which builds on extant models and includes a sixth externalizing behavior factor, provides the best dimensional representation of DSM-5 PTSD symptom clusters and demonstrates validity in assessing health outcomes of interest in this population.
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The tendency to respond with fear and avoidance can be seen as a shared vulnerability contributing to the development of post-traumatic stress disorder (PTSD) and chronic pain. Although several studies have examined which specific symptoms of PTSD (re-experiencing, avoidance, emotional numbing and hyperarousal) are associated with chronic pain, none has considered this association within the framework of fear-avoidance models.
Seven hundred fourteen patients with chronic musculoskeletal pain were assessed. Of these, 149 patients were selected for the study based upon the following inclusion criteria: exposure to a traumatic event before the onset of pain (with scores equal to or higher than 8 points on the fear and hopelessness scales of the Stressful Life Event Screening Questionnaire Revised) and scores equal to or higher than 30 on the Davidson Trauma Scale.
Structural equation modelling was used to test the association between PTSD symptoms and pain outcomes (pain intensity and disability) using the mediating variables considered in the fear-avoidance models. The results show that emotional numbing and hyperarousal symptoms, but neither re-experiencing nor avoidance, affected pain outcome via anxiety sensitivity (AS), catastrophizing and fear of pain. PTSD symptoms increased the levels of AS, which predisposes to catastrophizing and, in turn, had an effect on the tendency of pain patients to respond with more fear and avoidance.
This study provides empirical support for the potential role of PTSD symptoms in fear-avoidance models of chronic pain and suggests that AS is a relevant variable in the relationship between both disorders.
Objective
This meta-analysis systematically examined the association of reported psychological trauma and posttraumatic stress disorder (PTSD) with functional somatic syndromes including fibromyalgia, chronic widespread pain, chronic fatigue syndrome, temporomandibular disorder, and irritable bowel syndrome. Our goals were to determine the overall effect size of the association and to examine moderators of the relationship.Methods
Literature searches identified 71 studies with a control or comparison group and examined the association of the syndromes with traumatic events including abuse of a psychological, emotional, sexual, or physical nature sustained during childhood or adulthood, combat exposure, or PTSD. A random-effects model was used to estimate the pooled odds ratio and 95% confidence interval. Planned subgroup analyses and meta-regression examined potential moderators.ResultsIndividuals who reported exposure to trauma were 2.7 (95% confidence interval = 2.27-3.10) times more likely to have a functional somatic syndrome. This association was robust against both publication bias and the generally low quality of the literature. The magnitude of the association with PTSD was significantly larger than that with sexual or physical abuse. Chronic fatigue syndrome had a larger association with reported trauma than did either irritable bowel syndrome or fibromyalgia. Studies using nonvalidated questionnaires or self-report of trauma reported larger associations than did those using validated questionnaires.Conclusions
Findings highlight the limitations of the existing literature and emphasize the importance of conducting prospective studies, further examining the potential similarities and differences of these conditions and pursuing hypothesis-driven studies of the mechanisms underlying the link between trauma, PTSD, and functional somatic syndromes.
This study aimed to provide preliminary evidence for, and explore potential antecedents and correlates of, a phenomenon observed in aging combat veterans termed late-onset stress symptomatology (LOSS). LOSS is a hypothesized phenomenon among older veterans who (a) experienced highly stressful combat events in early adulthood; (b) functioned successfully throughout their lives, with no chronic stress-related disorders; but (c) begin to register increased combat-related thoughts, feelings, reminiscences, memories, or symptoms commensurate with the changes and challenges of aging, sometimes decades after their combat experiences. Using a qualitative focus group methodology with 47 World War II, Korean Conflict, and Vietnam War veterans, the authors obtained preliminary evidence for the presence of LOSS as defined, identified some of its features, revealed some normative late-life stressors that may precipitate LOSS, and uncovered potential intrapersonal risk and resilience factors for LOSS. The authors present illustrative quotations from the group discussions and discuss the implications and future directions of this research.
This study aimed to investigate the interrelationship between posttraumatic stress, emotional processing difficulties, altered self-capacity, and pain catastrophising. A cross-sectional design gathered data from 249 participants completing an internet based survey. Respondents completed: The Posttraumatic Stress Diagnostic Scale; Emotional Processing Scale (EPS), the Inventory of Altered Self-Capacities (IASC), General Health Questionnaire-28 (GHQ-28) and the Pain Catastrophising Scale (PCS). Respondents were allocated to post-traumatic stress disorder (PTSD), no-PTSD (depending on whether they met the screening criteria of PTSD using the Posttraumatic Stress Diagnostic Scale), and control group. Partial least squares (PLS) analysis confirmed the hypotheses: PTSD was significantly associated with pain catastrophising and poor psychological well-being. PTSD was significantly correlated with altered self-capacity which was in turn significantly associated with emotional processing difficulties. Emotional processing was significantly associated with pain catastrophising and poor psychological well-being whilst poor psychological well-being was associated with pain catastrophising. Emotional processing difficulties mediated the association between altered self-capacity and pain catastrophising and poor psychological well-being. To conclude, people's psychological well-being and perceptions of pain are closely related to PTSD severity from past traumas as well as self-capacities. Furthermore, the way in which they process their emotions also has an important role to play.
A paperback edition of the translation by Anrep, first published in 1927 by the Oxford University Press, containing a series of 23 lectures on the research of Pavlov's laboratory in the 1st quarter of the 20th century. From Psyc Abstracts 36:05:5CG30P. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Psychopathology and symptom patterns were studied in 60 former prisoners-of-war (POWs) by administering standardized tests including the Minnesota Multiphasic Personality Inventory (MMPI), an adjustment problem checklist, and a structured clinical interview. Most POWs showed marked psychological impairment, but modal profile analysis identified two prototypic MMPI patterns, which differed in pervasiveness and type of psychopathology. Profile subtypes were defined by unique clusters of clinical symptoms and differed in confinement stress severity. The typology of symptoms argues against a homogeneous conceptualization of stress-induced disorders and suggests the need for definition of the severity and subtype of stress phenomena and individual difference factors in responding to trauma.
The present study evaluated the relative importance of different cognitive factors (anxiety sensitivity and trauma-related beliefs) in predicting PTSD symptom severity and treatment-related changes in these symptoms. Eighty-one victims of motor vehicle accidents (MVAs) completed self-report measures of PTSD symptoms, anxiety sensitivity (AS), MVA-related beliefs and control variables (e.g., medication use, pain
severity). A subsample of patients (nG28), who received cognitive-behavioural treatment for PTSD, completed these measures pre- and post-treatment. For the combined sample (nG81), regression analyses indicated that AS and pain severity were significant predictors of PTSD symptoms, whereas MVA-related beliefs were not. For patients completing treatment, regression analyses indicated that reductions in AS and pain severity were significant predictors of reductions in PTSD symptoms. MVA-related
beliefs did not significantly predict symptom reduction once AS, pain severity and medication status was controlled for. These findings suggest that AS is a significant cognitive risk factor for exacerbating and maintaining PTSD symptoms. Treatment implications are discussed.
The present study examined catastrophizing in rheumatoid arthritis (RA) patients. Subjects were 223 RA patients who were participants in a longitudinal study. Each patient completed the Catastrophizing scale of the Coping Strategies Questionnaire (CSQ) on 2 occasions separated by 6 months (time 1, time 2). The Catastrophizing scale is designed to measure negative self-statements, castastrophizing thoughts and ideation (sample items = ‘I worry all the time about whether it will end,’ ‘It is awful and I feel that it overwhelms me’). Data analysis revealed that the Catastrophizing scale was internally reliable (alpha = 0.91) and had high test-retest reliability (r = 0.81) over a 6 month period. Correlational analyses revealed that catastrophizing recorded at time 1 was related to pain intensity ratings, functional impairment on the Arthritis Impact Measurement scale (AIMS), and depression at time 2. Predictive findings regarding catastrophizing while modest were obtained after controlling for initial scores on the dependent variables, demographic variables (age, sex, socioeconomic status), duration of pain, and disability support status. Taken together, these findings suggest that catastrophizing is a maladaptive coping strategy in RA patients. Further research is needed to determine whether cognitive-behavioral interventions designed to decrease catastrophizing can reduce pain and improve the physical and psychological functioning of RA patients.
Reliability, factor structure, and factor independence from other anxiety measures for the Anxiety Sensitivity Index (ASI) was assessed. One hundred and twenty-two anxious college students were administered the ASI, Cognitive-Somatic Anxiety Questionnaire, and the Reactions to Relaxation and Arousal Questionnaire. The results suggest that the ASI is a reliable measure which is factorially independent of other anxiety measures. Further, the ASI was supported as a measure of the variable anxiety sensitivity which has been suggested as an important personality variable in fear behavior.
How do adverse childhood experiences get 'under the skin' and influence health outcomes through the life-course? Research reviewed here suggests that adverse childhood experiences are associated with changes in biological systems responsible for maintaining physiological stability through environmental changes, or allostasis. Children exposed to maltreatment showed smaller volume of the prefrontal cortex, greater activation of the HPA axis, and elevation in inflammation levels compared to non-maltreated children. Adults with a history of childhood maltreatment showed smaller volume of the prefrontal cortex and hippocampus, greater activation of the HPA axis, and elevation in inflammation levels compared to non-maltreated individuals. Despite the clear limitations in making longitudinal claims from cross-sectional studies, work so far suggests that adverse childhood experiences are associated with enduring changes in the nervous, endocrine, and immune systems. These changes are already observable in childhood years and remain apparent in adult life. Adverse childhood experiences induce significant biological changes in children (biological embedding), modifying the maturation and the operating balance of allostatic systems. Their chronic activation can lead to progressive wear and tear, or allostatic load and overload, and, thus, can exert long-term effects on biological aging and health.
Persistent and disabling pain is the hallmark of osteoarthritis, rheumatoid arthritis, fibromyalgia, and various other rheumatologic conditions. However, disease severity (as measured by 'objective' indices such as those that employ radiography or serology) is only marginally related to patients' reports of pain severity, and pain-related presentation can differ widely between individuals with ostensibly similar conditions (for example, grade 4 osteoarthritis of the knee). Increasing evidence in support of the biopsychosocial model of pain suggests that cognitive and emotional processes are crucial contributors to inter-individual differences in the perception and impact of pain. This Review describes the growing body of literature relating depression and catastrophizing to the experience of pain and pain-related sequelae across a number of rheumatic diseases. Depression and catastrophizing are consistently associated with the reported severity of pain, sensitivity to pain, physical disability, poor treatment outcomes, and inflammatory disease activity, and potentially with early mortality. A variety of pathways, from cognitive to behavioral to neurophysiological, seem to mediate these deleterious effects. Collectively, depression and catastrophizing are critically important variables in understanding the experience of pain in patients with rheumatologic disorders. Pain, depression, and catastrophizing might all be uniquely important therapeutic targets in the multimodal management of a range of such conditions.
The gradual emergence of symptoms following exposure to traumatic events has presented a major conceptual challenge to psychiatry. The mechanism that causes the progressive escalation of symptoms with the passage of time leading to delayed onset post-traumatic stress disorder (PTSD) involves the process of sensitization and kindling. The development of traumatic memories at the time of stress exposure represents a major vulnerability through repeated environmental triggering of the increasing dysregulation of an individual's neurobiology. An increasing body of evidence demonstrates how the increased allostatic load associated with PTSD is associated with a significant body of physical morbidity in the form of chronic musculoskeletal pain, hypertension, hyperlipidaemia, obesity and cardiovascular disease. This increasing body of literature suggests that the effects of traumatic stress need to be considered as a major environmental challenge that places individual's physical and psychological health equally at risk. This broader perspective has important implications for developing treatments that address the underlying dysregulation of cortical arousal and neurohormonal abnormalities following exposure to traumatic stress.
The purpose of this article is to describe the current state-of-the-art regarding the co-occurrence of the anxiety disorders and chronic pain. First, we describe the core characteristics of chronic pain and its co-occurrence with the anxiety disorders. Second, we review data on the prevalence of co-occurrence. Third, we describe the mutual maintenance and shared vulnerability models, both of which have been offered to explain the co-occurrence of posttraumatic stress disorder (PTSD) and chronic pain and may have applicability to various other anxiety disorders. Fourth, we provide an integrative review of available research addressing the postulates of these models specific to the mechanisms of anxiety sensitivity, selective attention to threat, and reduced threshold for alarm. We conclude with general recommendations for improving assessment and treatment of patients who present with an anxiety disorder accompanied by clinically significant pain. Given that most of the available evidence has come from studies of PTSD and chronic pain, we provide a detailed agenda for future investigation of the co-occurrence of chronic pain and other anxiety disorders.
To examine the effects of combat stress reaction (CSR) and posttraumatic stress symptoms (PTS) on the level and trajectories of self-rated health (SRH) over 20 years after war exposure.
A total of 675 veterans comprising two groups, a CSR group (n = 369) and a matched control group without CSR (n = 306), were assessed in a prospective longitudinal design, 1, 2, 3, and 20 years after their participation in the 1982 Lebanon War. SRH and PTS were assessed repeatedly, at each point of measurement.
The CSR participants showed more impaired initial SRH than the controls. Although the CSR group showed an improvement in SRH over time, its SRH level remained lower than that of the control group in all 4 points in time. Initial levels of PTS were associated with more impaired SRH and lower improvement over time. In addition, increased levels of PTS in the first follow-up period were related to poorer SRH, in comparison to the predicted trajectory on the basis of CSR and initial PTS.
Stress reaction to war trauma affected the trajectory of SRH over a 20-year period. Although the differences between veterans who had shown acute stress reaction and those who had not persisted over the entire period, there was slow improvement in SRH over time among the more impaired CSR group. PTS in the first years after the war slowed this improvement and thus played a key role in the relationship between war trauma and physical health.
Exposure to a traumatic event is required for the diagnosis of posttraumatic stress disorder (PTSD). The symptoms of PTSD are believed to reflect stress-induced changes in neurobiological systems and/or an inadequate adaptation of neurobiological systems to exposure to severe stressors. More recently, there have been attempts to link the identified neurobiological changes to the specific features that constitute PTSD, such as altered mechanisms of learning and extinction, sensitization to stress, and arousal. Furthermore, there have been efforts to understand whether certain neurobiological changes in PTSD reflect preexisting vulnerability factors rather than consequences of trauma exposure or correlates of PTSD. Genetic variability, sex differences, and developmental exposures to stress influence neurobiological systems and moderate PTSD risk. On the basis of these findings, important hypotheses for developing novel strategies to identify subjects at risk, promote resilience, and devise targets for the prevention or treatment of PTSD can be derived.
The anterior insular cortex (AIC) is implicated in a wide range of conditions and behaviours, from bowel distension and orgasm, to cigarette craving and maternal love, to decision making and sudden insight. Its function in the re-representation of interoception offers one possible basis for its involvement in all subjective feelings. New findings suggest a fundamental role for the AIC (and the von Economo neurons it contains) in awareness, and thus it needs to be considered as a potential neural correlate of consciousness.
Hypotheses involving mediation are common in the behavioral sciences. Mediation exists when a predictor affects a dependent variable indirectly through at least one intervening variable, or mediator. Methods to assess mediation involving multiple simultaneous mediators have received little attention in the methodological literature despite a clear need. We provide an overview of simple and multiple mediation and explore three approaches that can be used to investigate indirect processes, as well as methods for contrasting two or more mediators within a single model. We present an illustrative example, assessing and contrasting potential mediators of the relationship between the helpfulness of socialization agents and job satisfaction. We also provide SAS and SPSS macros, as well as Mplus and LISREL syntax, to facilitate the use of these methods in applications.
The meaning people assign to physical sensations can have profound implications for their physical and psychological health. A predominant research question in somatic interpretation asks if it is more adaptive to distract one's attention away from a potentially unpleasant sensation or to focus one's attention on it. This question, however, has yielded equivocal answers. Many apparent ambiguities in this research can be traced to a failure to distinguish the content of a person's attention from its mere direction or degree. A model of somatic interpretation is discussed, incorporating not only perceptual focus but also the attributions, goals, coping strategies, and prior hypotheses of the perceiver, thus delineating the psychobiological conditions under which various attentional strategies should be adaptive. In contrast to the prevailing concern with when and why somatic distraction doesn't "work," this conceptual analysis also considers when and why somatic attention does. Theoretical and methodological issues are discussed, as is the potential utility of somatic attention in cardiac rehabilitation and multiple sclerosis.