Traumatic Events, Posttraumatic Stress Disorder, and Central Sensitization in Chronic Pain Patients of a German University Outpatient Pain Clinic

Towards a better definition of nociplastic pain conditions: a psychological grounded study on fibromyalgia, chronic headache and vulvodynia

Background: This study investigates the psychological underpinnings of chronic pain conditions, specifically fibromyalgia, chronic headache, vulvodynia, and mixed condition (consisting of fibromyalgia in comorbidity with chronic headache and/or vulvodynia), with a focus on nociplastic pain mechanisms.Objective: The aim of the study is to better understand the psychological functioning of women with different chronic pain conditions to identify and discuss similarities and differences. In particular, we aim to explore any significant differences in the domain of traumatic experiences, in global defensive functioning, and in the domain of alexithymia among the evaluated groups. Further, the 4 groups with chronic pain will be compared with a healthy control group.Methods: A sample of 1006 Italian women diagnosed with chronic pain participated in the study, categorized into four clinical groups and a healthy control group. Measures were assessed using self-report measures, in particular: Traumatic Experiences Checklist, Defense Mechanism Rating Scales, and Toronto Alexithymia Scale.Results: There are significant differences among groups, with mixed conditions exhibiting the highest levels of traumatic experiences, particularly emotional neglect and physical threats. Fibromyalgia and mixed condition groups displayed greater reliance on neurotic defense mechanisms. Additionally, fibromyalgia and mixed condition participants exhibited higher levels of alexithymia, indicating difficulties in emotional processing.Conclusions: These findings underscore the complex interplay between psychological factors and nociplastic pain conditions, emphasizing the importance of personalized psychological interventions in managing nociplastic pain. The study highlights the need for multidisciplinary approaches to nociplastic pain treatment, considering the diverse psychological profiles of affected individuals.

System-based pain groups are uniquely associated with sociodemographic and psychiatric correlates among those with posttraumatic stress disorder (PTSD)

OBJECTIVE

Chronic pain is a prevalent comorbidity among those with posttraumatic stress disorder (PTSD). Chronic pain can be divided into specific pain (i.e., involving a single body system) and complex pain (i.e., involving multiple body systems). We explored sociodemographic and psychiatric differences between pain groups among those with PTSD.

METHOD

Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III, N = 36,309). Pain groups were determined through health professional confirmed self-report of chronic pain conditions within three body systems (musculoskeletal, nerve or digestive conditions). Psychiatric conditions were identified with the Alcohol Use Disorder and Associated Disabilities Interview Schedule for DSM-5; suicide attempts were assessed via self-report.

RESULTS

Among our PTSD sub-sample (n = 1779; 4.7%), 53.9% had no conditions, 25.6% endorsed specific pain, and 19.1% endorsed complex pain. Multinomial logistic regressions revealed increased odds of certain sociodemographic correlates (e.g., older age) common to both pain groups when compared to those with PTSD alone, as well as decreased odds (e.g., being non-White) unique to those with complex pain. Multivariable logistic regressions revealed both specific pain and complex pain were associated with increased odds of any lifetime personality disorder relative to the no pain group (AOR = 1.56 and 2.38, respectively). Complex pain was uniquely associated with increased odds of any past-year anxiety disorder, past-year tobacco use disorder, and lifetime suicide attempts (AOR range = 1.46-1.69) relative to PTSD alone.

CONCLUSION

Findings indicate that those with PTSD and pain conditions impacting multiple body systems represent a particularly vulnerable group.

Stressful Life Events and Psychosomatic Symptoms in Fibromyalgia Syndrome and Rheumatoid Arthritis

OBJECTIVE

The study analyzed the role of traumatic experiences and psychosomatic components as potential predictors of the likelihood of chronic pain patients having or not having fibromyalgia.

METHODS

We examined the role of stressful life events (Traumatic Experiences Checklist), psychosomatic syndromes (Toronto Alexithymia Scale and Diagnostic Criteria for Psychosomatic Research), pain, and psychological distress (Beck Depression Inventory-II and State-Trait Anxiety Inventory) in 104 patients with fibromyalgia compared with a sample of 104 patients with rheumatoid arthritis.

RESULTS

Patients with fibromyalgia reported significantly more traumatic events, a higher prevalence of psychosomatic syndromes, and higher levels of pain, anxiety and depressive symptoms compared with patients with rheumatoid arthritis (all p < 0.01). Hierarchical binary logistic regression with group membership as the dependent variable showed that somatization syndromes (OR = 3.67), pain (OR = 1.56), and childhood trauma (OR = 1.11) were statistically significant predictors of group belonging, and the model explained 67% of the variance in diagnosis [χ2(9) = 143.66, p < 0.001].

CONCLUSION

These results highlighted that patients with fibromyalgia are characterized primarily by marked somatization and a high prevalence of early stressful life events compared with patients with rheumatoid arthritis, a primarily nociceptive chronic pain condition. A better knowledge of these mechanisms could allow clinicians to develop tailored interventions that take greater account of the psychological dimension of the disease.

Multisite pain among United States Veterans with posttraumatic stress disorder: Prevalence, predictors, and associations with symptom clusters

Persistent pain in multiple distinct body sites is associated with poorer functional outcomes above and beyond pain intensity and interference. Veterans, and especially those with posttraumatic stress disorder (PTSD), may be at risk for multisite pain. However, the research to date characterizing this presentation is limited. This secondary analysis examined the prevalence of multisite pain in a cross-sectional sample of Veterans and explored demographic, military service-related, and PTSD symptom cluster variables associated with multisite pain among those with clinically significant PTSD symptoms. Participants were 4303 post-9/11 U.S. Veterans (16.55% female gender, 58.45% White/Caucasian, Mage = 35.52), of whom 1375 (31.95%) had clinically significant PTSD symptoms. Multisite pain was defined as endorsing pain that "bothered [me] a lot" in ≥3 body sites out of 5 on the Patient Healthcare Questionnaire-15. A total of 20.03% of all participants, and 40.00% of those with likely PTSD, reported multisite pain. Female gender (OR = 1.55), older age (OR = 1.70), minority race identification (White/Caucasian racial identity OR = 0.75), history of military sexual trauma (OR = 1.99), and spine, abdomen and joint/muscle injuries (ORs = 1.66-3.68) were associated with higher odds of multisite pain. Adjusting for these potential confounders, higher z-scores on the PTSD arousal/reactivity (OR = 1.58, p <.001) subscale was associated with higher multisite pain odds. In summary, multisite pain was common among Veterans with PTSD, especially those who experienced military sexual trauma or certain physical injuries. Multisite pain and PTSD may be associated due to a shared threat reactivity mechanism. PERSPECTIVE: This study investigates the rates and factors associated with having pain in three or more distinct body sites (multisite pain) among United States Veterans. The study findings highlight the unique importance of specific posttraumatic stress symptoms and experiences associated with multisite pain.

Trauma Prevalence and Its Association With Health-related Quality of Life in Pregnant Persons With Opioid Use Disorder

OBJECTIVES

Trauma screening is recommended for pregnant persons with opioid use disorder (OUD), but there is limited literature on screening results from buprenorphine treatment. This study's objectives were to 1) describe the types, and severity, of traumatic events reported and 2) evaluate the associations between trauma and health-related quality of life (HRQoL).

METHODS

Baseline data from an ongoing trial were analyzed. Participants were 155 pregnant persons with OUD receiving, or enrolling in, buprenorphine treatment at one of 13 sites. The experience, and relative severity, of 14 high magnitude stressors were assessed with the trauma history screen. The Patient-Reported Outcomes Measurement Information System-29+2 was used to assess 8 HRQoL domains.

RESULTS

Traumatic stressors were reported by 91% of the sample (n = 155), with 54.8% reporting a lifetime persisting posttraumatic distress (PPD) event and 29.7% reporting a childhood PPD event. The most prevalent lifetime PPD event was sudden death of a close family/friend (25.8%); physical abuse was the most prevalent childhood PPD event (10.3%). Participants with lifetime PPD, relative to no PPD, reported significantly greater pain interference ( P = 0.02). Participants with childhood PPD, relative to no PPD, had significantly worse HRQoL overall ( P = 0.01), and worse pain intensity ( P = 0.002), anxiety ( P = 0.003), depression ( P = 0.007), fatigue ( P = 0.002), and pain interference ( P < 0.001).

CONCLUSIONS

A majority of pregnant persons enrolled/enrolling in buprenorphine treatment reported persisting posttraumatic distress with sudden death of close family/friend being the most prevalent originating event; clinicians should consider the impact that the opioid-overdose epidemic may be having in increasing trauma exposure in patients with OUD.

Measurement Properties of the Patient Health Questionnaire-15 and Somatic Symptom Scale-8: A Systematic Review and Meta-Analysis

Importance

The subjective experience of somatic symptoms is a key concern throughout the health care system. Valid and clinically useful instruments are needed.

Objective

To evaluate the measurement properties of 2 widespread patient-reported outcomes: the Patient Health Questionnaire-15 (PHQ-15) and Somatic Symptom Scale-8 (SSS-8).

Data Sources

Medline, PsycINFO, and Web of Science were last searched February 1, 2024.

Study Selection

English-language studies reporting estimates pertaining to factor analysis, taxometric analysis, internal consistency, construct validity, mean scores in relevant groups, cutoffs, areas under the receiver operating characteristic curves (AUROCs), minimal clinically important difference, test-retest reliability, or sensitivity to change.

Data Extraction and Synthesis

Search hits were reviewed by independent raters. Cronbach α, Pearson r, means, and between-group effect sizes indicative of sensitivity to change were pooled in random-effects meta-analysis. Study quality was assessed using 3 instruments. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 reporting guideline.

Main Outcomes and Measures

Comprehensive overview of evidence pertaining to the measurement properties of the PHQ-15 and SSS-8.

Results

A total of 305 studies with 361 243 participants were included. Most concerned routine care (178 studies) and the general population (27 studies). In factor analyses, both scales reflected a combination of domain-specific factors (cardiopulmonary, fatigue, gastrointestinal, pain) and a general symptom burden factor. The pooled PHQ-15 α was 0.81 (95% CI, 0.80-0.82), but with low item-total correlations for items concerning menstrual problems, fainting spells, and sexual problems (item-total correlations <0.40), and the SSS-8 α was 0.80 (0.77-0.83). Pooled correlations with other measures of somatic symptom burden were 0.71 (95% CI, 0.64-0.78) for the PHQ-15 and 0.82 (95% CI, 0.72-0.92) for the SSS-8. Reported AUROCs for identification of somatoform disorders ranged from 0.63 (95% CI, 0.50-0.76) to 0.79 (95% CI, 0.73-0.85) for the PHQ-15 and from 0.71 (95% CI, 0.66-0.77) to 0.73 (95% CI, 0.69-0.76) for the SSS-8. The minimal clinically important difference on both scales was 3 points. Test-retest reliability could not be pooled and was inconsistent for the PHQ-15 (PHQ-15: r = 0.65-0.93; ICC, 0.87; SSS-8: r = 0.996, ICC = 0.89). The PHQ-15 showed tentative sensitivity to change (g = 0.32; 95% CI, 0.08-0.56), but data for the SSS-8 were lacking.

Conclusions and Relevance

In this systematic review and meta-analysis, findings supported use of the PHQ-15 and SSS-8 for the assessment of symptom burden, but users should be aware of the complex, multifactorial structures of these scales. More evidence is needed concerning longitudinal measurement properties.

PTSD symptoms, pain catastrophizing, and pain outcomes after acute orthopedic injury

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.

Overview: Chronic Pain and Cannabis-Based Medicines

Chronic pain is primarily conceptualized as a disease in its own right when it is associated with emotional distress and functional impairment. Pathophysiologically, dysfunction of the cortico-mesolimbic connectome is of major importance, with overlapping signals in the nociceptive and stress systems. The endocannabinoid system plays an important role in the central processing of nociceptive signals and regulates the central stress response. Clinically, there is moderate evidence that cannabis-based medicines (CBM) can contribute to a significant reduction in pain, especially the associated pain affect, and improvement in physical function and sleep quality in a proportion of patients with chronic pain. The analgesic effect appears to be largely independent of the cause of pain. In this context, CBM preferentially regulates stress-associated pain processing.

Mental health markers and protective factors in students with symptoms of physical pain across WEIRD and non-WEIRD samples - a network analysis

BACKGROUND

Studies conducted in Western societies have identified variables associated with chronic pain, but few have done so across cultures. Our study aimed to clarify the relationship between specific mental health markers (i.e., depression, anxiety, posttraumatic stress disorder [PTSD], perceived stress) as well as specific protective factors (i.e., social support and self-efficacy) related to physical pain among university students across non-WEIRD and WEIRD samples.

METHOD

A total of 188 university students (131 women and 57 men) were included in the study. We used network analysis to ascertain mental health markers especially central to the experience of physical pain.

RESULTS

No statistically significant difference was found between mental health markers (i.e., depression, anxiety, perceived stress, and PTSD) and protective factors (i.e., social support and self-efficacy) associated with physical pain symptoms for Swiss students versus Indian students (M = 0.325, p = .11). In addition, networks for Swiss versus Indian students did not differ in global strength (S = 0.29, p = .803). Anxiety was the most central mental health marker, and social support was the most important protective factor related to physical pain in both countries. However, for Swiss students, perceived stress, and for Indian students, PTSD symptoms were central mental health markers related to physical pain.

CONCLUSION

Our results identify factors that may serve as important treatment targets for pain interventions among students of both countries before it becomes chronic.

Patients' perspectives on prescription cannabinoid therapies: a cross-sectional, exploratory, anonymous, one-time web-based survey among German patients

Introduction

Since cannabinoids were partially legalized as prescription medicines in Germany in 2017, they are mostly used when conventional therapies do not suffice. Ambiguities remain regarding use, benefits and risks. This web-based survey explored the perspectives of patients whose experiences are not well enough known to date.

Methods

In an anonymous, exploratory, cross-sectional, one-time web-based observational study, participants receiving cannabinoid therapy on prescription documented aspects of their medical history, diagnoses, attitudes toward cannabinoids, physical symptoms, and emotional states. Participants completed the questionnaires twice here: first regarding the time of the survey and then, retrospectively, for the time before their cannabinoid therapy. Participants were recruited in a stratified manner in three German federal states.

Results

N = 216 participants (48.1% female, aged 51.8 ± 14.0) completed the survey, most of which (72%, n = 155) reported pain as their main reason for cannabinoid therapy. When comparing the current state with the retrospectively assessed state, participants reported greater satisfaction with their overall medical therapy (TSQM II: +47.9 ± 36.5, p < 0.001); improved well-being (WHO-5: +7.8 ± 5.9, p < 0.001) and fewer problems in PROMIS subscales (all p < 0.001). Patients suffering primarily from pain (72%, n = 155) reported a reduction of daily pain (NRS: -3.2 ± 2.0, p < 0.001), while participants suffering mainly from spasticity (8%, n = 17) stated decreased muscle spasticity (MSSS: -1.5 ± 0.6, p < 0.001) and better physical mobility (-0.8 ± 0.8, p < 0.001). Data suggests clinically relevant effects for most scores. Participants' attitudes toward cannabinoids (on a 5-point scale) improved (+1.1 ± 1.1, p < 0.001). Most patients (n = 146, 69%) did not report major difficulties with the cannabinoid prescription process, while (n = 27; 19%) had their cannabinoid therapy changed due to side effects.

Discussion

Most participants experienced their therapy with cannabinoids as more effective than their previous therapy. There are extensive limitations to this cross-sectional study: the originally intended representativeness of the dataset was not reached, partly due to the SARS-CoV-2 pandemic; the sample has a larger proportion of privately insured and self-paying patients. Results does not suggest that cannabinoid patients belong to a particular clientele. Effect sizes observed for pain reduction, quality of life, social participation, and other outcomes suggest a therapeutic potential, particularly in the treatment of chronic pain.

Chronic pain, chronic stress and substance use: overlapping mechanisms and implications

Chronic pain is among the most common reasons adults in the U.S. seek medical care. Despite chronic pain's substantial impact on individuals' physical, emotional, and financial wellness, the biologic underpinnings of chronic pain remain incompletely understood. Such deleterious impact on an individuals' wellness is also manifested in the substantial co-occurrence of chronic stress with chronic pain. However, whether chronic stress and adversity and related alcohol and substance misuse increases risk of developing chronic pain, and, if so, what the overlapping psychobiological processes are, is not well understood. Individuals suffering with chronic pain find alleviation through prescription opioids as well as non-prescribed cannabis, alcohol, and other drugs to control pain, and use of these substances have grown significantly. Substance misuse also increases experience of chronic stress. Thus, given the evidence showing a strong correlation between chronic stress and chronic pain, we aim to review and identify overlapping factors and processes. We first explore the predisposing factors and psychologic features common to both conditions. This is followed by examining the overlapping neural circuitry of pain and stress in order to trace a common pathophysiologic processes for the development of chronic pain and its link to substance use. Based on the previous literature and our own findings, we propose a critical role for ventromedial prefrontal cortex dysfunction, an overlapping brain area associated with the regulation of both pain and stress that is also affected by substance use, as key in the risk of developing chronic pain. Finally, we identify the need for future research in exploring the role of medial prefrontal circuits in chronic pain pathology. Critically, in order to alleviate the enormous burden of chronic pain without exacerbating the co-occurring substance misuse crisis, we emphasize the need to find better approaches to treat and prevent chronic pain.