Pain flashbacks following the July 7th 2005 London bombings

The effect of eye movement desensitization and reprocessing (EMDR) on abdominal pain in patients with irritable bowel syndrome (IBS): a study protocol for a randomized controlled trial (EMDR4IBS)

BACKGROUND

Irritable bowel syndrome (IBS) is a highly prevalent disorder for which treatment options such as medication, diets, and hypnotherapy either have shown limited effect or relieve symptoms in only a limited subset of patients. Abdominal pain is the key criterion for the diagnosis and is deemed the most distressing IBS symptom, and the most disruptive of everyday life. A growing body of research demonstrates the effect of Eye Movement Desensitization and Reprocessing (EMDR) on chronic pain. EMDR is known as a safe and successful treatment for disorders in which unresolved traumatic memories play a role in the cause or maintenance of symptoms. In IBS, activated memories may increase pain through pain flashbacks and the stress generated by unresolved memories. The aim of this study is to ascertain whether applying EMDR to traumatic memories including pain memories will reduce abdominal pain in IBS patients.

METHODS

This study is a randomized controlled trial which will be conducted at a city hospital in the Netherlands. Adult patients with considerable IBS pain (pain intensity at least 60/100 during at least 5/10 days) will be randomly assigned to either EMDR therapy or the wait list. We aim to include 34 participants. The EMDR condition comprises seven sessions, around 90 min in length delivered weekly, the first of which is a case conceptualization session. All participants will be assessed at baseline, post-treatment, and at 3 months follow-up. The primary outcome measure is pain intensity on a Likert scale which is self-reported daily during a 2-week period. Secondary outcomes include similar daily ratings on other IBS symptoms and reported hindrance of valued activities, and also standardized questionnaires on IBS symptoms and Quality of Life. Data will be analyzed by a Linear Mixed Effects Model for repeated measures.

DISCUSSION

The results are expected to gain insight into the effectiveness of EMDR treatment on abdominal pain in IBS. As there are very few effective treatment options for IBS-related abdominal pain, this study could have important implications for clinical practice.

TRIAL REGISTRATION

Human ethics committee MEC-U NL71740.100.20. International Clinical Trial Registry Platform: NL8894. Prospectively registered on 28 January 2020.

Peritraumatic Pain in Child Maltreatment: A Systematic Literature Review

Extensive research has been conducted on the link between trauma, child maltreatment (CM), and chronic pain. Although the risk of suffering from chronic pain among CM survivors has been established, much less is known about the experience of pain during CM incidents or whether such peritraumatic pain sensations are associated with later chronic pain. This scoping review was conducted to synthesize the existing literature on pain during and a short time following CM (i.e., peritraumatic pain). Utilizing the preferred reporting items for systematic reviews and meta-analyses guidelines, the current review included 11 manuscripts, which met the following criteria: (a) refer to physical pain experienced during or a short time after CM, (b) were published in peer-reviewed journals, and (c) were written in English. The review demonstrated that most of the included studies were not intentionally focused on peritraumatic pain, the majority used qualitative research methods, and all were cross-sectional. Furthermore, although validated questionnaires are available, most of the studies did not utilize such measures. Those that intentionally reported pain demonstrated its high intensity and prevalence in CM incidents, indicating that pain is inherently embedded in the experience of maltreatment. The findings spotlight an underdeveloped research realm on a phenomenon that may hold significant empirical, clinical, and legal implications. Research endeavors should initiate interdisciplinary bodies of knowledge to establish well-validated research methodologies that properly quantify peritraumatic pain in trauma and CM.

Altered Resting-State functional connectivity in the anterior and posterior hippocampus in Post-traumatic stress disorder: The central role of the anterior hippocampus

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.

"And Then Cinderella Was Lying in My Bed": Dissociation Displays in Forensic Interviews With Children Following Intrafamilial Child Sexual Abuse

Child sexual abuse (CSA) has been implicated in dissociative peritraumatic and post-traumatic symptoms and disorders. Although explicitly relevant to the legal process following alleged CSA, very little is known about dissociative manifestations in the context of forensic interviews with children following abuse. The current study was designed to uncoverperi- and post-traumatic dissociation of abused children as revealed in forensic interviews. The study examines the display of dissociation in 42 forensic interviews with children (29 girls, aged 4-14) following intra familial child sexual abuse (IFCSA). Thematic analysis was used to identify key expressions of dissociation in all of the forensic interviews. The analyses identified depersonalization and derealization in the children's description of the abuse. This was manifested both in an inability to feel things that happened during the incidents or imagination and fantasies that were reported as part of the abusive incidents. The children's interviews also revealed the potential manifestations of dissociative amnesia, which was evident in the children's attempts to communicate their retrieval difficulties to the forensic interviewers. Finally, it was identified that the forensic interviews were a platform in which dissociative post-traumatic reactions were activated and often displayed in sensory flashbacks. The current findings uncover the importance of acknowledging trauma and dissociation in the context of forensic interviews with abused children and the urgent need to implement unique responses to trauma within practical guidelines.

Peritraumatic reactions, PTSD symptoms, and pain : A study of train disasters in Japan

Objective : The purpose of this study was to examine the relationship between peritraumatic reactions, posttraumatic stress disorder (PTSD) symptoms, and pain in people injured in train disasters. Methods : The participants were injured in a train crash in Japan that left more than 100 dead. There were 218 participants in the analysis, with a mean age of 37.50 ± 14.67 years. Peritraumatic reactions were assessed using the Peritraumatic Distress Inventory. PTSD symptoms were evaluated using the Impact of Event Scale-Revised Japanese-language version. Pain was measured using the Visual Analog Scale. Results : Peritraumatic reactions did not directly affect PTSD symptoms but were found to be associated via latent variables. Regarding pain and PTSD symptoms, intrusive memories were more associated with pain than other symptoms were. There was an associative path from intrusion to pain, but no such path from pain to intrusion. Conclusions : Our results suggest that a therapeutic approach to intrusion may be effective in ameliorating the pain caused by injury. Future research should examine integrated treatment approaches for both PTSD and pain, rather than just for aspects of PTSD. J. Med. Invest. 68 : 85-89, February, 2021.

Comorbid chronic pain and post-traumatic stress disorder in UK veterans: a lot of theory but not enough evidence

INTRODUCTION

Chronic pain and post-traumatic stress disorder (PTSD) are strongly correlated in military veteran populations. The aim of this article is to review what is known about the comorbidity of the two conditions.

METHODS

A literature search was carried out to establish evidence for current explanatory models of why the two conditions frequently co-occur, the most appropriate treatments and current UK service provision for veterans and to identify gaps in research.

RESULTS

Chronic pain and PTSD share a number of features, yet the mechanisms behind their comorbidity are not well understood, and while each condition alone has extensive literature, there is limited evidence to support specific care and treatment for the two conditions simultaneously. In addition, there is currently no UK data for veterans with comorbid chronic pain and PTSD so it is not possible to gauge the numbers affected or to predict the numbers who will be affected in the future, and there appear to be no co-located services within the United Kingdom for the management of the two conditions simultaneously in this population.

CONCLUSION

This review highlights a paucity of evidence in all areas of comorbid chronic pain and PTSD. Further work needs to consider fully the nature of the event that led to the development of the two conditions and examine further the possible mechanisms involved, and clinics need to establish routine and systematic evaluations of how any interventions work in practice.

A longitudinal analysis of pain experience and recall in fibromyalgia

AIM

To evaluate pain experiences and memories in fibromyalgia (FM) patients over time.

METHOD

Participants included 572 females who were members of a large health maintenance organization who had a diagnosis of FM syndrome (FMS) and met inclusion criteria for the study. Recruitment was for an intervention study that tested the effects of social support and education treatment arms, but there were no treatment effects. Reports of experiential pain (EP), historical peak pain (HPP), and historical valley pain (HVP) for FM were collected. Differences between HPP and EP and EP and HVP (bias) were calculated to determine whether HPP and HVP were distributed evenly around EP over time across participants. Models were performed to assess personal history and psychosocial factors that affect EP, HPP, HVP, and bias.

RESULTS

There was systematic tendency for HPP to be significantly larger than EP relative to EP vs HVP. EP and HPP decreased significantly over time, but not HVP. There were significant predictors of EP, HPP, HVP, and bias, including depression, self-efficacy, and sleep quality, among others.

CONCLUSION

The experiences and recollections of pain in FM appear to provide a unique means of understanding the maintenance of chronic pain-including factors that affect this process.

Posttraumatic Stress Disorder, Orientation to Pain, and Pain Perception in Ex-Prisoners of War Who Underwent Torture

OBJECTIVE

Studies suggest that torture survivors often experience 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, although 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

Although chronic pain was associated with PTSD (0.44 < β < 0.49, p < .002), increased pain perception was correlated with torture (0.33 < β < 0.65, p < .05). Pain catastrophizing was found to mediate the association between PTSD and chronic pain (β = 0.18 and 0.19, respectively; p < .05). Fear of pain moderated the association between torture and pain perception (β = 0.41 and 0.42, respectively; p < .017).

CONCLUSIONS

The findings suggest that chronic pain is contingent upon the psychological toll of torture, that is, 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 previous 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 after trauma.

Subliminal (latent) processing of pain and its evolution to conscious awareness

By unconscious or covert processing of pain we refer to nascent interactions that affect the eventual deliverance of pain awareness. Thus, internal processes (viz., repeated nociceptive events, inflammatory kindling, reorganization of brain networks, genetic) or external processes (viz., environment, socioeconomic levels, modulation of epigenetic status) contribute to enhancing or inhibiting the presentation of pain awareness. Here we put forward the notion that for many patients, ongoing sub-conscious changes in brain function are significant players in the eventual manifestation of chronic pain. In this review, we provide clinical examples of nascent or what we term pre-pain processes and the neurobiological mechanisms of how these changes may contribute to pain, but also potential opportunities to define the process for early therapeutic interventions.

Prevalence of pain flashbacks in posttraumatic stress disorder arising from exposure to multiple traumas or childhood traumatization

Background

Flashbacks are a form of multisensory memory that are experienced with a “happening in the present” quality. Pain flashbacks are a re-experiencing of pain felt at the time of a traumatic event. It is unclear how common pain flashbacks are.

Aims

The current study was designed primarily to assess the prevalence of pain flashbacks in a sample of patients with posttraumatic stress disorder (PTSD).

Methods

We assessed the prevalence of pain flashbacks over a period of 2 years in patients (n = 166) referred to a psychological trauma service in the UK. Patients underwent a clinical screen for PTSD and completed a self-report measure of pain flashbacks.

Results

Pain flashbacks were classified as present in 49% of a sample of complex trauma patients meeting criteria for PTSD. Pain flashbacks were positively associated with the extent of pain at the time of trauma.

Conclusions

Pain re-experiencing in PTSD, and its relative absence in nonclinical populations, supports an account of memory in which perceptual details can be re-experienced when memories have been encoded under conditions of extreme stress. It may be possible to conceptualize some cases of unexplained pain as pain flashbacks or of having a trauma origin.

Co-occurrence of posttraumatic stress symptoms, pain, and disability 12 months after traumatic injury

Supplemental Digital Content is Available in the Text.

This study showed that PTSD is associated with worse pain and disability at 12 months after traumatic injury. The associations between PTSD criterion symptoms and pain outcomes highlight the likely occurrence of shared mechanisms, particularly between the experience of severe pain, hyperarousal, avoidance, and cognitive appraisals of stress or pain. New efforts are required to develop and validate interventions that can effectively treat comorbid pain and PTSD to prevent their long-term impacts on psychological wellbeing and socioeconomic position.

Introduction:

Chronic pain is common after traumatic injury and frequently co-occurs with posttraumatic stress disorder (PTSD) and PTSD symptoms (PTSS).

Objectives:

This study sought to understand the association between probable PTSD, PTSS, and pain.

Methods:

Four hundred thirty-three participants were recruited from the Victorian Orthopaedic Trauma Outcomes Registry and Victorian State Trauma Registry and completed outcome measures. Participants were predominantly male (n = 324, 74.8%) and aged 17-75 years at the time of their injury (M = 44.83 years, SD = 14.16). Participants completed the Posttraumatic Stress Disorder Checklist, Brief Pain Inventory, Pain Catastrophizing Scale, Pain Self-Efficacy Questionnaire, Tampa Scale of Kinesiophobia, EQ-5D-3L and Roland-Morris Disability Questionnaire 12 months after hospitalization for traumatic injury. Data were linked with injury and hospital admission data from the trauma registries.

Results:

Those who reported having current problems with pain were 3 times more likely to have probable PTSD than those without pain. Canonical correlation showed that pain outcomes (pain severity, interference, catastrophizing, kinesiophobia, self-efficacy, and disability) were associated with all PTSSs, but especially symptoms of cognition and affect, hyperarousal, and avoidance. Posttraumatic stress disorder symptoms, on the contrary, were predominantly associated with high catastrophizing and low self-efficacy. When controlling for demographics, pain and injury severity, depression, and self-efficacy explained the greatest proportion of the total relationship between PTSS and pain-related disability.

Conclusion:

Persons with both PTSS and chronic pain after injury may need tailored interventions to overcome fear-related beliefs and to increase their perception that they can engage in everyday activities, despite their pain.

Chronic Pain and PTSD: Evolving Views on Their Comorbidity

PURPOSE

This paper presents a literature review of post-traumatic stress disorder (PTSD) and its link to chronic pain.

DESIGN AND METHODS

Twenty-four papers are reviewed (included research and reviews), with the goal of improving and updating our understanding on this issue and its theoretical and clinical repercussions.

FINDINGS

The tight interdependence of symptoms that can be observed in both PTSD and chronic pain syndromes lends support to the idea that these disorders both constitute a reactive disorder.

PRACTICE IMPLICATIONS

Various forms of therapy and treatment focus on PTSD, but chronic pain symptoms must also be assessed.

Symptoms of PTSD Associated With Painful and Nonpainful Vicarious Reactivity Following Amputation

Although the experience of vicarious sensations when observing another in pain have been described postamputation, the underlying mechanisms are unknown. We investigated whether vicarious sensations are related to posttraumatic stress disorder (PTSD) symptoms and chronic pain. In Study 1, 236 amputees completed questionnaires about phantom limb phenomena and vicarious sensations to both innocuous and painful sensory experiences of others. There was a 10.2% incidence of vicarious sensations, which was significantly more prevalent in amputees reporting PTSD-like experiences, particularly increased arousal and reexperiencing the event that led to amputation (φ = .16). In Study 2, 63 amputees completed the Empathy for Pain Scale and PTSD Checklist-Civilian Version. Cluster analyses revealed 3 groups: 1 group did not experience vicarious pain or PTSD symptoms, and 2 groups were vicarious pain responders, but only 1 had increased PTSD symptoms. Only the latter group showed increased chronic pain severity compared with the nonresponder group (p = .025) with a moderate effect size (r = .35). The findings from both studies implicated an overlap, but also divergence, between PTSD symptoms and vicarious pain reactivity postamputation. Maladaptive mechanisms implicated in severe chronic pain and physical reactivity posttrauma may increase the incidence of vicarious reactivity to the pain of others.

Re-experiencing traumatic events in PTSD: new avenues in research on intrusive memories and flashbacks

Posttraumatic flashbacks, consisting of the intrusive re-experiencing of traumatic experiences in the present, have been more clearly defined for the first time in DSM-5 and have been identified as a unique symptom of posttraumatic stress disorder in the proposed ICD-11 diagnostic criteria. Relatively little research into flashbacks has been conducted, however, and new research efforts are required to understand the cognitive and biological basis of this important symptom. In addition, there is considerable scope for research into how flashbacks should be assessed and into flashbacks occurring in different contexts, such as psychosis or intensive care.

Phantom limb pain: an energy/trauma model

Phantom limb pain (PLP) is a form of chronic neuropathic pain that responds poorly to treatment interventions derived from the neuroanatomic understanding of pain and analgesia. Several new psychological and behavioral treatments that have proven more effective have been explained by invoking neural plasticity as their mechanism of action. Other novel treatments that are based on an "energy medicine" model also appear to be quite effective, especially when addressing the psychological trauma of the amputation itself, a factor that is generally overlooked in the standard surgical approach to limb amputation. A speculative trauma/energy model for the etiology of PLP is proposed. This model is developed in some detail, and its utility in explaining several anomalous aspects of PLP, as well as the clinical efficacy of energy therapies, is outlined. This model is proposed as a step in the development of simple and effective energy/trauma treatment protocols for this widespread and largely treatment-resistant disorder.

Traumatization and chronic pain: a further model of interaction

Up to 80% of patients with severe posttraumatic stress disorder are suffering from “unexplained” chronic pain. Theories about the links between traumatization and chronic pain have become the subject of increased interest over the last several years. We will give a short summary about the existing interaction models that emphasize particularly psychological and behavioral aspects of this interaction. After a synopsis of the most important psychoneurobiological mechanisms of pain in the context of traumatization, we introduce the hypermnesia–hyperarousal model, which focuses on two psychoneurobiological aspects of the physiology of learning. This hypothesis provides an answer to the hitherto open question about the origin of pain persistence and pain sensitization following a traumatic event and also provides a straightforward explanatory model for educational purposes.

The interaction of persistent pain and post-traumatic re-experiencing: a qualitative study in torture survivors

CONTEXT

There are limited studies and few theoretical models addressing the interaction between pain and symptoms of post-traumatic stress disorder, with none concerning this interaction in survivors of torture, who frequently report persistent pain.

OBJECTIVES

We aimed to explore the relationship between persistent pain and re-experiencing of traumatic events in survivors of torture.

METHODS

Nine torture survivors were interviewed about their experiences of pain and re-experiencing, and the results analyzed using interpretative phenomenological analysis. Levels of pain and post-traumatic stress were assessed.

RESULTS

Four superordinate themes emerged, namely "pain is the enemy," "pain and intrusive memories are connected," "changed identity," and "resilience and resources." These themes showed a complex relationship between torture, pain, re-experiencing, and other aspects of individual experience, such as the multiple losses experienced by torture survivors. Both pain and post-traumatic stress disorder symptoms were shown to have profound impacts on the everyday lives of participants.

CONCLUSION

The results suggest that the relationship between pain and re-experiencing requires a broad model that considers the impact of a range of individual, social, and environmental factors on the interaction between pain and traumatic stress symptoms in survivors of torture. The study has clinical implications, most notably the need to attempt more integrated treatment of pain and traumatic symptoms where they occur together, and to consider the meaning and impact of pain when treating survivors of torture. Further investigation of the relationship between pain and traumatic stress symptoms in torture survivors is needed, as are studies of combined treatment for pain and trauma.

An fMRI investigation of posttraumatic flashbacks

Flashbacks are a defining feature of posttraumatic stress disorder (PTSD), but there have been few studies of their neural basis. We tested predictions from a dual representation model of PTSD that, compared with ordinary episodic memories of the same traumatic event, flashbacks would be associated with activity in dorsal visual stream and related areas rather than in the medial temporal lobe. Participants with PTSD, with depression but not PTSD, and healthy controls were scanned during a recognition task with personally relevant stimuli. The contrast of flashbacks versus ordinary episodic trauma memories in PTSD was associated with increased activation in sensory and motor areas including the insula, precentral gyrus, supplementary motor area, and mid-occipital cortex. The same contrast was associated with decreased activation in the midbrain, parahippocampal gyrus, and precuneus/posterior cingulate cortex. The results were discussed in terms of theories of PTSD and dual-process models of recognition.

Mirror-sensory synaesthesia: exploring 'shared' sensory experiences as synaesthesia

Recent research suggests the observation or imagination of somatosensory stimulation in another (e.g., touch or pain) can induce a similar somatosensory experience in oneself. Some researchers have presented this experience as a type of synaesthesia, whereas others consider it an extreme experience of an otherwise normal perception. Here, we present an argument that these descriptions are not mutually exclusive. They may describe the extreme version of the normal process of understanding somatosensation in others. It becomes synaesthesia, however, when this process results in a conscious experience comparable to the observed person's state. We describe these experiences as 'mirror-sensory synaesthesia'; a type of synaesthesia identified by its distinct social component where the induced synaesthetic experience is a similar sensory experience to that perceived in another person. Through the operationalisation of this intriguing experience as synaesthesia, existing neurobiological models of synaesthesia can be used as a framework to explore how mechanisms may act upon social cognitive processes to produce conscious experiences similar to another person's observed state.

Association between flashbacks and structural brain abnormalities in posttraumatic stress disorder

OBJECTIVE

Posttraumatic stress disorder (PTSD) is reliably associated with reduced brain volume relative to healthy controls, in areas similar to those found in depression. We investigated whether in a PTSD sample brain volumes in these areas were related to reporting specific symptoms of PTSD or to overall symptom severity.

METHOD

Structural MRI scans were obtained from 28 participants diagnosed with PTSD according to DSM-IV-TR. Participants reported the extent of individual PTSD symptoms using the Posttraumatic Diagnostic Scale. Voxel-based morphometry applying the Dartel algorithm implemented within SPM5 was used to identify volumetric changes, related to PTSD total, symptom cluster, and individual symptom scores.

RESULTS

Brain volume was unrelated to overall PTSD severity, but greater reexperiencing scores predicted reduced volumes in the middle temporal and inferior occipital cortices. Increased reports of flashbacks predicted reduced volume in the insula/parietal operculum and in the inferior temporal gyrus.

CONCLUSION

The data illustrate the value of analyses at the symptom level within a patient population to supplement group comparisons of patients and healthy controls. Areas identified were consistent with a neurobiological account of flashbacks implicating specific abnormalities in the ventral visual stream.

The menacing phantom: what pulls the trigger?

Phantom phenomena are frequent following amputation, but how this often painful experience is modified or triggered by spontaneous events or sensations often puzzles amputees and clinicians alike. We explored triggers of phantom phenomena in a heterogeneous sample of 264 upper and lower limb adult amputees with phantom sensations. Participants completed a structured questionnaire to determine the prevalence and nature of the triggers of phantom phenomena. The four categories of triggers identified include: (a) a quarter of participants experiencing psychological, emotional or autonomic triggers; (b) half experiencing behavioral triggers, "forgetting" the limb's absence and attempting to use the phantom; (c) one-fifth experiencing weather-induced triggers; and (d) one-third experiencing sensations referred from parts of the body. Upper limb amputees; and were more likely to experience weather-induced phantom phenomena than lower limb amputees; and upper and lower limb amputees were equally likely to experience referred sensations from the genitals, contradicting the homuncular remapping hypothesis. Traumatic amputees were more likely to report emotional triggers. Further, while those with emotional triggers exhibited poorer acceptance of the limitations of amputation, they were more likely to employ adaptive coping mechanisms. Finally, habitual "forgetting" behaviors were most common soon after amputation, whereas other more adaptive schemata (e.g., self-defense) were equally likely to be performed at any time following amputation. Various likely inter-related mechanisms are discussed in relation to phantom triggers. Ultimately, optimizing stump and neuroma management, as well as restoring function of central networks for pain, limb movement, and amputation-related memories, should help manage spontaneously triggered phantom phenomena.

Cortisol reduces recall of explicit contextual pain memory in healthy young men

Remembering painful incidents has important adaptive value but may also contribute to clinical symptoms of posttraumatic stress disorder and chronic pain states. Because glucocorticoids are known to impair memory retrieval processes, we investigated whether cortisol affects recall of previously experienced pain in healthy young men. In a double-blind, placebo-controlled crossover study, 20 male participants were presented pictures, half of them combined with a heat-pain stimulus. The next day, the same pictures were shown in the absence of pain. Cortisol (20 mg) administered 1h before retention testing reduced recall of explicit contextual pain memory, whereas it did not affect pain threshold or pain tolerance.

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

BACKGROUND

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

METHOD

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

RESULTS

In a saturated model we found that the relationship between acute pain and 12-month pain was mediated by arousal symptoms at 3 months. We also found that the relationship between baseline arousal and re-experiencing symptoms, and later 12-month arousal and re-experiencing symptoms, was mediated by 3-month pain levels. The final model showed a good fit [chi2=16.97, df=12, p>0.05, Comparative Fit Index (CFI)=0.999, root mean square error of approximation (RMSEA)=0.022].

CONCLUSIONS

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

Treatment of chronic phantom limb pain using a trauma-focused psychological approach

BACKGROUND

Chronic phantom limb pain (PLP) is a disabling chronic pain syndrome for which regular pain treatment is seldom effective. Pain memories resulting from long-lasting preamputation pain or pain flashbacks, which are part of a traumatic memory, are reported to be powerful elicitors of PLP.

OBJECTIVE

To investigate whether a psychological treatment directed at processing the emotional and somatosensory memories associated with amputation reduces PLP.

METHODS

Ten consecutive participants (six men and four women) with chronic PLP after leg amputation were treated with eye movement desensitization and reprocessing (EMDR). Pain intensity was assessed during a two-week period before and after treatment (mean number of sessions = 5.9), and at short- (three months) and long-term (mean 2.8 years) follow-up.

RESULTS

Multivariate ANOVA for repeated measures revealed an overall time effect (F[2, 8]=6.7; P<0.02) for pain intensity. Pairwise comparison showed a significant decrease in mean pain score before and after treatment (P=0.00), which was maintained three months later. All but two participants improved and four were considered to be completely pain free at three months follow-up. Of the six participants available at long-term follow-up (mean 2.8 years), three were pain free and two had reduced pain intensity.

CONCLUSIONS

These preliminary results suggest that, following a psychological intervention focused on trauma or pain-related memories, substantial long-term reduction of chronic PLP can be achieved. However, larger outcome studies are required.

Symptoms of acute posttraumatic stress disorder in patients with acute hand injuries

PURPOSE

Symptoms of posttraumatic stress disorder (PTSD) in patients with hand injuries may delay return to work, even when criteria of the Diagnostic and Statistical Manual of Mental Disorders-IV are not met. This study investigated which biomedical and psychosocial factors relate to symptoms of acute PTSD in hand-injured patients.

METHODS

Sixty-seven employed patients with hand injuries completed a number of questionnaires. The following factors were investigated: sociodemographic characteristics, injury severity, accident location, pain, satisfaction with hand functioning, aesthetics of the hand, social support, and coping styles. The primary outcome measure was the number of symptoms of PTSD. We analyzed factors that were univariately significantly associated with symptoms of PTSD using linear regression analysis, and explored interaction effects.

RESULTS

One patient met the criteria for PTSD; 44 patients experienced symptoms but did not meet the criteria (median, 1; interquartile range (IQR), 0-2); 22 patients experienced no symptoms of PTSD. Patients had a median pain score of 30 (IQR, 10-45), median satisfaction score of 60 (IQR, 45-70), median aesthetics score of 66.7 (IQR, 45.8-79.2), median palliative coping style score of 16 (IQR, 14.8-17.3), and median avoidance coping style of 15 (IQR, 13-16). Symptoms of PTSD were associated with pain (r, .530; p < .001), satisfaction with hand function (r, -.451; p < .001), aesthetics (r, -.320; p = .009), palliative coping style (r, .281; p = .022) and avoidance coping style (r, .283; p = .022). Pain and aesthetics remained significant after regression analysis. No interaction effects were significant.

CONCLUSIONS

Pain and aesthetics statistically predict symptoms of acute PTSD in patients with acute hand injuries. Patients with disproportionate pain or dissatisfaction with aesthetics should be evaluated for PTSD.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Pain sensation evoked by observing injury in others

Observing someone else in pain produces a shared emotional experience that predominantly activates brain areas processing the emotional component of pain. Occasionally, however, sensory areas are also activated and there are anecdotal reports of people sharing both the somatic and emotional components of someone else's pain. Here we presented a series of images or short clips depicting noxious events to a large group of normal controls. Approximately one-third of this sample reported an actual noxious somatic experience in response to one or more of the images or clips. Ten of these pain responders were subsequently recruited and matched with 10 non-responders to take part in an fMRI study. The subjects were scanned while observing static images of noxious events. In contrast with emotional images not containing noxious events the responders activated emotional and sensory brain regions associated with pain while the non-responders activated very little. These findings provide convincing evidence that some people can readily experience both the emotional and sensory components of pain during observation of other's pain resulting in a shared physical pain experience.