Pain and PTSD: Developing An Integrated Treatment Approach John D. Otis, PhD VA Boston Healthcare System

1. Pain and PTSD: Developing An Integrated Treatment ApproachJohn D. Otis, PhDVA Boston Healthcare System

2. Presentation Overview Prevalence of Pain and PTSD Rationale for the Development of an Integrated Treatment The Treatment Development Process Pilot Study Results Future Directions for Research

3. Pain often results from injuries related to events such as occupational injuries, motor vehicle accidents, or military combat. This has led to a growing interest in the interaction between pain and Posttraumatic Stress Disorder (PTSD), as research and clinical practice indicate that they frequently co-occur and can interact in such a way to negatively impact the course of treatment for either disorder.

4. Prevalence of Chronic Pain in OEF/OIF Veterans In a study of 1,800 OEF/OIF Veterans, 46.5% reported some pain, with 59% of those exceeding the VA clinical threshold of ≥ 4 on a 0 to 10 scale (Gironda et al., 2006).

5. Prevalence of PTSD in OEF/OIF Veterans • Seal et al., (2007) studied 103,788 OEF/OIF veterans to assess the proportion of veterans seen at VA facilities who received mental health diagnoses. • 13% met criteria for PTSD. • RAND (2008) studied 2,000 OEF/OIF veterans • 18.5% met criteria for PTSD or depression GP=6.8% (Kessler et al., 2005 ) • However, the true prevalence of PTSD secondary to these wars is unknown; research to date employed only screening measures for PTSD.

6. Summary of Research Literature Between 34% to 50% of patients referred for the treatment of pain have PTSD or significant PTSD symptomatology. Between 45 to 87% of patients referred for the treatment of PTSD have a chronic pain condition. The Comorbidity of Chronic Pain and PTSD

7. In a sample of 113 Veterans referred for pain treatment at VA Boston, 35% (n=50) met criteria for PTSD based on a PCL cutoff score of 50. In a sample of 30 OEF/OIF veterans referred for pain treatment at VA Boston, 73% (n=22) of the sample met criteria for PTSD based on a PCL cutoff score of 50. The Comorbidity of Chronic Pain and PTSD Morrison, J., Scioli, E, Schuster, J., & Otis, J. (March, 2009). The Prevalence and Impact of Comorbid Chronic Pain and PTSD on U.S. Veterans. Poster presented at the 29th annual meeting of the Anxiety Disorders Association of America, New Mexico.

8. The Interaction between Chronic Pain and PTSD Analysis of the entire sample (N=143) indicated that veterans with chronic pain who also met criteria for PTSD endorsed significantly higher scores on measures of pain, distress and disability than Veterans with chronic pain only. Morrison, J., Scioli, E, Schuster, J., & Otis, J. (March, 2009). The Prevalence and Impact of Comorbid Chronic Pain and PTSD on U.S. Veterans. Poster presented at the 29th annual meeting of the Anxiety Disorders Association of America, New Mexico.

9. Clinical Examples “When ever I'm laying in bed at night and my shoulder starts hurting, I start having thoughts of when I was shot.” “When I think about the day our humvee was hit I can feel the pain in my back flare up right where I was hurt.” “I tried my PT exercises but the pain started increasing and I started thinking about what I saw and heard in Vietnam so I just said the heck with it and called it quits for the day.” “I managed to avoid dealing with my PTSD all of my life, but when the other car hit me it brought all of the feelings to the surface (feeling powerless).

10. Potential Mechanisms Anxiety Sensitivity – a fear of arousal-related sensations arising from the belief that they will have harmful consequences. Catastrophizing – exaggerated beliefs and expectations that events will lead to negative outcomes. Both of these factors may increase the fear and avoidance of activities or thoughts associated with recovery. PAIN: The avoidance of physical activities PTSD: The avoidance of feared thoughts/situations

11. Given the high rates of comorbidity between chronic pain and PTSD, and evidence suggesting that these two disorders may interact in some way, efforts to develop more effective treatments for this population are greatly needed. A Need for Research

12. Choosing the Best Treatment Approach • Parallel Treatment • Poor collaboration among providers • Different philosophies of treatment • Patient receives no treatment because no one takes responsibility • Sequential Treatment • Untreated disorder worsens the treated disorder • Disagreement as to which should be treated first • Clinicians don’t follow through with referral for the untreated disorder

13. Efficacy of An Integrated CBT Approach to Treating Chronic Pain and PTSD John D. Otis, Ph.D. and Terence M. Keane Ph.D. A VA Merit Review funded by the VA Rehabilitation, Research & Development Service Evaluate the efficacy of an integrated CBT approach to the treatment of co-morbid Chronic Pain and PTSD A 12-session integrated treatment that contains elements of evidence-based treatments for Chronic Pain and PTSD.

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

15. Research Design Participants: Veterans with a co-morbid diagnosis of chronic pain and PTSD Participants are randomly assigned to 1 of 4 treatment conditions CBT - Pain CBT - PTSD CBT - PTR (Integrated treatment) Wait-List

16. Treatment CBT for Pain and CBT for PTSD Treatment follows a 12-session, individual, manualized treatment protocol. CBT-PTR Treatment follows a 12-session, individual, manualized treatment protocol developed for this research study that integrates empirically supported treatment components for both conditions.

17. Treatment Components Education re: pain Relaxation training Cognitive restructuring Stress management Activity pacing Pleasant activity scheduling Anger management Sleep hygiene Relapse prevention Education re: PTSD Cognitive restructuring vs Prolonged Exposure therapy Teach coping skills Social support Anger management & sleep Reprocessing the meaning of the event CBT for Pain CBT for PTSD

18. Treatment Development • GOALS: • Create a treatment that amounted to more than the sum of its parts. • Create a treatment that was effective and transportable so that it would be considered clinically practical to use by therapists. • It had to be easy to understand for therapist and patient and not too time intensive.

19. Treatment Development • Step 1 • Meetings with collaborators to discuss “essential elements” of treatment • Relaxation Training • Interoceptive exposure to address anxiety sensitivity • Behavioral goals to address behavioral avoidance • Cognitive elements from CPT to address the impact of the trauma on patient beliefs • The sequencing of treatment elements

20. Integrated Treatment Session 1 Education on Chronic Pain and PTSD Session 2 Making Meaning of Pain and PTSD Session 3 Thoughts/Feelings related to Pain and PTSD & Cognitive Errors Session 4 Cognitive Restructuring Session 5 Diaphragmatic Breathing and Progressive Muscle Relaxation Session 6 Avoidance and Interoceptive Exposure Session 7 Pacing and Pleasant Activities Session 8 Sleep Hygiene Session 9 Safety/Trust Session 10 Power/Control/Anger Session 11 Esteem/Intimacy Session 12 Relapse Prevention and Flare-up Planning

21. Treatment Development • Step 2 • Pilot test Treatment and Address Challenges to Implementation • Participant Alcohol Use • Establishing Trust • Attendance • Addressing Avoidance • Homework Completion

22. Pilot Data Six participants were recruited to pilot the treatment: Two of the six participants dropped out of treatment before the third session. One participant dropped out due to family health problems. A total of three participants completed the 12 session integrated treatment. Otis, J. D. Keane, T., Kerns, R.D., Monson, C., & Scioli, E., (In Press). The Development of an Integrated Treatment for Veterans with Comorbid Chronic Pain and Posttraumatic Stress Disorder. Pain Medicine.

23. Participant 1: • A 59 year old Caucasian male with pain and PTSD related to combat and injury in Vietnam. • Significantly depressed • Longstanding history of alcohol abuse, in remission. • Not socially active and avoided many situations • Participant 2: • A 51 year old African American female with pain and PTSD due to military sexual trauma. • Musculoskeletal pain located in her back, neck and shoulders. • Significant anger

24. Participant 3: • 58 year old Caucasian male with PTSD related to events witnessed while in Vietnam • Neck, shoulder and back pain • Marital difficulties, discomfort being around children, and difficulty trusting people in authority.

25. Participant 1 PTSD Measures Pain, Disability, & Distress

26. Participant 2 PTSD Measures Pain, Disability, & Distress

27. Participant 3 PTSD Measures Pain, Disability, & Distress

28. Outcomes for 3 Pilot Participants 28 CAPS: Clinician-Administered PTSD Scale (50 cutoff) PCL: PTSD Checklist-Specific Version (50 cutoff) MPQ: McGill Pain Questionnaire (0-78) BDI: Beck Depression Inventory (0-63) RMDQ: Roland & Morris Disability Questionnaire (0-24)

29. Current Status of Research Over 47 participants have participated to date Recruitment of new patients is ending One participant is completing treatment Several participants are in the 6-month follow-up phase Data analysis phase will begin once all follow-ups are completed

30. Future DirectionsIntensive Treatment of Pain and PTSD for OEF/OIF Veterans John D. Otis, Ph.D. and Terence M. Keane Ph.D. A Pilot Study funded by the VA RR&D Purpose: Develop an Intensive (3-week 6-session) integrated Pain and PTSD treatment program specifically for OEF/OIF Veterans Advantages of this approach: More time efficient = more acceptable to veterans Less costly to administer Quicker re-establishment of adaptive functioning (military or civilian)

31. Questions & discussion