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Dr. Merritt S. Oleski, Ph.D.

I am trained as both a Psychotherapist and a Neuropsychologist.

As a psychotherapist, specialties include:

• behavioral effects of chronic pain.
• treating depression
• anxiety

As a neuropsychologist, I assess the cognitive and behavioral status related to neurological-

trauma and neurological disease processes.

My Specialties include:

• Chronic Pain or Illness
• Depression
• Anxiety or Fears

Anne Oleski, P.T.

Frank Blymeier, Jr., Psychology Aid

- By Randy S. Roth, * Michael E. Geisser*, and Rachel Bates.

* To see the tables that go along with this article, please go to, Category: Journal, Subcategory, Table(s)*

Abstract: Symptoms of post-traumatic stress (PTSD) are a common comorbidity in patients with a history of accident-related chronic pain and depression. However, little is known regarding the influence of PTSD in contributing to the affective distress, pain experience, and disability associated with chronic pain in this population. This study used structural equation modeling to examine 3 models that assess these relations in a sample of chronic pain patients with accident-related pain. Subjects were assessed for pain experience,depressive symptoms, anxiety, PTSD symptoms, pain disability, and relevant demographic variables. Pearson correlations indicated that symptoms of depression were significantly associated with higher disability. The model of best fit indicated that after controlling for the influence of anxiety on the dependent measures, PTSD symptoms have a direct influence on severity of depressive symptoms, whereas depressive symptoms have a direct influence on pain intensity and an indirect impact on pain intensity by way of their effect on disability. These data point to the importance of unresolved PTSD symptoms in contributing to the level of depression, pain, and disability exhibited by chronic pain patients and highlight the need to consider directed and primary treatment of PTSD in pain rehabilitation programs.

Perspective: This study highlights the impact of symptoms of PTSD on levels of depression, disability, and pain in patients with pain secondary to physical injury. Our results suggest that pain rehabilitation programs provide directed interventions for PTSD symptoms among this population to improve pain treatment outcomes.

Studies of chronic pain patients with a history of accidental injury and physical trauma attest to the influence of post-traumatic stress in enhancing the pain experience and dysphoria commonly observed in this population. Traumatic events are independently associated with the development of both major depressive disorder and post-traumatic stress disorder (PTSD). Importantly, symptoms of both depression and PTSD are risk factors for more severe pain experience and pain morbidity. For example, chronic pain patients with depressive symptoms report more severe pain intensity, greater pain-related disability, and relatively poor treatment outcomes compared with chronic pain patients who are not depressed. Similarly, chronic pain patients who describe their pain as accident-related with or without symptoms of PTSD, report higher levels of pain, affective distress, and greater functional disability when compared with patients with pain of insidious onset. Despite the consistent association of post-traumatic stress symptoms with both depressive symptoms and pain, little is known regarding the mechanisms by which post-traumatic stress may contribute to the course and severity of mood disturbance in this population. PTSD may be associated with depressive symptoms through the presence of neurobiological abnormalities that are common to both disorders. PTSD also may have an indirect effect on depression through its impact on behavioral disability. Rudy et al describes a cognitive behavioral model of chronic pain that in part draws attention to the effect of pain interference with life activities in mediating the relation between chronic pain and depression. For example; PTSD can contribute to functional impairment as the result of its association with panic disorders and agoraphobia, which promote generalized patters of behavioral avoidance and psychosocial disability. Thus, it is possible that the functional disability exhibited by a depressed chronic pain patient, attributed to either depression or pain or their combination, may actually derive from an embedded PTSD.

Alternatively, a history of physical trauma with related symptoms of post-traumatic stress may influence pain morbidity through their effect on the development of maladaptive pain beliefs and coping strategies. Turk and Okifuju and Vlaeyan et al have proposed that when pain is acquired as a result of physical injury, some individuals adopt maladaptive beliefs about the origin of their pain and incorrectly interpret their pain to reflect underlying and progressive structural damage. These beliefs are hypothesized to foster a fear of of any movement that is associated with pain, catastrophic worry about the uncontrollability and inevitable enhancement of pain experience, leading to the avoidance of activities that are associated with pain. In this cognitive-behavioral formulation of chronic pain disability, the spiral of pain catastrophizing, and fear of (re)injury result in progressive disability, deconditioning and depression. Of note, the model proposed by Vlaeyen et al postulates somewhat contrary to clinical intuition, that pain intensity results from both functional disability and depression rather than the converse. Cook et al have recently reported data to support Vlaeyen’s proposed relation of disability and depressive symptoms to pain experience. This study will examine the contribution of PTSD to pain experience, functional disability, and frequency of depressive symptoms through the use of structural equation modeling. We will specifically examine 3 possible models that describe these interrelations for a cohort of chronic pain patients with accident-related pain. For the first model, following the pathway proposed by Rudy et al, it is proposed that pain influences disability, which in turn predicts depression. In this model, PTSD symptoms are hypothesized to have a simultaneous influence on levels of depression and disability. Based on the pain-related fear model suggested by Vlaeyen et al, the second model examined the seperate influence of depression and disability on pain, with symptoms of PTSD hypothesized to independently predict levels of depression. Finally, the third model examines the severity of depressive symptoms in relation to both pain and disability, as prior research has reported that depression influences functional activity independent of pain. For this model, PTSD symptoms are examined in association with depressive symptoms, and the influence of disability on pain are examined on the basis of the model proposed by Vlaeyen et al. Because PTSD is known to share collinearity with a number of psychosocial variables (eg, anxiety) for which PTSD may serve as proxy in an observed statistical association with depressive symptoms, additional analyses will be conducted to examine the independent influence of PTSD on depression, disability, and pain by controlling for the influence of anxiety on the variables of interest.

Materials and Methods

Sample Selection

Subjects in the present study comprised 241 consecutive patients with chronic pain (defined as duration of 3 months or greater) referred to a university hospital pain rehabilitation program and who reported that their pain began after a traumatic injury. The mean age of the sample was 39.1 years ( SD=9.4). One hundred forty-two subjects were female, and 99 were male. Participants had a mean duration of pain of 39.0 months ( SD=49.3). Fifty-five percent of the subjects indicated that their pain began after an accident at work, 35% reported that their pain was caused by a car accident, 8% indicated their pain began as a result of- an ” other” accident, and the remainder reported that their pain was caused by an accident at home. THe most common site of pain was low back pain ( N=102), followed by pain in 3 or more sites ( n=53), neck and upper back pain( n=51), and thoracic pain ( n=12). Two hundred sixteen subjects were Caucasian, 16 were African-American, 3 were Asian-American, 1 was Native-American, and 6 were Hispanic . Educational achievement was as follows: One subject reported ahving less than a 6th grade education, 16% reported that they did not complete high school, 22% reported having a high school education, 41% reported having some college or technical school training, 11% completed college, 9% reported having a graduate or professional degree. Education data were missing for 1 subject. Maritial status indicated that 60% reported being married, 15% had never married, 17% indicated they were divorced, 3% were seperated, 5% lived with a significant other, and 1 subject was widowed.

Instruments

Pain Assessment

Subjects completed the McGill Pain Questionnaire (MPQ). the MPQ measures the subjective pain experience in a quantitative form. This measure consists of 20 groups of single-word descriptors describing a wide range of sensory,emotional, and cognitive features of pain experience. The MPQ provides a measure of the sensory, affective, and evaluative aspects of pain experience, as well as an overall summed total of pain experience intensity. ( PRI; Pain Rating Index). The PRI was used in this analysis to measure self-reported pain intensity. Repeat administration of the MPQ has revealed a 70.3% rate of consistency in the PRI score.

Disability Assessment

To measure disability due to pain, subjects were administered the Pain Disability Index ( PDI). The PDI measures the degree that pain interferes with various activities of daily living. Areas of disability asses include ( 1) Family/home responsibilities, (2) recreation, (3) Social activity, (4) occupation, (5) Sexual behavior, (6) Self-care, and (7) life-support activity. Ratings of disability for each functional area are quantified along a 10-point scale from ” no disability” to ” total disability.” A total disability score is calculated by averaging the scores from all the responses . For this study, the total PDI score was used as a measure of activity interference of pain disability. Test-retest reliability for the total score is moderately high (r=0.44), and some of the subscales significantly correlate with levels of patient pain behavior.

PTSD Assessment

To measure symptoms of PTSD related to pain, the Post-traumatic Chronic pain Test ( PCPT) was issued in a modified form. THe PCPT was developed specifically to assess post-traumatic stress symptoms among a cohort of chronic pain patients who report the onset of their pain to coincide in time with a traumatic event. THe PCPT measures the presence of 6 symptoms of PTSD as it related to the accident or injury that is associated with the onset of pain. In its original form, the PCPT used a true/ false response set but what modified for this study to solicit subject responses along a 7-point Likert scale. Subjects were asked to rate the frequency with which they experience specific symptoms of PTSD for the following items: ( 1) I feel upset or nervous when exposed to events that caused my pain; ( 2) Since the Injury, I find myself avoiding places or activities that remind me of the accident or injury; (3) I have recurrent and intrusive memories of the events surrounding my accident or injury; (4) I have experienced recurrent dreams about the events surrounding my accident or injury; (5) Since the accident or injury I have become “wound up” and startle easily; and (6) At times, I have suddenly felt or acted as if the accident or injury were actually happening again. Subject responses range from 0 indicating ” not at all” to 6 indicating ” very much.” The summary score used was the average of the responses to all 6 items. The PCPT has demonstrated good test-retest reliability. (0.90), split-half reliability is reported to be 0.59, and inter-rater reliability reported to be 0.93. Using the revised format of the PCPT as described above, Geisser et al found that the scale has good internal consistency as measured by Cronbach’s man-Brown method. In the p resent sample,, Cronbach was 0.88 and split-half reliability using the Spearman-Broen method was 0.87. Scores on the PCPT are known to be predictive of PTSD, when assessed by structured diagnostic interview, with a criterion-based validity Spearman correlation coefficient of 0.75.

Depression Assessment

The severity of depressive symptoms was assessed by the Center for Epidemiological Studies-Depression Scale (CES-D). The CES-D is a 20-item questionaire that assesses the frequency of depressive symptoms experienced by the subject during the previous week. These symptoms are measured on a 0-3 scale from ” none of the time” to ” all of the time,” and a total score is obtained by totaling all of the item responses. Recent studies among patients with chronic pain indicated that the CES-D has good predictive validity for predicting major depression.

Anxiety Assessment

Anxiety was assessed by using the Anxiety subscale of the Brief Symptom Inventory (BSI). The BSI consists of 53 items that are purported to measure 9 symptoms dimensions including somatization, obsessive-compulsivity, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Scores for each of the subscales are computed by summing the responses and dividing by the total number of items on that subscale. Persons endorse the relevance of each item to their experience during the past 7 days on a 5-point scale, from ” not at all” ( 0) to ” extremely” ( 4). Internal consistency of the Anxiety subscale is reported to be .81 and test-retest reliability is .79.

Pain Questionaire

Last, Patients completed a general questionaire that included information regarding their pain duration, compensation and litigation status, and other demographic information.

Procedure

As part of their clinical evaluation, subjects were mailed the questionaires and asked to complete them before their initial evaluation appointment. This information was collected during the subject’s first appointment. The information was then examined for accuracy and thoroughness of completion. Data analysis was performed after approval from the University of Michigan Medical School Institutional Review Board. Retrospective data was collected after clinical assessment of patients referred to our center over a period of years; participant consent was therefore bypassed, as approved by the institutional review board.

Statistical Analysis

To examine the hypothesis that PTSD affects the experience of pain and disability through its association with us, Pearson correlations were examined first, then path models were tested, using Structural Equation Modeling (SEM). AMOS 5.0 was used to calculate the statistics for the models examined. Maximum likelihood estimation with bootstrapping was used to calculate the various parameter estimates. The fit of the path models was examined using the comparative fit index (CFI), adjusted goodness of fit index (AGFI), and root mean square error of aproximation (RMSEA). Acceptable levels of fit for these measures of CFI > .95, AGFI >.80, and RMSEA < .06. Path coefficients (p) for each model were calculated based on standardized regression coefficients. Error estimates for endogenous variables in the model were set at one. ?² values were also calculated for each model but were not examined as measures of fit because this statistic is influenced by factors such as sample size. The first model tested was based on results from Rudy et al, who reported that the impact of pain on depression in younger adults is mediated, in part, by one’s evaluation of how much pain interferes with daily activity. A model was constructed in which pain influences disability, which in turn predicts depression. PTSD was examined as a seperate influence on depression and disability. The second model examined was similar to the model presented by Cook et al, which examined the tenability of Vlaeyen’s fear-avoidance model of chronic pain. In the current dataset, we examined the seperate influence of depression and disability on pain. PTSD was added as a predictor for depression. Finally, a third model was examined whereby depression was allowed to be related to both pain and disability. PTSD was allowed to be associated with depression in this model, and disability is hypothesized to influence pain.

Results

Sample Means and Standard Deviations

The sample means and standard deviations for pain intensity, depression, PTSD symptoms, and disability are presented in table one. ( see other post category entitled: Journals: Tables) Because the data suggested that scores on the PCPT were positively skewed (0.91), these scores were log-transformed. This transformation reduced the skewness to 0.19. The remaining analyses examining scores on the PCPT were conducted on the log-transformed values.

Pearson Correlation Analysis

Pearson correlations between age, gender, pain intensity, disability, PTSD symptoms, and depression are presented in Table 2. Age and gender were not significantly correlated with any of the other variables of interest. Depression symptoms were significantly associated with higher pain intensity, greater PTSD symptoms, and greater disability. Also, greater endorsement of PTSD symptoms was significantly associated with higher disability and greater depressive symptoms.

Structural Equation Modeling Analysis

The first SEM is presented in Fig. 1. The ?² value for the model was statistically significant ( ?²(2)=8.6, p=.01), suggesting that the model did not fit the data. In addition, 2 of the goodness-of-fit statistics did not satisfy the a priori criteria for a good model fit ( CFI = .946; RMSEA = .117), but the AGFI was acceptable (.913).

The second model is presented in Fig. 2. Again, the ?² value was significant ( ?²(3)=45.5, p<.001), suggesting that the model was not a good fit. None of the goodness-of - fit statistics satisfied that a priori critera for a good model fit ( CFI= .655 ;AGFI =.735, RMSEA = .243).

The third model tested is presented in Fig. 3. ?² value for this model was not statistically significant ( ?²(2)=2.51, P= .29), suggesting that the model fit the data well. All of the a priori criteria for a good model fit were also satisfied. (CFI = .996 ; AGFI = .974, RMSEA =.033). This model indicated that PTSD symptoms have a direct influence on severity of depressive symptoms, whereas depressive symptoms have both a direct influence on pain intensity and indirect impact on pain intensity by way of their effect on disability. To determine whether the relationships observed in model 3 where due to an association of PTSD symptoms with anxiety, the model was recalculated while simultaneously examining or controlling for anxiety as measured by the Anxiety subscale of the BSI. First, anxiety was added as an additional variable in model 3 that could influence depression and was allowed to covary with PTSD. The ?² for this model was not statistically significant (?²(3) - 7.56, p = .11). CFI (.987) and AGFI (.954) were acceptable, but the RMSEA fell short of the acceptable limit (.061). Alternatively, another model was constructed that was identical to model 3, except that the transformed measure of PTSD was replaced with the standardized residuals of the transformed PTSD measure that excluded the influence of the BSI Anxiety subscale. These results are presented in Figure 4. This model had an acceptable fit, based on all 4 criteria ( ?²(2)=2.97, P=.23; CFI=.989; AGFI =.969; RMSEA = .045). Although the path coefficient from PTSD to depression is reduced compared with model 3, which did not control for anxiety, the influence of PTSD on depression remains statistically significant.

Discussion

Borrowing from 2 cognitive-behavioral models of chronic pain, the present stud used SEM to explore 3 models that examine possible contributions of PTSD symptoms to severity of pain experience, depressive symptoms, and disability among patients with chronic pain of traumatic onset. Consistent with previous studies, the correlational analysis found that symptoms of PTSD and depression are significantly correlated and further that both disorders correlate with perceived disability attributed to pain. For the SEM analysis, only 1 model demonstrated a significant fit for the data. In this model ( model 3), symptoms of PTSD were found to directly influence depressive symptoms, which in turn exerted both a direct influence on pain and an indirect influence on pain through its impact on disability. These relations remained significant even when the influence of anxiety on PTSD was statistically controlled. These data are interpreted to provide partial support for Vlaeyen’s chronic pain model of pain-related fear while also highlighting the critical importance of ongoing symptoms of PTSD in understanding the persistent affective disturbance and disability demonstrated by patients with accident-related chronic pain.

Influence of PTST on Depression

A main finding for this study suggests that in case of disabling accident-related chronic pain with co-morbid depression, PTSD symptoms may be critical to understanding the chronicity of both disorders and provide insight into intervention strategies for their remediation. Our data indicate that PTSD symptoms exert a significant influence on depressive symptoms, which then enhance disability and pain experience in multiple ways. Several studies have suggested that PTSD may be related to depression inc chronic pain patients with traumatic -onset chronic pain. For example, Toomey et al compared pain patients of idiopathic and post-traumatic onset. Patients with pain of post-traumatic onset reported higher levels of depression compared with pain patients whose pain was not associated with a physical trauma. Turk and of the idiopathic pain group, exhibited evidence for a depressive disorder. Importantly, our data suggest that reduction of symptoms of PTSD can have a significant influence on reducing depressive symptoms in chronic pain patients. Because depression is known to bear a negative influence on pain morbidity and pain treatment outcome, successful amelioration of PTSD symptoms in this population can be an important avenue for enhancing pain rehabilitation outcomes.

Treatment of PTSD in Chronic Pain

Increased attention to the treatment of PTSD as a primary focus in the rehabilitation of individuals with chronic pain and co- morbid depression is particularly important when prior treatment efforts for pain and depression have been disappointing, implicating the potential for PTSD symptoms to be an ” anchor” for prevailing mood disturbance and intractable pain disability. This concern is supported by evidence that patients with depression or chronic pain, with a co-morbid history of physical trauma, demonstrate a diminished response to treatment compared with a cohort of patients without a history of trauma. Moreover, recent clinical reports have described the indirect and successful treatment of intractable depression and chronic pain in patients with co-morbid PTSD only after instituting behavioral therapy ( eg, progressive exposure therapy) targeting the PTSD symptoms. As cognitive-behaviroal therapies with proven efficacy for the treatment of PTSD are now available to pain practitioners, it is noteworthy that these interventions are now being tailoreid within comprehensive pain rehabilitation programs. The mechanisms by which PTSD symptoms influence depressive symptoms in chronic pain remain unclear. Biological and psychological vulnerabilities may predispose some individuals who experience a physically traumatic event to develop both PTSD and major depression ( see Asmundson et al and Keane and Barlow for related discussion). PTSD symptoms may also contribute to depressive symptoms in some chronic pain patients by way of its association with intrusive memories of negative past experiences, a maladaptive cognitive style that is also present in major depression. From a treatment standpoint, a pain patient with PTSD may respond with a heightened psychophysiologic responce ( eg, muscle tension and spasm) to trauma-related and more general environmental stimuli, contributing to incsreased pain and interference with physical physical therapy efforts to restore muscle elasticity and function, leading to treatment failure and increased hopelessness and depression. Finally, PTSD symptoms may interfere with the psychological adjustment necessary for successful pain coping. For example, PTSD symptoms may mire a chronic pain patient in a whirl of fear, anger, feelings of victimization related to the trauma, and the experience of recurrent, trauma-related intrusions. Such emotional upheaval may delay or prevent a decision by the patient to accept and learn to live with his or hear pain and ” move on” to a more functional life despite persistent pain, portending continued affective distress as pain-related disability persists.

Implications for Cognitive-Behavioral Models of Chronic Pain

The present findings also have implications for cognitive-behavioral formulations of chronic pain disability. The SEM methodology did not replicate the previous report by Rudy et al, which found that, among a heterogeneous group of chronic pain patients, the relation of pain and depression was mediated by the perceived effect of pain to interfere with activity. The discrepancy may be due to differences in the sample composition of the 2 studies, particularly given that our sample consisted only of chronic pain patients who had sustained their pain as a result of injury. Furthermore, it is possible that the presence of PTSD symptoms may alter the interrelations of pain, disability, and depression and mitigate the mediational role of disability in explaining depressive symptoms among chronic pain patients. In addition, our study used the PDI as a measure of disability , whereas Rude et al assessed pain interference from the Multidimensional Pain Inventory. Although, the PDI asks patients to rate the degree to which pain interferes with their activities of daily living, which would appear to be comparable to a measure of pain interference, it is possible that these alternative measures of functional impairment are not comparable to a measure of pain interference , it is possible that these alternative measures of functional impairment are not comparable either psycho-metrically or conceptually. For example, pain interference implies the negative impact of pain on daily functioning, whereas pain disability may reflect, for many patients, a more global and stable level of decreased ability to function. Further research will need to determine the psychometric similarity of these factors as measures of pain-related functional impairment. The model of best fit for our SEM was drawn from a cognitive-behavioral paradigm that posits a central role for pain-related fear in explaining persistent and intractable pain disability. Vlaeyen et al, and more recently, Cook et al, have hypothesized that for patients who have chronic pain, after a physical injury the patient acquires a catastrophic cognitive style in experiencing and coping with pain, which leads sequentially to fear of movement and activity avoidance that results in multiple comorbidities including depression, disability, and disuse. Our SEM suggests a refinement of the Vlaeyen model. We replicated previous evidence that depression may have a direct influence of pain. However, our analysis further indicated a sequential influence of depressive symptoms on disability, which in turn influences pain experience. In addition, the present findings argue for a formalized inclusion of PTSD in the fear-avoidance for model of chronic pain proposed by Vlaeyen et al. As the model posits fear-avoidance for chronic pain patients who receive a physical injury , it is likely that many of these persons have post-traumatic stress symptoms or actual PTSD. Future studies should consider a formal assessment of PTSD in investigations of fear avoidance approaches to chronic pain, given the potential for PTSD symptoms to contribute to depression, anxiety, and avoidance. More specifically, the presence of PTSD may be associated with an enhanced risk for pain catastrophizing, which may lead to greater pain-related fear, activity avoidance, affective disturbance, and pain.

Study limitations

This study has several methodological constraints. First, although SEM permits an influence of causality among variables examined, the study design is cross-sectional and correlational, and, as such, no causal direction for the obtained associations can be definitively determined. In addition, the subject pool was composed of chronic pain population that derived from a tertiary care, university hospital locale. As a result, the clinical sample probably represents pain patients with relatively severe pain morbidity. Thus, our findings may not generalize to pain patients with comorbid depression and PTSD who present with acute pain or within community clinical care settings. Third, Our measures of depression, PTSD, and pain disability may constrain the validity of our findings. These diagnostic measures were obtained by self-report inventories and are susceptible to methodological problems associated with factors that distort self-report estimations of psychological functioning. Moreover, the assessments of depression and PTSD represent a measure of symptom severity for each disorder rather than a categorical diagnosis of major depression and PTSD such as would be determined by the strict adoption of DSM-IV diagnostic criteria. Future studies will nedd to replicate our findings using empirically validated interview schedules to determine categorical assignments of pain patients to major depression and PTSD diagnostic groups.

With, regard to the assessment of PTSD used in this study, the PCPT has preliminary empirical support for its psychometric validity as a measure of PTSD, but further investigation is warranted to ensure its divergent validity apart from the measures of affective distress and anxiety. In our sample, the average PTSD score was modest ( 1.7 on a 0-6 scale), suggesting that a majority of our subjects did not have severe PTSD symptoms. As our study design is cross sectional, it is possible that a third variable, for which the PCPT scores sever as proxy, may actually account for the relation between PTSD and depressive symptoms observed in our analysis. For example, PTSD is known to have a consistent and significant collinearity with anxiety disorders and affective distress. This is attributable, in part, to the diagnostic overlap between PTSD and somatic symptoms that are commonly associated with anxiety and affective distress such as emotion distress, physiologic reactivity, hyper-vigilance, difficulty concentrating, and exaggerated startle response. When we controlled for the influence of a measure of general anxiety in our analysis, the variance was substantially reduced although continued to have a significant influence on depressive symptoms. Although these findings support a unique association of PTSD symptoms with depressive symptoms that is independent of more general psychological disturbance, it raises concern that measure of PTSD may serve as a marker for anxiety or global affective distress in studies examining the relation of PTSD symptoms to depression among a chronic pain population. Taken together, future pain studies are encouraged to assess PTSD with psychometric tools with established and sound psychometric validity and to examine the effet of PTSD on depression in chronic pain patients while controlling for potential psychological comorbidities that are known to share covariation with PTSD, depression and pain.

Finally, our results and data from other centers encourage the consideration of prospective, controlled, investigations that isolate PTSD as a significant influence on depression in chronic pain patients and that examine the effect of targeted treatment of PTSD in ameliorating co-morbid symptoms of depression and disability.

Beginning to Take Control of Your Pain

You may still have doubts about whether you can ever enjoy life again while you are in chronic pain, or whether life will ever be worth living with chronic pain.  Nevertheless, let’s at least explore how living a life of quality with chronic pain is possible.  THe keys are to take responsibility for your pain ( not in the sense of accepting blame for it yourself or assigning blame to others,, but in the sense of accepting ” ownership” of it); to determine exactly what your problems are as a result of the pain; and to reassess your goals in the light of this information.  This chapter gives you your first set of tools for begininng to take control of your pain: diary keeping and goal setting.  TO start with, however, let’s look at the first of the three keys: accepting ownership of your pain.

Accepting Ownership of Yours Pain

As you define it at this moment, your problem is that you are in pain and the pain won’t go away.  This is an important first step, before you can do anything about your pain, you need to acknowledge that it exists.  However, you may also feel inclined at this point to blame others for your pain.  You may feel that your doctors have failed you by not finding and curing the source of the pain, or at least for not making you feel better.  You may believe that your loved ones are not doing anything to help you, or are showing a lack of understanding or empathy about your problem.  You may even feel that society is to blame for causing the situation that put you in pain in the first pace, or for not making it easier for you to seek help.    The fact that you may be sad, angry, or anxious about the disruption of your whole life as a result of the pain experience is both understandable and normal.  Under these circumstances, it may be very tempting to feel that others are to blame for the pain and ought to be responsible for taking it away.  Indeed, may people in pain put their whole lives on hold waiting for others– their physicians, their families, or society– to do just this.   The difficulty with this, however, is that wanting to give away both the pain and the responsibility for it will only prolong and contribute to your feelings of powerlessness.  if you pain is not going away any time soon– and this is the very nature of chronic pain– then taking upon yourself the responsibility for living with it may begin to return control of your life to you.  If you can adopt an attitude of “ownership” of the pain problem, you have the potential for gaining the upper hand over it.   Although you may need assistance from your health care provider, your family and society in untangling yourself from your pain web, gathering the threads together and reweaving them into a safety net for yourself are ultimately your tasks and yours alone.        What you now may be thinking is something like this: ” Oh, great.  So I’m responsible for my pain, huh? I’m to blame? That’s what everybody’s been saying– or at least hinting–all along.  I feel bad and guilty enough as it is.” That is not what is meant here at all.  As you probably already know, self-blame and guilt can be paralyzing emotions.  They can make you feel that since you are such a bad and worthless person, there is no point in doing anything at all.  Accepting ownership of your pain, on the other hand, means acknowledging that you are a worthwhile prson, that there  is  a point in doing something, and that you  do have choices.  It is very different from blaming yourself.     Chronic pain is complex, with numerous origins and treatments, and is grossly misunderstood.  This will provide you with the information you need to mvoe forward. Even though your life will be different from the way it was before you developed pain, you can change some aspects of the pain, and can learn to accept or work with other aspects so that they cause you less distress.  Your task will be difficult– but not impossible.

Determining Exactly What Your Problems Are

  ORDER AND SIMPLIFICATION ARE THE FIRST STEPS TOWARD MASTERY OF A SUBJECT– THE ACTUAL ENEMY IS UNKNOWN. — Thomas Mann, THe Magic Mountain ( 1924)

The Importance of Tracking Your Pain Levels

 One important way to gain control over your pain is to record it so that you can see how certain factors– for instance, activities, the weather, tension, and sleeplessness– increase or decrease your pain levels.  This should be done three times a day, at regular times that are convenient for you.  For example, you might record your pain level when you awaken, after lunch, and then again at bedtime.   Such consistency is important, because if you record your pain only when you are aware of it, you won’t neccessarily feel it all the time when your pain is altered.  Recording the pain at regular intervals will allow you to detect over time whether there are any patterns to your pain experience.  These patterns should permit you to determine the exact nature of your problems more easily.    Many people are resistant to the idea of recording their pain, and you may be one of them.  Not only are you in pain to begin with, but it’s an additional hassle to have to record all this stuff– and three times a day! ” Why do i have to do this? It’s not fair!” you may say.  Perhaps the following story may help.

  Paula was very angry at the thought of recording her pain levels. Her back hurt and she already knew she was in pain.  Why did she have to write it down three times a day?  She didn’t have time for such a ridiculous activity.  At first, Paula was so misterable that recording the pain just made her realize how bad she felt.  Gradually, she realized how much she had denied the pain in her back and how it prevented her from doing anything productive or pleasurable.  Not only had she had to give up working outside of the home; she barely kept up with the household chores.  Her house certainly wasn’t as clean as it used to be.  Even worse, she was irritable toward her husband and yelled at her children. She rearely saw her friends, and really didn’t care any more about going out.  Somehow this just wasn’t the way Paula wanted to live.    Paula also began to see how she pushed herself throughout the day and then collapsed at night.  Her back was stiff when she awoke, and the pain gradually increased during the day.  What was causing it?  Was she not pacing herself? Was she stressed by her routine? Slowly, the answers because clear.  Over time, Paula saw that recording her painhelped her learn more about the relationship her pain had with what she did and how she did it.  She was able to incorporate the skills she learned in the pain management program into her daily routine,and was eventually able to bring the pain much more under her control.

If you don’t think that recording your pain will be a chore, that’s great.  If you do, consider this: You have done your best in your current situation, and it still has not been effective in controlling your pain.  Recording your pain levels can help you determine where you might be stuck and point you in the right direction.  You can’t count on remembering exactly what your pain feels like under all conditions over a long period of time.  So give the recording method a shot–it just might work for you. Remember:  what you know, you can master. 

 Keeping a pain diary

An effective way of recording your pain is to use the pain diary worksheet that is provided at the end of this book. There is a sample of a completed pain diary form, along with a blank pain diary form that can be copied.

Instructions

On the pain diary, it is important that you differentiate between ” Pain sensation” and ” Pain distress” as follows.  ” Pain sensation” refers to the phyiscal component of your pain– for example: th e achiness, stabbing,burning, tightness, and other physical sensations you may feel.  ” Pain distress” refers to your perception of pain and is a measure of the emotional suffering you experience– for example, the frusturation, anxiety, anger, or sadness you may feel. 

Note the word “feel” can be used to describe both physical/body sensations and emotional/mind reactions.  This can give rise to confusion when you try to describe the pain experience to yourself and to the outside world.  I began asking patients to make the sensation-distress distinction years ago when i noticed that at the last session of the pain group they were talking about how great they felt, and yet their pain recordings were only decreased a little from the beginning of the program.  I was puzzles by this, so i asked them to explain it.  They responded without hesitation: ” we still have the pain [ the physical sensation], but we feel so much better about it [ the distress]. We aren’t so helpless. We know what to do about our pain, and we feel in control again.”     Much can be done about your level of distress. You can begin by getting in touch with how you experience your pain, both physically and emotionally.  You may find that either the physical or the emotional feelings predominate, it will take some time for you to make the distinction.  Some of the exercises in the next few chapters will help you to seperate these feelings. 

1. Record your  pain level on the pain diary form three times a day at regular intervals, as described above– for example, morning, noon, and bedtime.
2. On the diary sheet there is a space to describe the situation for each pain  sensation/distress rating. For example. were you watching TV, eating lunch, sitting at a computer, fixing dinner? Note what activity you were engaged in at the time.
3. Rate your pain sensation and distress by using numbers from one to 10. As follows:

0 = No pain/ distress

1-9 = Range in degree of sensation/distress

10 = Worst pain/ terribly distressed

It may take several weeks to establish what the numbers mean to you.  This is quite normal. Pain is a personal experience, and you will only be rating your own experience.  ( If you have particular or continuing difficulty, however, see the ” Rating Your Pain” exercise under the ” Listening to Your Body” in Chapter 4)

Many patients who participate in the pain program work in offices and use computers on a daily basis. If you are one of these patients, correctly setting up your computer work area so that you are comfortable is very important in reducing or preventing the following:

• Neck and shoulder pain
• Eyestrain
• Stiffness
• Carpal tunnel syndrome
• Wrist pain
• Back pain
• Headaches
• Repetitive strain injury

Most larger companies are very “ergonomically aware” of correctly setting up work areas. If you are fortunate enough to work for such a company, take advantage of the services it offers. Even if your company does not offer ergonomic services, you can set up your own office so it is comfortable for you to work in.

Adjusting your chair

The best type of chair for office work is a “secretarial” chair ( no arms) that has four types of adjustments:

• Seat height
• Seat angle
• Back height
• Back angle

Use the following guidelines when adjusting your chair:

1. Adjust the seat height so that your knees are bent at an angle of slightly over 90 degrees and that your feet are comfortable flat on the floor.
2. Don’t cross your legs while working. That can contrict blood flow, causing tingling and making your legs ” go to sleep.”
3. Adjust the seat angle of your chair so that there is not a great deal of pressure on the part of your upper leg just above the knee.
4. Try to avoid chair with arms. They put extra pressure on your arms, and also position them at an unnatural angle if you tend to rest your arms on them.
5. You may need further lower back support than your chair provides. Check with your physician or physical therapist for recommendations of back support pillows that best suit your needs.

Adjusting the Monitor Height and Distance

Now that your chair is comfortable, move it to your desk and sit down. You’re not going to adjust the height of your monitor so less stress is placed on your neck and shoulders.

1. Sit comfortably on your chair. Keep your feet flat on the floor.
2. Hold your head up so that you are looking staright ahead, not down and not up. This is the position your head should maintain when looking at the monitor. Relax your shoulders and arms while you are doing this.
3. Raise or lower the height of your monitor sot hat you are looking straight ahead–neither up nor down. The monitor height shold be approximately the same as your forehead height. You can raise the height of your monitor in a variety of ways:

• Telephone books
• Packages of paper
• Catalogues
• Specially designed shelving

4. The viewing distance from your eyes to the monitor should be between 16 and 24 inches.

5. IF the angle of your monitor can be adjusted, try tilting it 10-20 degrees.

6. Once you hae set the height of your monitor, sit down and see whether the position is comfortable for you. If you feel stress on your neck, try raising, or lowering the monitor until iti s comfortable for you.

Preventing Glare

Glare is the biggest single cause of eyestrain when a computer is being used. It is relatively easy to avoid eyestrain by following these suggestions:

1. Avoid setting your monitor in direct light ( sunlight, overhead light, etc.).
2. Fluorescent overhead lights are the biggest culprits in causing glare. If possible, have the ones directly over your monitor turned off. You can always use a small portable light for desktop lighting if neccessary.
3. Various types of glare screens are available at your local computer store. These can easily be attached directly to the front of your monitor.
4. Eyeglasses for glare prevention are also available, even for people who do not wear perscription glasses. Check with your opthalmologist for suggestions.
5. Something as simply as a large piece of cardboard that extends over the top of the monitor can help reduce glare.
6. Avoid staring at the screen for too long a period of time. People who do this tend not to blink as often, this causes dry, hot eyes. Look away and focus on an object at a distance for a few seconds. Blink frequently to avoid dryness.

Adjusting the Keyboard Height

Carpal tunnel syndrome and repetitive strain injury have become the fashionable ailments of the 1990s, thanks to keyboards and mouse devices. If you use a keyboard or mouse device, you are susceptible to these problems, but your chances of getting them can be greatly reduced by a proper keyboard height. Follow these guidelines when setting up your keyboard:

1. The table height of your work surface should be between 23 and 28 inches ( floor to typing surface).
2. Use a comfortable wrist pad in front of your keyboard, so that your wrists lie comfortably on the pad instead of the hard table top.
3. Adjust the table height so that when you position your hands on the keyboard, your elbows are bent at a 90 degree angle and your wrists are not bent up or down. Make sure that your wrists lie flat and that your fingers are stretched out in front.

Using a Mouse Pad

If you use a mouse devce, follow these suggestions to prevent wrist and shoulder stress:

1. Use a mouse pad to protect your mouse and make it easier for you to operate the mouse.
2. Try to move your entire arm when using a mouse. Many people make sharp, jerky movements with just their wrists when using a mouse. This puts added stress on the wrist.
3. Take a ” mouse break” every now and then.
4. Position the mouse pad next to the keyboard so you don’t have to reach too far for the mouse.

Taking Breaks

If you spend more than an hour a day at your computer, the best thing you can do for your body and mind is to take breaks. Most computers have bult-in clocks, and you can set an alarm that will tell you it’s time to take a berak. Determine how long you can work comfortably before you need to take a break. Then take that break!

Exercising

Exercising is also a good way to reduce stress while you are working at a computer. Here are a few exercises that you can try:

Breathing

Preform diaphragmatic breaking to help relax your boxy and to reduce stress and tension. Let your head relax along with your shoulders and arms.

Eye Exercises

1. Look away from your monitor and focus on an object at a distance for a few seconds.
2. Blink your eyes frequently to provide moisture.
3. Move your eyes to the left, then to the right. Look up and then look down.

Stretching Exercises

The following exercises can help reduce any tension or muscle strain that occurs while using your computer.

Shoulders and Neck

1. Raise your shoulders toward your ears, and hold that slight tension for just a moment.
2. Relax your shoulders and arms.
3. Repeat this five times to prevent tightness in the shoulder and neck area.

Upper Back

1. Make sure you are sitting up straight
2. Put your hands behind your head so that your elbows point out to the side.
3. Pull your shoulder blades toward each other until you feel a slight tightness in your upper back.
4. Hold this for about 10 seconds. Then release and relax.

Hands

There are two exercises for the hands. Here is the first:

1. Make a tight fist.
2. Hold for a few seconds.
3. Relax your hands.

And the second:

1. Straighten your fingers out in front of you.
2. Spread them as far apart from one another as you can.
3. Hold the spread until you feel slight tension.
4. Relax.

General Stretching

A good general exercise is just to get up from your desk and walk around, swining your arms and moving your body.

1. They are frequently overlooked
2. Certain aspects of their causes or treatment considerations are not well known by health care providers.
3. There are medical treatments, usually aimed at the abnormality contributing to the pain syndrome, that might help reduce the pain experience.

Fibromyalgia

Fibromyalgia is a chronic pain syndrome that is currently throught to affect primarily women ( the ratio of women to men with fibromyalgia is 10 to 1).  Many terms are used to describe this syndrome, and overlaps among several of the terms suggest points along a symptom continuum.  These terms include ” fibrositis,” ” Myofascial pain,” “postviral fatigue syndrome,” ” Chronic fatigue syndrome,” ” Tension myalgia,” and ” generalized tendomyopathy.” In 1990, the American COllege of Rheumatology developed the following criteria for the classification of fibromyalgia:

1. History of widespread pain.
2. Pain in 11 or 18 tender point sites on digital palpation.

For classification purposes, patients are said to have fibromyalgia if both criteria are satistifed.  Widespread pain must have been present for at least three months.  The presence of a second clinical disorder does not exclude the diagnosis of fibromyalgia, but the diagnosis is made many times after other diseases have been excluded. (e.g., thyroid disease, luus, rheumatoid arthritis,etc.).  Many patients with fibromyalgia will also have associated complaints, such as headache, irritable bowel, irritable bladder, painful menstrual periods, intermittent blurred vision, and short-term memory problems. These complaints imply that the disorder involves more than the musculoskeletal system.    The symptoms are quite variable and are marked by their intermittent, waxing-wanning, and migratory pattern.  This probably contributes to the long lag time between development of symptoms and diagnosis.  The cause is unknown, and so far the two abnormal components that have been consistently reported are sleep disturbance and depression.  The treatment to date has focused on the sleep disorder by using drugs such as imipramine, atitriptyline, and cyclobenzaprine to restore restful sleep.   Regular, moderate exercise and cognitive therapy are also recommended.  If patients have access to natural bodies of warm water or to a heated pool, I find that swimming or moving in warm water is very helpful to them.      Many communities have support groups for fibromyalgia, and your stats’s Arthritis Foundation may sponsor such groups in your locale.   There is also an informative, proactive newsletter available from the Fibromyalgia Network, which makes a good effort to report the latest developments and advocated for more research funding.  Wire to the Fibromyalgia Network, P.O. Box 31750, Tucson, AZ 85751-1750, For more information on how to subscribe to this newsletter.

 Chronic Neck and Low Back Pain

Chronic pain in the neck or lower back is very difficult to diagnose and treat, particularyly if no obvious structural abnormalities are found, such as a herniated disc, a tumor ( a common fear of many who have developed chronic pain symptoms), or significant bony abnormalities ( arthritis with or without clearn nerve impingement, fractures).   Many times , surgery in the presence of a herniated disc does not always result in postoperative pain relief.  This has caused many surgeons to recommend conservative or nonsurgical treatment if only pain is present. ( i.e., if there are no nerve compression signs on examination).   Since i see either the people who have had unsuccessful surgery or those who have ” no abnormalities” on X-ray or MRI studies, I have developed a different way of looking at these individuals in an atetmpt to discover whether there is some other treatable reason for their symptoms.     In postsurgical patients whose pain is not coming from scar tissue pressing on a nerve or from an unstable spine, and in those patients without any surgically correctable problem, the pain is often the result of deconditioning in both the abdominal and back muscles.  In addition, poor body mechanics and misalignment may contribute to abnormal forces on sensitized nerves and soft tissue.  A good conditioning program to strengthen the muscles of the abdomen and back can be very beneficial.  For alignment problems and poor techniques as myofascial release, Jones trigger point therapy, and muscle energy techniques can be very helpful.  The use of Alexander and Feldenkrais therapies can be useful for poor body mechanics as well.    One of my frusturations as a pain specialists has been the realization that physical therapists and physical therapy treatments vary enormously.  Physical therapy, like many medical disciplines, is very much of an art.  However, Physical therapists do need to have some experience in working with chronic pain patients.  What I look for in a physical therapist is someone who is comfortable with a patient’s not getting total pain relief; who can help educate a patient regarding his or her body and how it moves; and whose goal is to get the patient into an independent program of self-management.  I expet the therapists not to persist in treatment once the patient has stopped responding or progressing or is noncomliant with a home program.      With regard to chiropractic treatment in chronic neck and back pain, evidence has been presented that in acute flare-ups of low back pain this form of treatment can be quite beneficial for some individuals.  I believe that chiropractic and manipulative medicine has been instrumental in stimulating the dialogue that is now taking place on the contribution of abnormal body mechanics to neck and back pain, particularly in those acute and chronic pain patients with no X-ray abnormalities(in the conventional sense).     Many chronic neck pain problems are complicated by what i prefer to label as ” posttraumatic fibrositis.”  After traumatic events such as motor vehicle accidents and lifting injuries, many of my patients with chronic neck pain report not sleeping well and having multiple tender points that were not present, according to the patients, before their accidents.  Whether this syndrome is the same as fibromyalgia ( see above) is not clear.  It does not seem to be associated with the nonmusculoskeletal symptoms present in primary fibromyalgia.  In addition to physical therapy addressing posture and conditioning of the upper back and extremities , medication to induce restorative sleep can be helpful ( e.g., amitriptyline, imipramine).

Headaches

Hundreds of books and research papers have been written, and many clinics hae been created, to help with the very common and disabling problem of headaches.  Fortunately, most headache syndromes are chronic but intermittent problems.  As in the case of back pain, multiple factors are possible as triggers or causes.  I would like to mention some overlooked factors that can be responsibile for chronic headaches.   The overconsumption of caffeine and chronic use of anti-inflammatory agents such as aspirin or ibuprofen may lead to ” rebound headaches” (i.e., headaches related to the chronic use of either substance). The same thing can happen with headache drugs like fioricet, Fiorinal, and Esgic.  In addition, these latter drugs can be habit-forming because they contain a barbiturate-like component.    When i see patients with complaints of daily headaches, I frequently find that they are suffering from muscle tension or spasm of their neck muscles.  ( Variations on this theme are patients with temporomandibular joint strain caused by clenching or grinding of their teeth; a night gaurd for the teeth may be helpful in such a case.)  Therapy directed at strengthening of the upper extremeties and  good  posturing of the head, neck, and upper back are extremely valuable, sometimes eliminating the problem altogether.   Patients who experience increased headaches after exercising their upper extremities should take special care: They are probably using muscles incorrectly because of weakness and straining, and should have supervision at the beginning.    The avoidance of long fasting periods during the day can be helpful to those individuals who may be prone to low blood sugar.  Skipping meals is often associated with headaches in susceptible individuals.  

Interstitial Cystitis

Interstitial cystitis is a chronic inflammation of the bladder that occurs primarily in women; the cause is unknown.  Symptoms include pain and pressure in the pelvis, urinary frequency( both day and night), painful sexual intercourse, and backaches.  THe urine is negative for the presence of infection, though it may feel as though infection exists.  The diagnosis is usually made by passing a scope into the bladder (cystoscopy), looking at the blader all, and taking a sample of tissue.  Treatment is available, but does not always resolve or help with the symptoms.  They are both national and local organizations to support women with interstitial cystitis and keep them informed as to the latest research and treatment developments.    You can contact the national group, The Interstitial Cystitis Association, at P.O. Box 1553, Madison Square Station, New York, NY 10159, or call (212)979-6057.

Endometriosis

 Endometriosis is a disorder of women involving the appearance of uterine tissue ( endometrium) outside of the uterine cavity ( womb).  It is unknown why the tissue becomes embedded in areas outside of the uterus.  The pain associated with endometriosis is thought to be the result of the microhemorrhages that occur with the monthly menstrual cycle, and the resultant irritation of surrounding tissue.  However,  the number of abnormal tissue implants does not correlate with the amount, intensity, or frequency of the pelvic pain experienced, so there may be several complicated mechanisms for pain production.  Treatments may vary from simple birth control pills to testosterone-like medications to hysterectomy.  This pain syndrome also has national and local groups for patient support and inforamtion resources.     Contact the Endometriosis Association at 8585 North 76th Place, Milwaukee,WI 53223, or call (414) 355-2200 for more information.

Neuropathies

Several well-known pain conditions are associated with nerve damage or irritation, and are thus known as ” neuropathies.” One of these is postherpetic neuralgia.  This is caused by the same virus that causes chicken pox, herpes zoster.  It can infect any peripheral nerve and is associated with a funny sensation of the skin, followed by a small blistery rash that over the course of about two weeks becomes crusted and weepy.  It may be associated with fever and flu-like symptoms.  In individulas over 65 years of age, there is a high likelihood of developing nerve pain that lasts long after the rash has gone.   Currently, it is recommended that older individuals at high risk receive nerve blocks from an anesthetist within days to weeks after the rash appears.   Another potentially effective treatment is to apply Zostrix, to the painful skin after the rash has healed five times a day.  Follow the instructions in the box. Zostrix is available without a prescription, but consult your health care provider to confirm the diagnosis.    Diabetes can be associated with a painful neuropathy, in additionto the neuropathy characterized by numbness in the hands and lower extremeities.  Most of the painful diabetic neuropathies are time-limited and ” burn out” after 12 to 18 months.  Amitriptyline, baclofen, and mexiletine are medications used for this condition that may help.    Sympathetically medicated pain, also known as ” reflex sympathetic dystrophy,” ” Sudecks dystrophy,” or ” hand/shoulder syndrome,” is a condition that develops after major or minor trauma to the extremities.  It is unclear what the true abnormality is, but the result is that the sympathetic nervous system– which controls blood vessel diameter and leakiness, as sweating in the extremeities– becomes involved in the pain process as well.   Thus the syndrome is characterized by swelling, increased sweating, blood vessel constriction ( causing the skin to dark red to blue), and sever pain in the involved extremeity.  Even light touch can cause excruciating pain.  It is a very complicated syndrome and needs to be treated by pain specialists or by someone familiar with the diagnosis.  I mention it so that if you have such symptoms but have not been diagnosed yet,  you can bring this description to the attention of your health care provider.  Sometimes nerve blocks aimed at blocking the sympathetic nervous system can be very effective altering this pain syndrome, but early intervention is critical.   Certain blood pressure medication, such as calcuim channel blockers, alpha-, and beta-blockers, are also used for treatment.  Physical therapy, using contrast baths, desensitization of the painful limb, and high voltage galvanic skin stimulation, may help as well.   The presence of a burning, tingling, sensitive-to-light-touch area with any chronic pain problem probably implies the presence of a neuropathy.  The use of low-dose amitriphtyline or imipramine may be beneficial.

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