Massachusetts General Hospital: Annual Conference on Complexities and Challenges of PTSD and TBI

BOSTON – For clinicians evaluating returning soldiers for posttraumatic stress disorder and traumatic brain injury, one of the greatest obstacles may be the soldiers’ inability to admit they may have a problem, said a specialist at a conference on the complexities and challenges of PTSD and TBI.

The DSM-IV diagnostic criteria for PTSD include experiencing or witnessing an event involving actual or threatened death or serious injury, and a response involving "intense fear, helplessness, or horror," noted Dr. Lisa Brenner, associate professor of psychiatry, neurology, and physical medicine and rehabilitation at the University of Colorado, Aurora.

"When I have a 25- or 26-year-old soldier or a veteran in my office, and I say, ‘Were you afraid?’ What do you think they say to me? ‘No. I wasn’t afraid. I am trained to not be afraid.’ How do you engage in a conversation about whether or not this event really did have the impact on them that we think it did, in language that makes sense to our returning soldiers?" she asked.

Combat-associated trauma differs significantly from trauma experienced by, say, an auto-accident victim, Dr. Brenner added. PTSD in military service members develops following long-term exposure to multiple traumatic events, possibly during multiple deployments.

In addition, at least two of the key symptom clusters of PTSD – numbness/detachment from others and hyperarousal – may be protective or even lifesaving on the battlefield, but don’t work well when soldiers return home, she noted. Soldiers may need help finding alternative ways of coping in their off-duty lives, without losing the advantage that the aforementioned coping mechanisms could give them should they return to the front lines.

Equally challenging for the clinician is differentiating symptoms of mild TBI from those of PTSD, especially when they co-occur, Dr. Brenner said.

Screening for PTSD and TBI

Screening instruments can help to identify those who need further assessment for PTSD, but screening alone is not sufficient for a diagnosis, Dr. Brenner cautioned.

In the military, service members are commonly screened with the PTSD checklist, a 17-item self-report measure of the 17 DSM-IV–designated symptoms of PTSD. The checklist appears to be a clinically useful screening instrument, but a critical review published in 2010 showed that it performs differently across civilian, military, and other specific populations. The authors concluded that it should be used with a second-tier diagnostic test such as a standardized interview (Clin. Psychol. Rev. 2010;30:976-87).

Traumatic brain injury (TBI) involves an alteration in consciousness, ranging from brief changes (mild TBI) to an extended period of unconsciousness or amnesia (severe TBI).

"Most of the people in Iraq and Afghanistan who sustain TBIs sustain mild brain injuries, and we expect recovery," Dr. Brenner said.

Nearly everyone who sustains a mild TBI or concussion reports immediate postinjury symptoms that may include headache, poor concentration, memory loss, irritability, fatigue, depression, anxiety, dizziness, or light and sound sensitivity. These symptoms are not specific, however, and should not be the basis for a diagnosis of TBI.

Returning service members are screened with a questionnaire that asks whether they had an injury event and, if so, whether they lost consciousness, felt dazed or confused, didn’t recall experiencing the event, or had a diagnosed concussion or head injury. They are also asked about acute and persistent problems with memory, balance, ringing in the ears, photosensitivity, headache, and sleep problems.

"I think this is a perfectly good screen; we just need to be really, really clear about what we’re screening for. We’re not screening for a history of TBI; we’re screening for a history of TBI with persistent symptoms," Dr. Brenner said.

TBI screening of soldiers returning from Iraq and Afghanistan has been routine since 2007 in the Veterans Affairs health system and since 2008 in the Department of Defense medical system. As a result, many veterans deployed earlier may have had TBIs that went undetected. In addition, returning soldiers, anxious to get home, may falsely report having no exposure, in the fear that a positive response would further delay their return, Dr. Brenner said.

Co-Occurring PTSD and TBI

PTSD and mild TBI can co-occur and have many overlapping symptoms, including problems with sleep, memory, cognition, and mood. The gold standard for diagnosing the conditions is a validated, structured clinical interview such as the Clinician-Administered PTSD Scale (CAPS) or the Ohio State University Traumatic Brain Injury Identification Method.

Dr. Brenner and her colleagues found in a recent study that "in soldiers with histories of physical injury, mild TBI and PTSD were independently associated with postconcussive symptom reporting. Those with both conditions were at greater risk for postconcussive symptoms than those with either PTSD, mild TBI, or neither" (J. Head Trauma Rehabil. 2010;25:307-12).

Regarding treatment, "there’s no reason not to provide somebody with the best PTSD treatment if they have a mild TBI," Dr. Brenner said. A 2008 VA consensus conference on treatment of veterans with comorbid mild TBI, pain, and PTSD recommended that "veterans who experience mild TBI and/or pain, along with PTSD, should have the opportunity to receive the two best evidence-based treatments in the VA/DoD practice guidelines for PTSD: prolonged exposure therapy or cognitive processing therapy."

The conference was sponsored by Massachusetts General Hospital, Boston. Dr. Brenner presented her research at a symposium supported by the Home Base Program, a joint project of the Red Sox Foundation and Massachusetts General Hospital. She reported no relevant conflicts of interest.

BOSTON – For clinicians evaluating returning soldiers for posttraumatic stress disorder and traumatic brain injury, one of the greatest obstacles may be the soldiers’ inability to admit they may have a problem, said a specialist at a conference on the complexities and challenges of PTSD and TBI.

The DSM-IV diagnostic criteria for PTSD include experiencing or witnessing an event involving actual or threatened death or serious injury, and a response involving "intense fear, helplessness, or horror," noted Dr. Lisa Brenner, associate professor of psychiatry, neurology, and physical medicine and rehabilitation at the University of Colorado, Aurora.

"When I have a 25- or 26-year-old soldier or a veteran in my office, and I say, ‘Were you afraid?’ What do you think they say to me? ‘No. I wasn’t afraid. I am trained to not be afraid.’ How do you engage in a conversation about whether or not this event really did have the impact on them that we think it did, in language that makes sense to our returning soldiers?" she asked.

Combat-associated trauma differs significantly from trauma experienced by, say, an auto-accident victim, Dr. Brenner added. PTSD in military service members develops following long-term exposure to multiple traumatic events, possibly during multiple deployments.

In addition, at least two of the key symptom clusters of PTSD – numbness/detachment from others and hyperarousal – may be protective or even lifesaving on the battlefield, but don’t work well when soldiers return home, she noted. Soldiers may need help finding alternative ways of coping in their off-duty lives, without losing the advantage that the aforementioned coping mechanisms could give them should they return to the front lines.

Equally challenging for the clinician is differentiating symptoms of mild TBI from those of PTSD, especially when they co-occur, Dr. Brenner said.

Screening for PTSD and TBI

Screening instruments can help to identify those who need further assessment for PTSD, but screening alone is not sufficient for a diagnosis, Dr. Brenner cautioned.

In the military, service members are commonly screened with the PTSD checklist, a 17-item self-report measure of the 17 DSM-IV–designated symptoms of PTSD. The checklist appears to be a clinically useful screening instrument, but a critical review published in 2010 showed that it performs differently across civilian, military, and other specific populations. The authors concluded that it should be used with a second-tier diagnostic test such as a standardized interview (Clin. Psychol. Rev. 2010;30:976-87).

Traumatic brain injury (TBI) involves an alteration in consciousness, ranging from brief changes (mild TBI) to an extended period of unconsciousness or amnesia (severe TBI).

"Most of the people in Iraq and Afghanistan who sustain TBIs sustain mild brain injuries, and we expect recovery," Dr. Brenner said.

Nearly everyone who sustains a mild TBI or concussion reports immediate postinjury symptoms that may include headache, poor concentration, memory loss, irritability, fatigue, depression, anxiety, dizziness, or light and sound sensitivity. These symptoms are not specific, however, and should not be the basis for a diagnosis of TBI.

Returning service members are screened with a questionnaire that asks whether they had an injury event and, if so, whether they lost consciousness, felt dazed or confused, didn’t recall experiencing the event, or had a diagnosed concussion or head injury. They are also asked about acute and persistent problems with memory, balance, ringing in the ears, photosensitivity, headache, and sleep problems.

"I think this is a perfectly good screen; we just need to be really, really clear about what we’re screening for. We’re not screening for a history of TBI; we’re screening for a history of TBI with persistent symptoms," Dr. Brenner said.

TBI screening of soldiers returning from Iraq and Afghanistan has been routine since 2007 in the Veterans Affairs health system and since 2008 in the Department of Defense medical system. As a result, many veterans deployed earlier may have had TBIs that went undetected. In addition, returning soldiers, anxious to get home, may falsely report having no exposure, in the fear that a positive response would further delay their return, Dr. Brenner said.

Co-Occurring PTSD and TBI

PTSD and mild TBI can co-occur and have many overlapping symptoms, including problems with sleep, memory, cognition, and mood. The gold standard for diagnosing the conditions is a validated, structured clinical interview such as the Clinician-Administered PTSD Scale (CAPS) or the Ohio State University Traumatic Brain Injury Identification Method.

Dr. Brenner and her colleagues found in a recent study that "in soldiers with histories of physical injury, mild TBI and PTSD were independently associated with postconcussive symptom reporting. Those with both conditions were at greater risk for postconcussive symptoms than those with either PTSD, mild TBI, or neither" (J. Head Trauma Rehabil. 2010;25:307-12).

Regarding treatment, "there’s no reason not to provide somebody with the best PTSD treatment if they have a mild TBI," Dr. Brenner said. A 2008 VA consensus conference on treatment of veterans with comorbid mild TBI, pain, and PTSD recommended that "veterans who experience mild TBI and/or pain, along with PTSD, should have the opportunity to receive the two best evidence-based treatments in the VA/DoD practice guidelines for PTSD: prolonged exposure therapy or cognitive processing therapy."

The conference was sponsored by Massachusetts General Hospital, Boston. Dr. Brenner presented her research at a symposium supported by the Home Base Program, a joint project of the Red Sox Foundation and Massachusetts General Hospital. She reported no relevant conflicts of interest.

BOSTON – For clinicians evaluating returning soldiers for posttraumatic stress disorder and traumatic brain injury, one of the greatest obstacles may be the soldiers’ inability to admit they may have a problem, said a specialist at a conference on the complexities and challenges of PTSD and TBI.

The DSM-IV diagnostic criteria for PTSD include experiencing or witnessing an event involving actual or threatened death or serious injury, and a response involving "intense fear, helplessness, or horror," noted Dr. Lisa Brenner, associate professor of psychiatry, neurology, and physical medicine and rehabilitation at the University of Colorado, Aurora.

"When I have a 25- or 26-year-old soldier or a veteran in my office, and I say, ‘Were you afraid?’ What do you think they say to me? ‘No. I wasn’t afraid. I am trained to not be afraid.’ How do you engage in a conversation about whether or not this event really did have the impact on them that we think it did, in language that makes sense to our returning soldiers?" she asked.

Combat-associated trauma differs significantly from trauma experienced by, say, an auto-accident victim, Dr. Brenner added. PTSD in military service members develops following long-term exposure to multiple traumatic events, possibly during multiple deployments.

In addition, at least two of the key symptom clusters of PTSD – numbness/detachment from others and hyperarousal – may be protective or even lifesaving on the battlefield, but don’t work well when soldiers return home, she noted. Soldiers may need help finding alternative ways of coping in their off-duty lives, without losing the advantage that the aforementioned coping mechanisms could give them should they return to the front lines.

Equally challenging for the clinician is differentiating symptoms of mild TBI from those of PTSD, especially when they co-occur, Dr. Brenner said.

Screening for PTSD and TBI

Screening instruments can help to identify those who need further assessment for PTSD, but screening alone is not sufficient for a diagnosis, Dr. Brenner cautioned.

In the military, service members are commonly screened with the PTSD checklist, a 17-item self-report measure of the 17 DSM-IV–designated symptoms of PTSD. The checklist appears to be a clinically useful screening instrument, but a critical review published in 2010 showed that it performs differently across civilian, military, and other specific populations. The authors concluded that it should be used with a second-tier diagnostic test such as a standardized interview (Clin. Psychol. Rev. 2010;30:976-87).

Traumatic brain injury (TBI) involves an alteration in consciousness, ranging from brief changes (mild TBI) to an extended period of unconsciousness or amnesia (severe TBI).

"Most of the people in Iraq and Afghanistan who sustain TBIs sustain mild brain injuries, and we expect recovery," Dr. Brenner said.

Nearly everyone who sustains a mild TBI or concussion reports immediate postinjury symptoms that may include headache, poor concentration, memory loss, irritability, fatigue, depression, anxiety, dizziness, or light and sound sensitivity. These symptoms are not specific, however, and should not be the basis for a diagnosis of TBI.

Returning service members are screened with a questionnaire that asks whether they had an injury event and, if so, whether they lost consciousness, felt dazed or confused, didn’t recall experiencing the event, or had a diagnosed concussion or head injury. They are also asked about acute and persistent problems with memory, balance, ringing in the ears, photosensitivity, headache, and sleep problems.

"I think this is a perfectly good screen; we just need to be really, really clear about what we’re screening for. We’re not screening for a history of TBI; we’re screening for a history of TBI with persistent symptoms," Dr. Brenner said.

TBI screening of soldiers returning from Iraq and Afghanistan has been routine since 2007 in the Veterans Affairs health system and since 2008 in the Department of Defense medical system. As a result, many veterans deployed earlier may have had TBIs that went undetected. In addition, returning soldiers, anxious to get home, may falsely report having no exposure, in the fear that a positive response would further delay their return, Dr. Brenner said.

Co-Occurring PTSD and TBI

PTSD and mild TBI can co-occur and have many overlapping symptoms, including problems with sleep, memory, cognition, and mood. The gold standard for diagnosing the conditions is a validated, structured clinical interview such as the Clinician-Administered PTSD Scale (CAPS) or the Ohio State University Traumatic Brain Injury Identification Method.

Dr. Brenner and her colleagues found in a recent study that "in soldiers with histories of physical injury, mild TBI and PTSD were independently associated with postconcussive symptom reporting. Those with both conditions were at greater risk for postconcussive symptoms than those with either PTSD, mild TBI, or neither" (J. Head Trauma Rehabil. 2010;25:307-12).

Regarding treatment, "there’s no reason not to provide somebody with the best PTSD treatment if they have a mild TBI," Dr. Brenner said. A 2008 VA consensus conference on treatment of veterans with comorbid mild TBI, pain, and PTSD recommended that "veterans who experience mild TBI and/or pain, along with PTSD, should have the opportunity to receive the two best evidence-based treatments in the VA/DoD practice guidelines for PTSD: prolonged exposure therapy or cognitive processing therapy."

The conference was sponsored by Massachusetts General Hospital, Boston. Dr. Brenner presented her research at a symposium supported by the Home Base Program, a joint project of the Red Sox Foundation and Massachusetts General Hospital. She reported no relevant conflicts of interest.

BOSTON – Cognitive therapies and acupuncture can be as powerful as narcotics and analgesics for treating the chronic pain associated with posttraumatic stress disorder and traumatic brain injury, investigators reported at the annual conference on the complexities and challenges of PTSD and TBI.

An intensive, integrated approach that combines elements of evidence-based cognitive behavioral treatments for chronic pain and PTSD may help some patients find substantial relief with little or no additional medication, said John D. Otis, Ph.D., who is with the department of psychiatry at Boston University, and is a clinical psychologist at the VA Boston Healthcare System.

In addition, complementary and alternative medicine (CAM) techniques that are performed "in theater" can offer what one soldier calls "a moment of peace in a sea of pain," noted Capt. Robert Koffman, director of deployment health at the National Naval Medical Center in Bethesda, Md.

"Emotional pain" appears to have a solid grounding in biology, Dr. Otis said, pointing to a recent study in which people who recently experienced an unwanted breakup viewed photos of their former partners during a functional MRI scan. The scans showed that areas supporting the sensory components of pain, including the somatosensory cortex and dorsal posterior insula, became active (Proc. Natl. Acad. Sci. U. S. A. 2011;108:6270-5).

Chronic Pain Common Among Vets

About half of all veterans in the VA health care system report chronic pain. A 2006 study of 1,800 veterans of the wars in Afghanistan and Iraq showed that 46.5% of those seeking VA care reported some pain, and that 59% had a pain score of 4 or greater on a scale of 0-10, which exceeded the VA pain threshold (Pain Med. 2006;7:339-43).

"Pain is usually considered to be chronic when it lasts for 3 months or longer. That’s not a very long time. Most of the people I see at the VA have had pain for a lot longer than 3 months; they’ve had it for 3 years, 10 years, sometimes even 30 years," Dr. Otis said.

Pain is also a frequent comorbidity with PTSD and traumatic brain injury (TBI). A sample of 340 veterans of the conflicts in Iraq and Afghanistan showed that 42.1% had a confluence of PTSD, TBI, and chronic pain (J. Rehabil. Res. Dev. 2009;46:697-702).

CBT for Chronic Pain Relief

Although pain is an adaptive reaction to an injury and will gradually decrease over time for many people, for some it can be persistent, leading to negative mood (including depression) and disability. For such patients, cognitive behavioral therapy (CBT) can provide significant relief. CBT has been found to be effective in the treatment of headache, rheumatic disease, chronic pain syndrome, chronic low-back pain, and irritable bowel syndrome, Dr. Otis said.

Elements of CBT in chronic pain treatment include setting activity goals for patients, identifying and challenging their inaccurate beliefs about pain, teaching coping skills (such as activity pacing and restructuring of negative thoughts), practicing and consolidating the newly learned skills, and reinforcing their appropriate use.

In their integrated approach, Dr. Otis and his colleagues present CBT as part of a multidisciplinary pain management program incorporating anesthesiology, neurology, physical and occupational therapy, and psychology. The CBT component consists of 11 sessions that begin with a discussion of the rationale for therapy so that patients "buy in," followed by sessions focusing on theories of pain; breathing and relaxation techniques (such as yoga and tai chi); cognitive errors and restructuring; stress management; time-based activity pacing; scheduling of pleasant activities; anger management; sleep hygiene; and relapse prevention.

CBT for Comorbid Pain and PTSD

"In PTSD samples, the prevalence of chronic pain is approximately 66%-80%. In pain samples, the prevalence of PTSD is approximately 34%-50%," Dr. Otis said. He pointed to a significant overlap between the conditions, which suggests an opportunity for therapy to treat both conditions.

In a study of pain and PTSD comorbidity that he and his colleagues conducted with 149 veterans who participated in a VA pain management program, the researchers found that the presence of PTSD predicted experience of chronic pain, even after they controlled for the effects of depressed mood. They also found that "the largest portion of the association between PTSD and pain was accounted for by pain-relevant affective distress" such as anxiety, anger, and irritability (Psychol. Serv. 2010;7:126-35).

Given the similarity of CBT for both pain and PTSD, Dr. Otis and his colleagues are testing a treatment they developed for both conditions that is designed to be "transportable," so that clinicians can learn the technique with a minimum of training. The treatment was originally designed to be given in 12 sessions focusing on education and attitudes about chronic pain and PTSD, cognitive interventions, relaxation, avoidance issues, interoceptive exposure, and other elements focusing on anger control, safety, trust, and relapse prevention. In a pilot study with six patients, however, two dropped out before the third session because of the lengthy time commitment. The investigators have since modified the program to be more intensive, with six sessions given over 3 weeks.

In a pilot study with eight patients to test the feasibility of the program, there were significant reductions in the CAPS (Clinician Administered Assessment of PTSD) inventory from baseline to post treatment (P = .03) and in the Pain Catastrophizing Scale (P = .05). There were also nonsignificant reductions in the Numerical Rating Scale, Beck Depression Inventory, and Anxiety Sensitivity Index.

"We had great feedback from the patients. They all really enjoyed learning skills for pain and PTSD," Dr. Otis said. There were no dropouts.

The investigators are continuing to study the treatment, and if it proves to be successful in a larger treatment sample it could be a first step to help veterans of current wars to learn how to effectively cope with pain and PTSD in their daily lives, Dr. Otis concluded.

Acupuncture Near the Front Line

In a related presentation, Dr. Koffman discussed the use of acupuncture as a pain-relief and relaxation technique for active duty military.

"Acupuncture is now listed as one of the acceptable modalities" in the Department of Defense/VA clinical practice guideline, he said.

The guidelines note that research focusing on the efficacy of acupuncture "is still relatively limited. The few available studies are well done and demonstrate significant improvement in both PTSD and PTSD-associated symptomatology. A larger numbers of studies exist, concluding acupuncture’s efficacy in pain management, insomnia, depression, and substance abuse."

A recent, unpublished, Department of Defense/VA randomized controlled trial cited in the guidelines looked at 55 active-duty service members with PTSD who were randomized to treatment as usual with or without acupuncture sessions. The study showed that a 4-week course of twice-weekly 90-minute acupuncture sessions was associated with significantly greater improvement in PTSD symptoms and depression and pain scores.

The guidelines also state that "CAM approaches that facilitate a relaxation response [such as mindfulness, yoga, acupuncture, massage, and others] may be considered for adjunctive treatment of hyperarousal symptoms, although there is no evidence that these are more effective than standard stress inoculation techniques."

Dr. Otis and Dr. Koffman presented their research at a symposium supported by the Home Base Program, a joint project of the Red Sox Foundation and Massachusetts General Hospital. Neither clinician reported relevant conflicts of interest.

BOSTON – Cognitive therapies and acupuncture can be as powerful as narcotics and analgesics for treating the chronic pain associated with posttraumatic stress disorder and traumatic brain injury, investigators reported at the annual conference on the complexities and challenges of PTSD and TBI.

An intensive, integrated approach that combines elements of evidence-based cognitive behavioral treatments for chronic pain and PTSD may help some patients find substantial relief with little or no additional medication, said John D. Otis, Ph.D., who is with the department of psychiatry at Boston University, and is a clinical psychologist at the VA Boston Healthcare System.

In addition, complementary and alternative medicine (CAM) techniques that are performed "in theater" can offer what one soldier calls "a moment of peace in a sea of pain," noted Capt. Robert Koffman, director of deployment health at the National Naval Medical Center in Bethesda, Md.

"Emotional pain" appears to have a solid grounding in biology, Dr. Otis said, pointing to a recent study in which people who recently experienced an unwanted breakup viewed photos of their former partners during a functional MRI scan. The scans showed that areas supporting the sensory components of pain, including the somatosensory cortex and dorsal posterior insula, became active (Proc. Natl. Acad. Sci. U. S. A. 2011;108:6270-5).

Chronic Pain Common Among Vets

About half of all veterans in the VA health care system report chronic pain. A 2006 study of 1,800 veterans of the wars in Afghanistan and Iraq showed that 46.5% of those seeking VA care reported some pain, and that 59% had a pain score of 4 or greater on a scale of 0-10, which exceeded the VA pain threshold (Pain Med. 2006;7:339-43).

"Pain is usually considered to be chronic when it lasts for 3 months or longer. That’s not a very long time. Most of the people I see at the VA have had pain for a lot longer than 3 months; they’ve had it for 3 years, 10 years, sometimes even 30 years," Dr. Otis said.

Pain is also a frequent comorbidity with PTSD and traumatic brain injury (TBI). A sample of 340 veterans of the conflicts in Iraq and Afghanistan showed that 42.1% had a confluence of PTSD, TBI, and chronic pain (J. Rehabil. Res. Dev. 2009;46:697-702).

CBT for Chronic Pain Relief

Although pain is an adaptive reaction to an injury and will gradually decrease over time for many people, for some it can be persistent, leading to negative mood (including depression) and disability. For such patients, cognitive behavioral therapy (CBT) can provide significant relief. CBT has been found to be effective in the treatment of headache, rheumatic disease, chronic pain syndrome, chronic low-back pain, and irritable bowel syndrome, Dr. Otis said.

Elements of CBT in chronic pain treatment include setting activity goals for patients, identifying and challenging their inaccurate beliefs about pain, teaching coping skills (such as activity pacing and restructuring of negative thoughts), practicing and consolidating the newly learned skills, and reinforcing their appropriate use.

In their integrated approach, Dr. Otis and his colleagues present CBT as part of a multidisciplinary pain management program incorporating anesthesiology, neurology, physical and occupational therapy, and psychology. The CBT component consists of 11 sessions that begin with a discussion of the rationale for therapy so that patients "buy in," followed by sessions focusing on theories of pain; breathing and relaxation techniques (such as yoga and tai chi); cognitive errors and restructuring; stress management; time-based activity pacing; scheduling of pleasant activities; anger management; sleep hygiene; and relapse prevention.

CBT for Comorbid Pain and PTSD

"In PTSD samples, the prevalence of chronic pain is approximately 66%-80%. In pain samples, the prevalence of PTSD is approximately 34%-50%," Dr. Otis said. He pointed to a significant overlap between the conditions, which suggests an opportunity for therapy to treat both conditions.

In a study of pain and PTSD comorbidity that he and his colleagues conducted with 149 veterans who participated in a VA pain management program, the researchers found that the presence of PTSD predicted experience of chronic pain, even after they controlled for the effects of depressed mood. They also found that "the largest portion of the association between PTSD and pain was accounted for by pain-relevant affective distress" such as anxiety, anger, and irritability (Psychol. Serv. 2010;7:126-35).

Given the similarity of CBT for both pain and PTSD, Dr. Otis and his colleagues are testing a treatment they developed for both conditions that is designed to be "transportable," so that clinicians can learn the technique with a minimum of training. The treatment was originally designed to be given in 12 sessions focusing on education and attitudes about chronic pain and PTSD, cognitive interventions, relaxation, avoidance issues, interoceptive exposure, and other elements focusing on anger control, safety, trust, and relapse prevention. In a pilot study with six patients, however, two dropped out before the third session because of the lengthy time commitment. The investigators have since modified the program to be more intensive, with six sessions given over 3 weeks.

In a pilot study with eight patients to test the feasibility of the program, there were significant reductions in the CAPS (Clinician Administered Assessment of PTSD) inventory from baseline to post treatment (P = .03) and in the Pain Catastrophizing Scale (P = .05). There were also nonsignificant reductions in the Numerical Rating Scale, Beck Depression Inventory, and Anxiety Sensitivity Index.

"We had great feedback from the patients. They all really enjoyed learning skills for pain and PTSD," Dr. Otis said. There were no dropouts.

The investigators are continuing to study the treatment, and if it proves to be successful in a larger treatment sample it could be a first step to help veterans of current wars to learn how to effectively cope with pain and PTSD in their daily lives, Dr. Otis concluded.

Acupuncture Near the Front Line

In a related presentation, Dr. Koffman discussed the use of acupuncture as a pain-relief and relaxation technique for active duty military.

"Acupuncture is now listed as one of the acceptable modalities" in the Department of Defense/VA clinical practice guideline, he said.

The guidelines note that research focusing on the efficacy of acupuncture "is still relatively limited. The few available studies are well done and demonstrate significant improvement in both PTSD and PTSD-associated symptomatology. A larger numbers of studies exist, concluding acupuncture’s efficacy in pain management, insomnia, depression, and substance abuse."

A recent, unpublished, Department of Defense/VA randomized controlled trial cited in the guidelines looked at 55 active-duty service members with PTSD who were randomized to treatment as usual with or without acupuncture sessions. The study showed that a 4-week course of twice-weekly 90-minute acupuncture sessions was associated with significantly greater improvement in PTSD symptoms and depression and pain scores.

The guidelines also state that "CAM approaches that facilitate a relaxation response [such as mindfulness, yoga, acupuncture, massage, and others] may be considered for adjunctive treatment of hyperarousal symptoms, although there is no evidence that these are more effective than standard stress inoculation techniques."

Dr. Otis and Dr. Koffman presented their research at a symposium supported by the Home Base Program, a joint project of the Red Sox Foundation and Massachusetts General Hospital. Neither clinician reported relevant conflicts of interest.

BOSTON – Cognitive therapies and acupuncture can be as powerful as narcotics and analgesics for treating the chronic pain associated with posttraumatic stress disorder and traumatic brain injury, investigators reported at the annual conference on the complexities and challenges of PTSD and TBI.

An intensive, integrated approach that combines elements of evidence-based cognitive behavioral treatments for chronic pain and PTSD may help some patients find substantial relief with little or no additional medication, said John D. Otis, Ph.D., who is with the department of psychiatry at Boston University, and is a clinical psychologist at the VA Boston Healthcare System.

In addition, complementary and alternative medicine (CAM) techniques that are performed "in theater" can offer what one soldier calls "a moment of peace in a sea of pain," noted Capt. Robert Koffman, director of deployment health at the National Naval Medical Center in Bethesda, Md.

"Emotional pain" appears to have a solid grounding in biology, Dr. Otis said, pointing to a recent study in which people who recently experienced an unwanted breakup viewed photos of their former partners during a functional MRI scan. The scans showed that areas supporting the sensory components of pain, including the somatosensory cortex and dorsal posterior insula, became active (Proc. Natl. Acad. Sci. U. S. A. 2011;108:6270-5).

Chronic Pain Common Among Vets

About half of all veterans in the VA health care system report chronic pain. A 2006 study of 1,800 veterans of the wars in Afghanistan and Iraq showed that 46.5% of those seeking VA care reported some pain, and that 59% had a pain score of 4 or greater on a scale of 0-10, which exceeded the VA pain threshold (Pain Med. 2006;7:339-43).

"Pain is usually considered to be chronic when it lasts for 3 months or longer. That’s not a very long time. Most of the people I see at the VA have had pain for a lot longer than 3 months; they’ve had it for 3 years, 10 years, sometimes even 30 years," Dr. Otis said.

Pain is also a frequent comorbidity with PTSD and traumatic brain injury (TBI). A sample of 340 veterans of the conflicts in Iraq and Afghanistan showed that 42.1% had a confluence of PTSD, TBI, and chronic pain (J. Rehabil. Res. Dev. 2009;46:697-702).

CBT for Chronic Pain Relief

Although pain is an adaptive reaction to an injury and will gradually decrease over time for many people, for some it can be persistent, leading to negative mood (including depression) and disability. For such patients, cognitive behavioral therapy (CBT) can provide significant relief. CBT has been found to be effective in the treatment of headache, rheumatic disease, chronic pain syndrome, chronic low-back pain, and irritable bowel syndrome, Dr. Otis said.

Elements of CBT in chronic pain treatment include setting activity goals for patients, identifying and challenging their inaccurate beliefs about pain, teaching coping skills (such as activity pacing and restructuring of negative thoughts), practicing and consolidating the newly learned skills, and reinforcing their appropriate use.

In their integrated approach, Dr. Otis and his colleagues present CBT as part of a multidisciplinary pain management program incorporating anesthesiology, neurology, physical and occupational therapy, and psychology. The CBT component consists of 11 sessions that begin with a discussion of the rationale for therapy so that patients "buy in," followed by sessions focusing on theories of pain; breathing and relaxation techniques (such as yoga and tai chi); cognitive errors and restructuring; stress management; time-based activity pacing; scheduling of pleasant activities; anger management; sleep hygiene; and relapse prevention.

CBT for Comorbid Pain and PTSD

"In PTSD samples, the prevalence of chronic pain is approximately 66%-80%. In pain samples, the prevalence of PTSD is approximately 34%-50%," Dr. Otis said. He pointed to a significant overlap between the conditions, which suggests an opportunity for therapy to treat both conditions.

In a study of pain and PTSD comorbidity that he and his colleagues conducted with 149 veterans who participated in a VA pain management program, the researchers found that the presence of PTSD predicted experience of chronic pain, even after they controlled for the effects of depressed mood. They also found that "the largest portion of the association between PTSD and pain was accounted for by pain-relevant affective distress" such as anxiety, anger, and irritability (Psychol. Serv. 2010;7:126-35).

Given the similarity of CBT for both pain and PTSD, Dr. Otis and his colleagues are testing a treatment they developed for both conditions that is designed to be "transportable," so that clinicians can learn the technique with a minimum of training. The treatment was originally designed to be given in 12 sessions focusing on education and attitudes about chronic pain and PTSD, cognitive interventions, relaxation, avoidance issues, interoceptive exposure, and other elements focusing on anger control, safety, trust, and relapse prevention. In a pilot study with six patients, however, two dropped out before the third session because of the lengthy time commitment. The investigators have since modified the program to be more intensive, with six sessions given over 3 weeks.

In a pilot study with eight patients to test the feasibility of the program, there were significant reductions in the CAPS (Clinician Administered Assessment of PTSD) inventory from baseline to post treatment (P = .03) and in the Pain Catastrophizing Scale (P = .05). There were also nonsignificant reductions in the Numerical Rating Scale, Beck Depression Inventory, and Anxiety Sensitivity Index.

"We had great feedback from the patients. They all really enjoyed learning skills for pain and PTSD," Dr. Otis said. There were no dropouts.

The investigators are continuing to study the treatment, and if it proves to be successful in a larger treatment sample it could be a first step to help veterans of current wars to learn how to effectively cope with pain and PTSD in their daily lives, Dr. Otis concluded.

Acupuncture Near the Front Line

In a related presentation, Dr. Koffman discussed the use of acupuncture as a pain-relief and relaxation technique for active duty military.

"Acupuncture is now listed as one of the acceptable modalities" in the Department of Defense/VA clinical practice guideline, he said.

The guidelines note that research focusing on the efficacy of acupuncture "is still relatively limited. The few available studies are well done and demonstrate significant improvement in both PTSD and PTSD-associated symptomatology. A larger numbers of studies exist, concluding acupuncture’s efficacy in pain management, insomnia, depression, and substance abuse."

A recent, unpublished, Department of Defense/VA randomized controlled trial cited in the guidelines looked at 55 active-duty service members with PTSD who were randomized to treatment as usual with or without acupuncture sessions. The study showed that a 4-week course of twice-weekly 90-minute acupuncture sessions was associated with significantly greater improvement in PTSD symptoms and depression and pain scores.

The guidelines also state that "CAM approaches that facilitate a relaxation response [such as mindfulness, yoga, acupuncture, massage, and others] may be considered for adjunctive treatment of hyperarousal symptoms, although there is no evidence that these are more effective than standard stress inoculation techniques."

Dr. Otis and Dr. Koffman presented their research at a symposium supported by the Home Base Program, a joint project of the Red Sox Foundation and Massachusetts General Hospital. Neither clinician reported relevant conflicts of interest.