Integrating Treatment for Pain 

and PTSD

Steven K. Dobscha MD

Portland VA Medical Center

Oregon Health & Science University

April 2013
Disclosure Statement

With respect to the following presentation, 

there is nor has been no relevant (direct or 

indirect) financial relationship between Dr. 

Dobscha (or spouse) and any for-profit 

company which could be considered a conflict 

of interest.
Outline

• Prevalence of pain and PTSD

• Impacts

• Overview of models

– Psychological

– Biological

– Care models

• Clinical demonstration project at Portland VA

• Other ongoing/proposed research

• Best practice suggestions
Prevalence of pain and of PTSD

• Pain

– Most common physical symptom reported to 

physicians

– One-third to one-half of patients treated in 

ambulatory care clinics (chronic pain)

– Rates high among OEF/OIF/OND (Returning) 

Veterans, especially those treated in polytrauma

programs

• PTSD

– 7% - 12% lifetime risk in general population (Sharp 2004)

– 20 - 30% lifetime risk among Vietnam Veterans

– 13 - 17% among Returning Veterans (may be higher 

with multiple deployments)

4
Comorbid pain &PTSD—prevalence

• Among patients presenting for pain treatment, 35% to 

50% have PTSD or significant PTSD symptomatology

– In our earlier study of 400 patients with chronic pain 

recruited from a primary care setting, 17% had positive 

trauma stem plus PCL>50

• Among patients presenting for PTSD treatment, 45% to 

80% report chronic pain problems.

• Up to half of patients with pain secondary to motor 

vehicle accidents or burns have symptoms of PTSD

• Among immigrant refugee populations with trauma 

exposure, it is estimated that half have comorbid pain 

and PTSD

5
Impacts of comorbid pain & PTSD

• Multiple studies show that, compared to patients 

with either condition alone, patients with both 

disorders have:

– More intense pain

– More affective distress

– Greater levels of life interference/disability

• Greater healthcare utilization (Outcalt et al, Pain Medicine 2013)

– pain + PTSD group had 7% more VA primary care visits 

than pain only group

– pain + PTSD group had 46% more primary care visits than 

PTSD only group

– Rates of opioid and non-opioid analgesics, 

antidepressants, benzodiazepines were higher in the pain 

+ PTSD group

6
PTSD and prescription opioids

• Patients with PTSD more likely to be prescribed opioids 

for pain, and at higher doses

• In study of 141,000 Returning Veterans, over 1 year:

– 18% of veterans with PTSD were prescribed opioids, 

compared to 12% with other mental health disorders, and 

7% of veterans with no diagnosed MH disorders

– Veterans with PTSD more likely to receive high doses (23% 

vs. 16%) and to receive sedative hypnotics (41% vs. 20%) 

compared to no mental health diagnosis group.

– Using inpatient and emergency room data, PTSD group had 

greatest incidence of opioid-related accidents and 

overdoses; self-inflicted injuries, and violence-related 

injuries (Seal et al. JAMA, 2012)
Why are pain and PTSD so frequently 

comorbid and how might they 

interact?

• Several models:

– Mutual maintenance

– Shared and triple vulnerability

– Depression and coping as mediators between pain 

and PTSD

– Biological

8
Before we get to the models:

• Anxiety Sensitivity: Dispositional tendency (or trait) 

to be fearful of arousal related sensations, based on 

beliefs they may have harmful social, somatic or 

psychological consequences (Reiss and McNally, 1985; 

Asmundson et al, 2002)

• Fear-Avoidance (“kinesiophobia”): Fear that pain 

will lead to more injury (damage) which leads to 

avoidance of activity

• Catastrophizing: Coping style in which one worries 

about uncontrollable and inevitably negative 

outcomes (thinking the worst) (see Sharp and Harvey, 2001)

9
Mutual maintenance

• Physiological, affective and behavioral components 

of PTSD maintain or exacerbate symptoms of pain

 and

• Cognitive, affective and behavioral components of 

chronic pain maintain or exacerbate symptoms of 

PTSD

(Sharp and Harvey, 2001)

10
11

From (Sharp and Harvey, Clinical Psychology Review, 2001)
Shared vulnerability

12

From Asmundson and Katz, Depression and Anxiety, 2009
Depression mediates relationship 

between PTSD and pain (Roth et al, 2007)

• Cross sectional study of 241 patients at university 

hospital pain program whose pain began with 

traumatic injury

13
Coping strategies and depression symptoms 

mediate relationship between PTSD and pain 

(Morasco et al 2012)

14
Biological considerations

• Autonomic nervous system, endogenous opioid 

system, and serotonergic system dysregulations

have been observed in both disorders

• Contributions of state and trait anxiety to 

hyperalgesia have been documented

• There is some evidence to support genetic factors 

in anxiety sensitivity traits (Stein et al 1999)

• More recently, Neuropeptide Y and neuroactive

steroids allpregnanolone and pregnanolone have 

been found to regulate pain and to be low in 

persons with pain and to be inversely correlated 

with PTSD symptom severity

15
Summary of models

• Pain and PTSD share a number of features that 

can explain their development, maintenance and 

co-occurrence, and which may have implications 

for treatment

• Anxiety sensitivity/fear- avoidance/catastrophizing are intertwined and 

likely work together to enhance fear of somatic 

sensations (anxiety and of pain).

• This fear contributes to avoidance and depression 

and, ultimately, more disability and symptoms 

due to increased isolation, deconditioning, and 

decreased habituation to anxiety provoking cues

16
Why an integrated approach?

• Specific reasons to integrate treatment

– Models suggest substantial overlap in causes, 

maintenance and potential treatment approaches

– CBT approaches have been shown to be effective for 

both conditions—overlap in content

– Efficiencies to be gained in terms of implementation, 

especially since comorbidity is so common

• Problems when treatment is not integrated

– Communications between involved clinicians

– Clear communications to patients

– Untreated condition may limit response of other 

condition to treatment

17
Promising integrated approaches

• Cognitive and Behavioral Treatments: goal-oriented 

psychotherapy approaches that systematically 

address maladaptive thoughts and behaviors

– Cognitive Processing Therapy (CPT): incorporates traumaspecific cognitive techniques (addressing safety, trust, 

power, control, esteem and intimacy)

– Acceptance and Commitment Therapy: Focuses on 

accepting rather than modifying internal experience; 

emphasizes shift toward seeking valued life

– Behavioral Activation: Helps patient engage in activities 

that are rewarding and consistent with long-term goals

18
Behavioral activation

19

Adapted from Jacobsen, Martell and Dimidjian, 2001
Evidence-Based Chronic Disease Management 

Approaches for Treating Depression 

Ed Wagner & Institute for Healthcare Innovation (IHI)

Informed,

Activated

Patient

Productive

Interactions

Prepared,

Proactive

Practice Team

Functional and Clinical 

Outcomes

Delivery

System

Design

Decision

Support 

Clinical

Information

Systems

SelfManagement 

Support

Community Health System

Resources Health Care Organization

& Policies
Integrative (CAM) therapies—pain

21

From National Center for Complementary and Alternative Medicine (NCCAM)

http://nccam.nih.gov/health/pain/chronic.htm?nav=gsa
Integrative therapies—PTSD

22

From VA/DoD Clinical Practice Guideline for Management of 

Post-Traumatic Stress:

• There is insufficient evidence to recommend CAM 

approaches as first line treatments for PTSD. [I]

• CAM approaches (e.g. mindfulness, yoga, acupuncture, 

massage, and others) may be considered for adjunctive 

treatment of hyperarousal symptoms

• CAM approaches may be considered as adjunctive 

approaches to address some co-morbid conditions (e.g. 

acupuncture for pain). [C]
Integrated treatment—smaller 

studies

• Liedl et al (2011): 36 traumatized refugees randomized to 

[Cognitive Behavioral Therapy (CBT) + biofeedback (BF)], 

[CBT + BF + physical activity]; wait-list control

– Patients in the [CBT + BF + physical activity] group showed 

greater change in cognitive coping]

• Morina et al (2012): 15 traumatized refugees received 10 

sessions of BF then 10 sessions of Narrative Exposure 

Therapy

– Significant pre-post reductions in pain and PTSD symptoms

– BF increased motivation for subsequent therapy

23
• Muller et al (2009): 11 traumatized refugees 

received 10 sessions of BF/CBT

– Positive pre-post small/medium effects for pain 

outcomes

• Wald et al (2010): 5 women from an urban area 

with pain and PTSD received 4 sessions of 

interoceptive exposure (IE) exercises followed by 

8 sessions of trauma related exposure therapy 

(TRE)

– 4 patients had pre-post reductions in PTSD symptoms 

and pain, though pain symptoms recurred at 3 months

24
Salt Lake City Integrative Health Clinic 

and Program (IHCP) (Smeeding et al 2010)

• Outpatient program offering 10 non-pharmacological CAM 

therapies and mind-body skills classes:

– Acupuncture

– Aquatic bodywork

– Stress management

– Hypnosis

– Meditation,

– Qigong

– Yoga

– Herb–drug interaction counseling

– Multidisciplinary weight management

– Tobacco cessation classes 25
• Data collected over 2 years

• Post-hoc quasi-experimental design, creating 

groups based on initial assessments for 

comparison:

– Anxiety (low/high)

– Depression (low/high)

– PTSD (low/high)

• Outcomes examined within group, not examined 

by type of treatment received

• Each group demonstrated improvements in 

depression and anxiety scores, and in some SF-36 

categories at 6 months; some improvements 

persisting for at least 12 months

26
IMPPROVE: Integrated Management of 

Pain and PTSD in Returning 

OEF/OIF/OND VEterans

• Clinical Demonstration project at the Portland 

VAMC

• Supported by funding from VA Mental Health 

Services through the Pacific Northwest MIRECC

• Contributors:

– Jane Plagge PsyD

– Mary Lu MD

– Travis Lovejoy PhD

– Andrea Karl MD

– Amy Wagner PhD

27
IMPPROVE: 2010-2012

• Primary goals:

– Provide integrated treatment for chronic pain and PTSD;

– Improve collaboration among primary care, mental health, and 

other clinicians to facilitate treatment of these two conditions

• Most referrals from post-deployment and primary care 

clinics

• Psychologist working with part-time Physiatrist

• Initial evaluation and limited care management by 

psychologist; pt. data collected routinely to facilitate care

• Weekly meetings with physiatrist who reviews records; 

together create recommendations to primary care 

providers.

• Limited physiatrist consultation

• Up to 8 behavioral activation (BA) sessions

28
Behavioral Activation components

• Flexible approach guided by Veteran’s values/goals

• Education about chronic pain, PTSD, and avoidance

• Rationale for BA, exploration of values

• Identification of treatment goals and barriers

• Identification of areas for activation

• Development of activity schedule—increase awareness of 

interactions between activities, emotions, and pain, and 

identify helpful and unhelpful behavioral patterns

• Ongoing review of values, goals and progress

• Problem solve and develop alternative coping strategies

29
Preliminary outcomes

• Retrospective review/analysis

• Demographic and diagnosis data obtained from VISN 

Data Warehouse (ICD codes back to 2001)

• Compared completers to non-completers; examined 

outcome measures over time (baseline, mid-treatment, 

and post-treatment) using GEE modeling

• Primary outcomes: PTSD Checklist (PCL-C), Chronic Pain 

Grade (CPG) pain severity, and CPG pain interference

• Other measures included health related quality of life 

(CDC HRQOL-4), Satisfaction with life (SWLS), and 

Global rating of change

30
Results

• Of 73 eligible Veterans, 58 (79%) decided to participate

• 45 of 58 (78%) were referred from primary care or postdeployment; remainder from mental health clinicians

• Mean age 33; 98% male, 88% white

• Most frequently recommended pain management 

strategies:

– physical therapy (85% of participants)

– pain medication or pain medication adjustments (74%)

– imaging, or other workup (59%).

– psychiatric medications (35%),

– prostheses (24%),

– complementary therapies (e.g., tai chi, yoga; 12%),

31
Completers and non completers

• 30 Veterans (52%) completed BA (83% of these completed 

8 sessions, but some had fewer if felt goals had been 

reached)

• Completers older than non-completers but otherwise did 

not differ on other variables

• Reasons for discontinuation:

– 16 did not respond to outreach attempts

– 4 were discontinued due to poor treatment adherence, alcohol 

dependence, or crises requiring psychiatric hospitalization

– 3 geographically relocated

– 2 cited travel inconveniences

– 1 was “too busy”

– 1 could not tolerate treatment

– 1 did not believe treatment would help

32
33

Variable Pre-Intervention

MidIntervention

PostIntervention

Wald χ 2 p-value

PTSD Checklist 63.4 ± 10.2 53.8 ± 16.5 54.6 ± 13.9 17.20 < 0.001

Pain Severity 6.8 ± 1.4 6.1 ± 2.0 5.8 ± 2.2 5.95 0.050

Pain Interference 6.9 ± 2.1 5.1 ± 2.4 4.9 ± 2.5 22.52 < 0.001

PHQ-9 Depression 16.1 ± 4.4 12.4 ± 5.3 22.35 < 0.001

Pain Catastrophizing Scale 32.9 ± 13.0 23.9 ± 10.5 19.04 < 0.001

Tampa Kinesiophobia Scale 27.4 ± 4.3 24.1 ± 5.2 17.49 < 0.001

Life Satisfaction 14.7 ± 6.7 17.2 ± 7.8 7.39 0.007

Physical Quality of Life 20.5 ± 9.4 14.2 ± 11.1 11.00 0.001

Mental Quality of Life 20.9 ± 9.1 14.7 ± 10.6 13.25 < 0.001

Interference with ADLs 17.9 ± 8.6 11.9 ± 10.2 22.67 < 0.001

AUDIT-C Alcohol 3.6 ± 3.9 3.1 ± 3.1 1.56 0.212

Changes in mental health, quality of life, and pain-related variables
Additional findings

• Intervention completers were generally satisfied with 

the program. At post-intervention, participants, on 

average, rated their perceived benefit with the program 

as 7.45 (SD = 1.70) on a 0-10 scale, where 0 = “Not at 

all,” 5 = “Moderately,” and 10 = “Extremely.”

• On average, intervention completers reported being 

“somewhat better” (Mean Global Improvement Rating = 

4.03 [SD = 1.27], where 1 = “Worse,” 4 = “Somewhat 

better,” and 7 = “Completely better”)

34
IMPPROVE next steps

• Decrease number of sessions—rationale:

– Most gains were made by 5 sessions

– May reduce dropouts

– May improve feasibility of translating to standard 

clinical settings

– Other BA programs have used shorter numbers of 

sessions (see Wagner et al, 2007)

• Add phone “booster” sessions after BA

• Expand reach to non-Returning Veteran groups

• Take more referrals from PTSD Clinical Teams

• Testing group format

35
Integrated treatment using CBT and 

CPT—initial pilot (Otis et al 2009)

• 12 session treatment combining components of 

CBT for pain with components of CPT for PTSD

36

•Session 1 Education on Chronic Pain and PTSD

•Session 2 Making Meaning of Pain and PTSD

•Session 3 Thoughts/Feelings related to Pain and PTSD & 

Cognitive Errors

•Session 4 Cognitive Restructuring

•Session 5 Diaphragmatic Breathing and Progressive Muscle Relaxation

•Session 6 Avoidance and Interoceptive Exposure

•Session 7 Pacing and Pleasant Activities

•Session 8 Sleep Hygiene

•Session 9 Safety/Trust

•Session 10 Power/Control/Anger

•Session 11 Esteem/Intimacy

•Session 12 Relapse Prevention and Flare-up Planning
Outcomes for 3 Initial Pilot Participants

Participant 1 Participant 2 Participant 3

Measure Pre Post Imp Pre Post Imp Pre Post Imp

CAPS 83 35 58% 91 55 40% 91 79 13%

PCL 73 36 51% 64 48 25% 60 54 10%

MPQ 15 1 93% 41 16 61% 41 40 2%

BDI 30 34 -13% 28 21 25% 24 33 -38%

RMDQ 15 10 33% 8 4 50% 20 11 45%

CAPS: Clinician-Administered PTSD Scale (50 cutoff)

PCL: PTSD Checklist-Specific Version (50 cutoff)

MPQ: McGill Pain Questionnaire (0-78)

BDI: Beck Depression Inventory (0-63)

RMDQ: Roland & Morris Disability Questionnaire (0-24) 

37

(slide from Dr. Otis)
Next steps: Intensive Treatment of 

Chronic Pain and PTSD (Otis, ongoing)

• VA RR&D-funded study of 102 Veterans from VA 

Boston and VA Connecticut with comorbid 

chronic pain and PTSD

• Participants randomized to:

– Intensive Integrated Pain and PTSD treatment vs.

– Standard care

• Intervention:

– 6 bi-weekly outpatient therapy sessions of 90 minutes

38
Proposed project: Exercise training 

program for pain and PTSD (Scioli, ongoing)

• Rationale:

– Exercise programs shown to be effective for pain.

– Limited evidence to support exercise helpful for PTSD, but 

shown to be helpful for anger, stress, depression, self 

esteem

– Studies suggest that exercise may affect anti-stress 

hormones allopregnanalone and pregnanalone and NPY

• Aims:

– Test effects of 12 week progressive exercise training 

program on 1) symptoms of pain and PTSD, 2) pain 

thresholds and tolerance, and 3) stress hormone levels

39
Treatment of Chronic Stress Reaction 

and Chronic Pain after Traumatic 

Orthopedic Injury (Gatchel, ongoing)

• DoD-funded STRONGSTAR project

• Randomized clinical trial with 4 arms

– Treatment as usual

– Pain treatment (5 sessions, self care)

– PTSD treatment only (5 session adaptation of 

prolonged exposure therapy)

– Combined treatment (combination of pain and PTSD 

treatments)

• Primary outcomes: psychosocial and functional 

measures over 6 and 12 months

40
Best practices for pain and PTSD

• Conduct assessment including biopsychosocial history. Assess 

for other medical and psychiatric problems, including

– Risk of misuse of substances

– Evaluation of impact of pain on function and activities

– Identification of avoidance behaviors that contribute to emotional 

distress and/or impaired functioning. 

• Management should be multidisciplinary, and multimodal 

addressing physical, social, psychological, and spiritual 

components in an individualized treatment plan.

• Consider CBT including 1) addressing fear avoidance, 2) BA 

emphasis, 3) cognitive and behavioral coping skills

• Consider use of other non-pharmacological modalities such as 

biofeedback, physical therapy, and complementary alternative 

modalities (mindfulness, meditation, yoga, acupuncture)

• Centrally acting medications should be used in caution in 

patients with PTSD (in particular opioids and benzodiazepines)

41
Selected References

• Asmundson, GJ, et al. PTSD and the experience of pain: research and clinical implications of shared vulnerability 

and mutual maintenance models. Can J Psychiatry 47 (2002): 930-937.

• Asmundson, GJ, and J Katz. Understanding the co-occurrence of anxiety disorders and chronic pain: 

state-of-the-art. Depression and anxiety 26.10 (2009): 888-901.

• Dobscha SK, et al. Correlates of prescription opioid initiation and long-term opioid use in veterans with persistent 

pain. Clin J Pain 29 (2013): 102–108.

• Edlund MJ, et al. Trends in use of opioids for chronic noncancer pain among individuals with mental health and 

substance use disorders: the TROUP study. Clin J Pain 26 (2010): 1-8. 

• Gibson, CA. Review of posttraumatic stress disorder and chronic pain: the path to integrated care. JRRD 49 (2012): 

753-776.

• Jacobson, NS, et al. Behavioral activation treatment for depression: returning to contextual roots. Clinical 

Psychology: Science and Practice 8.3 (2001): 255-270.

• Kobus, AM, et al. Correlates of higher-dose opioid medication use for low back pain in primary care. The Journal of 

Pain 13 (2012): 1131-1138.

• Liedl A, et al. Physical activity within a CBT intervention improves coping with pain in traumatized refugees: results 

of a randomized controlled design. Pain Medicine 12.2 (2011): 234-245.

• Morasco BJ, Dobscha SK, et al. The relationship between PTSD and chronic pain: mediating role of coping strategies 

and depression. Pain 154 (2013): 609-616.

• Morina, N, et al. Combining biofeedback and narrative exposure therapy for persistent pain and PTSD in refugees: 

a pilot study. European J of Psychotraumatology 3 (2012).

• Muller, J, et al. Bi0feedback for pain management in traumatised refugees. Cognitive Behaviour Therapy 38.3 

(2009): 184-190.

• Norton, PJ, and GJ Asmundson. Anxiety sensitivity, fear, and avoidance behavior in headache pain. Pain 111.1 

(2004): 218-223. 42
Selected References • Otis, JD., et al. An examination of the relationship between chronic pain and post-traumatic stress disorder. Journal 

of rehabilitation research and development 40.5 (2003): 397-406.

• Otis, JD, et al. The development of an integrated treatment for veterans with comorbid chronic pain and 

posttraumatic stress disorder. Pain Medicine 10.7 (2009): 1300-1311.

• Outcalt, SD, et al. Health care utilization among veterans with pain and posttraumatic stress symptoms. Pain 

Medicine (2013).

• Rasmusson, AM, et al. Low baseline and yohimbine-stimulated plasma neuropeptide Y (NPY) levels in combatrelated PTSD. Biological psychiatry 47.6 (2000): 526-539.

• Roth, RS, et al. The relation of post-traumatic stress symptoms to depression and pain in patients with accidentrelated chronic pain. The Journal of Pain 9.7 (2008): 588-596.

• Seal K, et al. Association of mental health disorders with prescription opioids and high-risk opi0id use in US 

veterans of Iraq and Afghanistan. JAMA 307 (2012): 940-947.

• Seal K, et al. Mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at 

department of veterans affairs facilities. Arch Intern Med 167 (2007): 476-482.

• Seal K, et al. Posttraumatic stress disorder and opioid use among US veterans—reply. JAMA 307 (2012) 2485-2486. 

• Sharp, TJ and AG Harvey. Chronic pain and posttraumatic stress disorder: mutual maintenance?. Clinical psychology 

review 21.6 (2001): 857-877.

• Smeeding, SJW, et al. Outcome evaluation of the Veterans Affairs Salt Lake City Integrative Health Clinic for chronic 

pain and stress-related depression, anxiety, and post-traumatic stress disorder. The Journal of Alternative and 

Complementary Medicine 16.8 (2010): 823-835.

• Wagner, AW, et al. Behavioral activation as an early intervention for posttraumatic stress disorder and depression 

among physically injured trauma survivors. Cognitive and Behavioral Practice 14.4 (2007): 341-349.

• Wald, J, et al. Posttraumatic stress disorder and chronic pain arising from motor vehicle accidents: efficacy of 

interoceptive exposure plus trauma-related exposure therapy. Cognitive Behaviour Therapy 29.2 (2010): 104-113.

43