An Investigation of the Relationship between Posttraumatic Stress Disorder and Chronic Pain due to Whiplash Injury.

Rachael Dunne (2010). An Investigation of the Relationship between Posttraumatic Stress Disorder and Chronic Pain due to Whiplash Injury. PhD Thesis, School of Psychology, The University of Queensland.

       
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Author Rachael Dunne
Thesis Title An Investigation of the Relationship between Posttraumatic Stress Disorder and Chronic Pain due to Whiplash Injury.
School, Centre or Institute School of Psychology
Institution The University of Queensland
Publication date 2010-09
Thesis type PhD Thesis
Supervisor Justin Kenardy
Michele Sterling
Total pages 299
Total black and white pages 299
Subjects 17 Psychology and Cognitive Sciences
Abstract/Summary Whiplash associated disorders (WAD) are a common and incur substantial personal and economic costs. This is a complex condition involves both physical and psychological impairments and research has shown that a persistent posttraumatic stress reaction is associated with poor functional recovery (Buitenhuis, de Jong, Jaspers, & Groothoff, 2006; Sterling, Kenardy, Jull, & Vicenzino, 2003). Many studies have demonstrated general support for the fact that Posttraumatic Stress Disorder (PTSD) influences the experience of pain; however, the specific mechanism through which this may operate has not yet been clearly established. One possible mechanism is an abnormal stress system function, involving psychophysiological reactivity and disturbances in the sympathetic nervous system; however empirical testing of this hypothesis is limited. Guided by theoretical models (Asmundson, Coons, Taylor, & Katz, 2002; Asmundson, Stein, & McCreary, 2002; Keane & Barlow, 2002; Liedl & Knaevelsrud, 2008; Sharp, 2001; Sharp & Harvey, 2001; Vlaeyen & Linton, 2000), the present research aimed to explore the nature of the relationship between PTSD and chronic pain due to whiplash injury through two empirical studies. The first study investigated the impact of comorbid PTSD on mental and physical health outcomes in seventy-two individuals with chronic WAD. Participants were classified into two groups, according to diagnosis of current injury-related PTSD based of the Structured Clinical Interview for DSM-IV (SCID) (PTSD: n = 33; No PTSD n = 39). The first part of the study utilised a cross sectional design to assess differences between individuals with and without PTSD on self-report measures. Results indicated that those with PTSD were more likely to report greater number of locations of pain (particularly back and shoulder pain), medication use (specifically analgesics and anti-depressants) and general disability (as measured by the SF-36). While there was a trend for individuals with PTSD to report more neck disability (as measured by the Neck Disability Index) this did not reach significance. Significant relationships were however found between neck disability levels and PTSD severity (particularly the avoidance and hyperarousal subscales). Significant relationships were also found between physical health (as measured by the SF-36) and PTSD severity (particularly the avoidance subscale). An additional aim of this first study was to examine the direct impact of activation of PTSD symptoms on affect, arousal and pain threshold measures. Utilising an experimental design, individuals with and without PTSD underwent a series of sensory pain threshold measures under standard conditions and again after exposure to an individually relevant trauma cue. As expected, under standard conditions individuals with PTSD reported more negative affect and pain and demonstrated greater physiological arousal and lower sensory pain thresholds than those without PTSD. Exposure to specific trauma cues resulted in significantly greater increases in physiological arousal and negative affect for those with PTSD compared to those without PTSD. Changes in sensory pain thresholds between and across the groups revealed mixed results. As predicted, individuals with PTSD demonstrated lower pain thresholds compared to those without PTSD across all sensory measures at baseline. For individuals with PTSD, exposure to the trauma cue resulted in further significant decreases in cold and pressure pain thresholds at the site of injury (i.e. a hyperalgesic effect) however, no significant changes in self-reported pain or heat and remote pressure pain thresholds were found. As expected, for individuals without PTSD the trauma cue had minimal impact on any sensory pain threshold measures. Building on the findings of study 1 and previous research reporting poorer WAD outcomes (Buitenhuis, et al., 2006; Sterling, et al., 2003) and responses to physical therapies for individuals with comorbid PTSD (Jull, Sterling, Kenardy, & Beller, 2007), study 2 aimed to assess treatment of PTSD within a chronic WAD sample. Trauma-focused Cognitive Behavioural Therapy (CBT) has shown moderate effectiveness in chronic pain samples however, there have been no clinical trials within WAD and thus Study 2 aimed to fill the gap in this research. The impact of the PTSD treatment on disability, physiological arousal and sensory pain thresholds was also investigated. Individuals with both chronic WAD and PTSD (taken from the PTSD group in study 1) were randomly allocated to either CBT (n = 13) or a waitlist control (n = 13). Treatment effects were evaluated at 10-12 weeks and 6-month follow-up, using a structured clinical interview for DSM-IV TR (SCID), self-report questionnaires and measures of physiological arousal and sensory pain thresholds. Results indicated clinically significant reductions in PTSD symptoms in the CBT group compared to the waitlist group at the post-assessment. Further gains in the PTSD group were also noted at the follow-up. The treatment of PTSD was also associated with improvements in self-reported disability (as measured by the NDI) and improved physical, emotional and social functioning and physiological reactivity to trauma cues, however minimal changes in sensory pain thresholds were observed between groups or over time. This study provides support for the effectiveness of trauma-focused CBT to target PTSD symptoms within chronic WAD. The finding that treatment of PTSD resulted in improvements in self-reported disability and quality of life with minimal changes in sensory pain thresholds highlights the complex and inter-relating mechanisms that underlie both WAD and PTSD. The theoretical and clinical implications of the results and the need for development and refinement of the understanding of these comorbid conditions through future research is discussed.
Keyword Whiplash Associated Disorders
post traumatic stress disorder, children, traumatic brain injury, memory, information processing
MVC
pain
Randomised Control Trial
Additional Notes landscape pages: 135, 146, 190, 205, 208, 212, 216 and 218.

 
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