Preliminary Analysis of Posttraumatic Stress Disorder Screening within Specialty Clinic Setting for OIF/OEF Veterans Seeking Care for Neck or Back Pain

Article excerpt


Posttraumatic stress disorder (PTSD) is defined by behavioral symptoms of reexperiencing, avoidance, and autonomic hyperarousal stemming from exposure to a threatening traumatic event that resulted in a response of fear, helplessness, or horror [1]. The criteria for the diagnosis of PTSD specify that symptoms must be present for more than 4 weeks and cause distress or impairment regarding social, occupational, or other areas of functioning [1]. In addition to the effect PTSD has on individual health, quality of life, general function, and healthcare service use, the healthcare system and society as a whole are considerably burdened economically [2-5]. Among returning Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) Veterans, most prevalence estimates of PTSD range from 5 to 20 percent and are generally higher among those seeking treatment [6]. The prevalence and costs associated with PTSD establish a need for detecting PTSD early and accurately and implementing evidence-based interventions to prevent chronic mental illness and disability [7].

Studies have also reported that a substantial percentage of OIF/OEF and Persian Gulf war veterans experience chronic pain following their period of Active Duty [8-10]. Mounting evidence exists within the scientific literature regarding the co-occurrence of and the relationship between PTSD and chronic pain [11-18]. Otis et al. has published a comprehensive summary of theoretical models, including mutual maintenance and shared vulnerability, underlying comorbid chronic pain and PTSD [14]. They report that chronic pain and PTSD frequently co-occur, they increase the symptom severity of either condition, and their interaction may negatively affect the management for either disorder [14]. Authors suggest that clinicians who evaluate and manage chronic pain or PTSD should diagnostically assess for both disorders [13-14].

Despite the use of the four-item primary care PTSD (PC-PTSD) screening tool within Department of Veterans Affairs (VA) primary care clinics [19-20], the diagnosis of PTSD is reportedly often missed within primary care settings [21]. Based upon high rates of mutually occurring PTSD and chronic pain, patients with musculoskeletal pain may have PTSD that has not been recognized. Thus, specialty clinic settings addressing musculoskeletal pain may provide additional opportunities for recognizing PTSD for appropriate referral for clinical management. The screening instrument used within this study was the PTSD Checklist (PCL) for military experiences [22]. A conventional cutoff score of 50 had been used for screening veterans within this clinic consistent with work done by Weathers et al. [22].

Because operating characteristics of the PCL vary considerably across populations and settings, use of a conventional cutoff score could lead to a PCL misapplication [23]. For this reason, this study specifically aimed to determine whether the optimal PCL cutoff score differed from 50 for a sample of OIF/OEF veterans seeking treatment for neck or back pain within a specialty clinic addressing musculoskeletal pain.


Study Population

The sampling frame was represented by OIF/OEF veterans with a chief complaint of neck pain or back pain consecutively referred to the VA Western New York Healthcare System (VAWNYHS) chiropractic clinic during 12 months between January 1 and December 31, 2009, with a completed PCL at baseline. Patients were suspected of having PTSD based on the diagnosis being embedded either within the problem list or within patient encounters. A clinical psychologist experienced in diagnosing and managing PTSD in veterans reviewed the clinical records of patients with suspected PTSD to confirm the diagnosis of PTSD through the presence of one or more of the following criteria: (1) diagnostic evaluation by a licensed behavioral health professional, (2) positive PCL, (3) positive PC-PTSD screen, and (4) service-connected disability status for PTSD. …