Pain with PTSD May Yield to CAM Techniques

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EXPERT ANALYSIS FROM THE ANNUAL CONFERENCE ON THE COMPLEXITIES AND CHALLENGES OF PTSD AND TBI

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 conference.

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, 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 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. …