Chronic pain and psychiatric injuries can go hand in hand. So says a new scientific article from a group of highly specialized VA doctors entitled, Pain and psychiatric comorbidities among two groups of Iraq- and Afghanistan-era Veterans.
The study was designed “to more precisely identify the prevalence and severity of pain and mental health comorbidities among . . . Veterans and service members . . . .” Not surprisingly, the wars in Iraq and Afghanistan have resulted in exceptionally high rates of postdeployment chronic pain, traumatic brain injury, Post Traumatic Stress Disorder, and other mental health and behavioral disorders.
Simply put, Iraq and Afghanistan servicemembers are at high risk for both pain and psychological problems. The article goes into detail, stating:
Data from this study confirm and extend initial reports regarding high prevalence of pain and psychiatric disorders among OIF/OEF/OND servicemembers who have returned from deployment. Using two geographically diverse study sites; structured, face-to-face clinical diagnostic and history interviews; and standardized self-report measures of symptom severity, we found that 86 percent of our sample reported experiencing an injury, one-third of which were associated with blast exposure. As hypothesized, pain complaints were the most common problem reported, and more than half of participants reported pain during the past week that exceeded the threshold for moderate or severe pain. In addition, the majority of participants reported experiencing pain plus at least one psychiatric disorder. Regarding onset of problems and treatment received, more than half of participants with mental health problems reported onset postdeployment or postservice, and while the vast majority (88%) reported that mental health problems are ongoing, only 65 percent of these participants reported currently receiving treatment. Of those with pain, fewer than half (43%) reported receiving treatment in the past 3 mo. Results not only highlight the high rates of current pain and psychiatric comorbidities, they also suggest that many of our Veterans are not receiving treatment.
Results confirmed the complexity of problems experienced by returning servicemembers. More than half of our sample met criteria for at least two problems, and nearly one-third met criteria for four or more problems. Of note, PTSD alone was very infrequent, and no participants met criteria for postconcussional disorder in the absence of pain or another psychiatric condition. The high rate of comorbidities may be explained by an integration of the fear-avoidance models of pain and PTSD and the maintenance/shared vulnerability models, which propose that chronic avoidance serves to maintain functional limitations associated not only with pain and PTSD but also with postconcussional, anxiety, and mood symptoms. This integrated model emphasizes the roles of fear and avoidance in the development and maintenance of co-occurring chronic pain, posttraumatic symptoms, and functional impairments. It may be argued that a similar fear-avoidance process may be extended to the maintenance of symptoms associated with TBI in that a belief that brain injury or cognitive problems are “permanent” may develop. This belief leads to the assumption by patients that symptoms may not be responsive to treatment, therefore treatment itself may be avoided. Moreover, as cognitive complaints may result from pain or anxiety in addition to or instead of history of concussion, the fear-avoidance processes that maintain anxiety or PTSD and pain ultimately serve to reinforce the cognitive difficulties reported. Thus, treatments are needed that concurrently treat pain and comorbid symptoms through decreasing avoidance.
These findings support the rationale underlying the VA’s bipartite system of care for OIF/OEF/OND servicemembers and our hypothesis that PSC patients would exhibit more complex and severe problems when compared with Registry patients. PSC patients were more likely to be injured in combat, particularly by blasts; had a higher proportion of head injuries; and more frequently experienced headaches. Diagnostically, they were significantly more likely to have more than one condition, particularly PTSD and other anxiety disorders, mood disorders, and postconcussional disorder. Indeed, rates of postconcussional disorder were seven times more common, and PTSD was three times more likely within the PSC group compared with the Registry group. Comparisons of symptom scores between groups adjusted for age and education yielded similar results: PSC patients reported greater severity of symptoms on all self-report measures (i.e., the MFSI-SF, SPQ, STAI, CES-D, and DAS-SF).
While the findings that PSC participants had more frequent and severe mental health problems were expected, we were surprised by the extent of reported pain and mental health issues among members of the Registry group. Recall that Registry participants were recruited from a list of individuals who had registered for VA healthcare but were not necessarily actively receiving care for identified problems. Nevertheless, almost one-half of Registry subjects reported moderate or severe pain during the past week, and half also met criteria for at least one psychiatric condition.
Given the high prevalence of pain and concurrent mental health problems that we observed in our multisite sample, best clinical practice should include interdisciplinary, multidomain assessments of mental health and physical health status at the time of VA healthcare registration. This would facilitate the rapid identification of individuals with complex conditions requiring more intensive treatment. The mandatory brief screens for TBI, PTSD, SUD, and pain (5th Vital Sign) that are in national use partially fulfill this need in that they trigger more detailed second-level, problem-focused evaluations. However, success of these mechanisms depends on the availability, comprehensiveness, and follow through of subsequent evaluations and ultimately on potential treatment alternatives that result. Additionally, our data suggest that the high prevalence of headaches and sleep problems in our samples supports the need to assess all returning servicemembers enrolling for VA care during initial clinical contacts. A thorough and detailed evaluation of blast exposure history will also be essential in efforts to identify blast-related risk factors, long-term effects, and treatment alternatives.
I would argue that many of the same problems also apply to Defense Base Act contractors.