The Resurrection of Interdisciplinary Pain Rehabilitation: Outcomes Across a Veterans Affairs Collaborative.

OBJECTIVE: Despite empirical support for interdisciplinary pain rehabilitation programs improving functioning and quality of life, access to this treatment approach has decreased dramatically over the last 20 years within the United States but has grown significantly in the Department of Veterans Affairs (VA). Between 2009 and 2019, VA pain rehabilitation programs accredited by the Commission on Accreditation of Rehabilitation Facilities increased 10-fold in the VA, expanding from two to 20. The aim of this collaborative observational evaluation was to examine patient outcomes across a subset of six programs at five sites. METHODS: Outcomes were assessed using agreed-upon measures of patient-reported pain intensity, pain interference across various domains, pain catastrophizing, and sleep. RESULTS: A total of 931 patients enrolled in the selected VA interdisciplinary pain programs, with 84.1% of participants completing the full course of treatment. Overall, all programs showed significant improvements from pretreatment to posttreatment in nearly all patient-reported outcomes. The effect sizes ranged from medium to large. Notably, the results demonstrate that positive outcomes were typical despite differences in structure and resources across programs. CONCLUSIONS: The adverse impacts of opioid use have highlighted the importance of chronic pain treatment approaches that emphasize team-based care focused on functional improvements. This study represents the first and largest analysis of outcomes across chronic pain rehabilitation programs and demonstrates the need for increased access to similar comprehensive approaches to pain management across the health care system. Further, it suggests that a variety of structures may be effective, encouraging flexibility in adopting this interdisciplinary approach.

An Interdisciplinary Pain Rehabilitation Program for Veterans with Chronic Pain: Description and Initial Evaluation of Outcomes.

Objective: Chronic pain conditions are prominent among Veterans. To leverage the biopsychosocial model of pain and comprehensively serve Veterans with chronic pain, the San Francisco Veterans Affairs Healthcare System has implemented the interdisciplinary pain rehabilitation program (IPRP). This study aims to (1) understand initial changes in treatment outcomes following IPRP, (2) investigate relationships between psychological factors and pain outcomes, and (3) explore whether changes in psychological factors predict changes in pain outcomes. Methods: A retrospective study evaluated relationships between clinical pain outcomes (pain intensity, pain disability, and opioid use) and psychological factors (depressive symptoms, catastrophizing, and "acceptable" level of pain) and changes in these outcomes following treatment. Multiple regression analysis explored whether changes in psychological variables significantly predicted changes in pain disability. Results: Catastrophizing and depressive symptoms were positively related to pain disability, while "acceptable" level of pain was idiosyncratically related to pain intensity. Pain disability and psychological variables showed significant changes in their expected directions. Regression analysis indicated that only changes in depressive symptoms significantly predicted changes in pain disability. Conclusion: Our results are consistent with evidence-based clinical practice guidelines for the management of chronic pain in Veterans. Further investigation of interdisciplinary treatment programs in Veterans is warranted.

Tele-pain management: use of videoconferencing technology in the delivery of an integrated cognitive-behavioral and physical therapy group intervention.

Chronic pain has been recognized as a highly prevalent problem, and interdisciplinary treatments have been shown to be effective in the treatment of chronic pain. An integrated cognitive-behavioral and physical therapy group protocol has been developed and then implemented at remote sites using videoconferencing technology to provide pain management for veterans. The treatment model is summarized and recommendations are made for addressing challenges in implementing this type of treatment via videoconferencing.

The Driving Behavior Survey: scale construction and validation.

Although long recognized in the clinical literature, problematic behavior characteristic of anxious drivers has received little empirical attention. The current research details development of a measure of anxious driving behavior conducted across three studies. Factor analytic techniques identified three dimensions of maladaptive behaviors across three college samples: anxiety-based performance deficits, exaggerated safety/caution behavior, and anxiety-related hostile/aggressive behavior. Performance deficits evidenced convergent associations with perceived driving skill and were broadly related to driving fear. Safety/caution behaviors demonstrated convergence with overt travel avoidance, although this relationship was inconsistent across studies. Safety/caution scores were associated specifically with accident- and social-related driving fears. Hostile/aggressive behaviors evidenced convergent relationships with driving anger and were associated specifically with accident-related fear. Internal consistencies were adequate, although some test-retest reliabilities were marginal in the unselected college sample. These data provide preliminary evidence for utility of the measure for both research and clinical practice.

Understanding the interpersonal impact of trauma: contributions of PTSD and depression.

To build on the growing literature on interpersonal relationships among individuals with PTSD, this study examined the separate influences of PTSD symptoms and depression on functioning with friends, romantic partners, and family. To examine the influence of measurement, both interviewer-rated assessment of interpersonal functioning and self-reported assessment of perceived social support were included. The sample included 109 community members who sought help for mental health problems in the aftermath of a serious motor vehicle accident. Building on previous research, hierarchical regression models were used to examine the impact of re-experiencing, avoidance, emotional numbing, and hyperarousal on relationship functioning, followed by depression. Results suggest that assessment modality makes a difference in understanding factors contributing to interpersonal strain. When assessed by an interviewer, depression seems to play a larger role in interpersonal strain, relative to PTSD symptoms. When assessed via self-reported perceived social support, weaker associations were observed, which highlighted the role of emotional numbing. Results are discussed in light of the possible role that PTSD comorbidity with depression plays in interpersonal functioning following a traumatic event, with implications for future research.

The structure of distress following trauma: posttraumatic stress disorder, major depressive disorder, and generalized anxiety disorder.

The current report used confirmatory factor analysis to examine the latent structures of both key features and associated symptoms of three disorders that commonly develop following a traumatic event: posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD). Participants were 228 motor-vehicle accident survivors who sought treatment for emotional difficulties. PTSD, MDD, and GAD were assessed with a combination of self-report and interview-based measures. The results of construct level analyses suggested that PTSD, MDD, and GAD are distinguishable but highly correlated disorders following a traumatic event. Symptom level analyses supported a model where the Reexperiencing, Avoidance, and Hypervigilance factors were subsumed under the PTSD construct. However, in this model the Dysphoria factor was a higher order construct correlated with the PTSD, MDD, and GAD factors, suggesting that the Dysphoria cluster may not be unique to PTSD. Diagnostic and theoretical implications of these results are discussed.

Unpacking the relationship between posttraumatic numbing and hyperarousal in a sample of help-seeking motor vehicle accident survivors: replication and extension.

The current study is a replication and extension of previous research that has found support for a relationship between posttraumatic numbing and hyperarousal. This study examined this association while controlling for depression in 345 motor vehicle accident survivors. Additionally, the relationships among specific hyperarousal symptoms and numbing were explored. Results provided further evidence for an association between hyperarousal and numbing, even while controlling for the influence of depression, and revealed that all hyperarousal symptoms (except hypervigilance) contribute to this association.

Development and examination of the social appearance anxiety scale.

The Social Appearance Anxiety Scale (SAAS) was created to measure anxiety about being negatively evaluated by others because of one's overall appearance, including body shape. This study examined the psychometric properties of the SAAS in three large samples of undergraduate students (respective ns = 512, 853, and 541). The SAAS demonstrated a unifactorial structure with high test-retest reliability and internal consistency. The SAAS was positively associated with measures of social anxiety. The SAAS was also related to greater disparity between perceived, actual, and ideal physical attributes, beliefs that one's appearance is inherently flawed and socially unacceptable and that being unattractive is socially deleterious, feelings of unattractiveness, emphasis on appearance and its maintenance, and a preoccupation with being overweight. It was a unique predictor of social anxiety above and beyond negative body image indicators. Findings suggest that the SAAS is a psychometrically valid measure of social anxiety regarding one's overall appearance.

An examination of the synergy of pain and PTSD on quality of life: additive or multiplicative effects?

Although models have been proposed to explain common factors that maintain comorbid pain and PTSD [Sharp TJ, Harvey AG. Chronic pain and posttraumatic stress disorder: mutual maintenance? Clin Psychol Rev 2001; 21: 857-77], the exact nature of the relationship between these two conditions and their impact on quality of life (QOL) is unknown. The aim of the present investigation was to examine the unique and interactive effects of PTSD and pain on role functioning and life satisfaction--two important domains of QOL. The study utilized a help-seeking sample of motor vehicle accident (MVA) survivors whose accidents resulted in symptoms of comorbid PTSD and pain (N=192). Hierarchical regression models were used to examine the relationship between four PTSD symptom clusters, pain, and the interaction of each cluster and pain on role functioning and life satisfaction separately. Results of these analyses revealed a significant interaction of pain and emotional numbing on role functioning, suggesting a multiplicative effect on this domain of QOL. Decomposition of this interaction revealed a negative association between numbing and functioning at low levels of pain but no relationship at higher levels. A marginal interaction of pain and hyperarousal also was noted for life satisfaction. Decomposition of the interaction effect revealed a marginal association between hyperarousal and decreased satisfaction only at high levels of pain. A main effect of emotional numbing on decreased life satisfaction also was observed in this model, suggesting a unique influence of numbing. The results of the current research indicate that the synergistic relationship of pain and PTSD may vary across domains of QOL.

The impact of event scale-revised: psychometric properties in a sample of motor vehicle accident survivors.

This study examined the factor structure, internal consistency, concurrent validity, and discriminative validity of the Impact of Event Scale-Revised (IES-R, [Weiss, D. S. & Marmar, C. R. (1997). The Impact of Event Scale-Revised. In: J. P. Wilson & T. M. Keane (Eds.). Assessing psychological trauma and PTSD (pp. 399-411). New York: Guilford Press]) in a sample of 182 individuals who had experienced a serious motor vehicle accident. Results supported the three-factor structure of the IES-R, Intrusion, Avoidance, and Hyperarousal, with adequate internal consistency noted for each subscale. Support was obtained for the concurrent and discriminative validity, as well as the absence of social desirability effects. Although some differences were noted between the IES-R Avoidance subscale and diagnostically based measures of this cluster of symptoms, these differences do not necessarily signify measurement problems with the IES-R. The IES-R seems to be a solid measure of post-trauma phenomena that can augment related assessment approaches in clinical and research settings.

Virtual Reality Exposure Therapy for PTSD symptoms after a road accident: an uncontrolled case series.

This report examined whether Virtual Reality Exposure Therapy (VRET) could be used in the treatment of posttraumatic stress disorder (PTSD) symptoms in the aftermath of a serious motor vehicle accident. Six individuals reporting either full or severe subsyndromal PTSD completed 10 sessions of VRET, which was conducted using software designed to create real-time driving scenarios. Results indicated significant reductions in posttrauma symptoms involving reexperiencing, avoidance, and emotional numbing, with effect sizes ranging from d=.79 to d=1.49. Indices of clinically significant and reliable change suggested that the magnitude of these changes was meaningful. Additionally, high levels of perceived reality ("presence") within the virtual driving situation were reported, and patients reported satisfaction with treatment. Results are discussed in light of the possibility for VRET to be useful in guiding exposure in the treatment of PTSD following road accidents.

Rebound effects following deliberate thought suppression: does PTSD make a difference?

This study was designed to examine the effects of deliberate suppression of trauma-related thoughts in 44 individuals who were PTSD+ and 26 individuals who were PTSD- following a motor vehicle accident (MVA). In an effort to resolve discrepancies in the literature, the PTSD- group was selected from the same help-seeking population as the patient group. Measures included the percentage of MVA-related thoughts, mood, perceived controllability of thoughts, and physiological arousal (heart rate, skin conductance, and two measures of facial EMG). Contrary to hypothesis, both PTSD+ and PTSD- groups showed a rebound in trauma-related thoughts following deliberate thought suppression. This rebound was associated with increases in negative affect, anxiety, and distress and diminished perceptions of controllability over thoughts. Examination of the physiological measures did not mirror the pattern noted for trauma-related thoughts, although the data suggest that suppression was associated with higher levels of frontalis EMG and possibly, reduced heart rate. The current study indicates that help-seeking individuals who are distressed about their psychological state following a serious MVA will show a rebound in MVA-related thoughts, irrespective of PTSD diagnosis. Implications for the study of thought suppression as a potential maintaining factor for trauma-related problems are discussed, with suggestions for future research.

Screening for PTSD in motor vehicle accident survivors using the PSS-SR and IES.

The current study compares the total scores of two potential posttraumatic stress disorder (PTSD) screening tools, the Impact of Event Scale (IES) and the PTSD Symptom Scale, Self-Report (PSS-SR), to the Clinician-Administered PTSD Scale (CAPS) in a large sample of motor vehicle accident (MVA) survivors (N = 229, of whom 43% met criteria for PTSD). For the IES using a cutoff score of 27, sensitivity was .91, specificity was .72, and overall correct classification was .80. For the PSS-SR using a cutoff score of 14, sensitivity was .91, specificity was .62, and overall correct classification was .74. Compared to those in studies of other trauma populations, the identified IES cutoff score is somewhat lower for this population of MVA survivors and the identified PSS-SR cutoff score is consistent with previous findings. These data support the use of the IES and the PSS-SR as PTSD screening tools in MVA samples.

What factors are associated with the maintenance of PTSD after a motor vehicle accident? The role of sex differences in a help-seeking population.

To investigate potential sex differences in factors that are associated with chronic PTSD, data from 223 participants were examined using logistic regression analyses. Each participant had been involved in a serious motor vehicle accident (MVA), which had occurred at least 6 months earlier (range 6mos-37 years). Although men and women did not differ in the rate of diagnosed PTSD, four variables were found to interact significantly with sex in the prediction of chronic PTSD: peritraumatic experiences of helplessness, danger, and the certainty that one would die during the MVA and lack of employment. Follow up analyses indicated that although the peritraumatic experience variables were statistically significant, no notable differences emerged in the odds ratios of men and of women. In contrast, men who were unemployed were 9.94 times more likely to be diagnosed with PTSD, relative to men who were employed, while unemployed women were 2.85 times more likely to be diagnosed with PTSD, relative to women who were employed. Results are discussed in light of the role of functional limitations and their impact on the maintenance of PTSD in men and women.

Post-traumatic stress disorder symptoms, pain, and perceived life control: associations with psychosocial and physical functioning.

The symptoms of PTSD and pain frequently co-occur following a traumatic event; however, very little is known about how these two conditions are associated with physical and psychosocial functioning. The current study intended to first examine the differential association of co-occurring pain complaints and PTSD symptoms with disability in the domains of psychosocial and physical functioning, and second, to test whether perceived life control is a mediator of these relationships. All participants experienced a motor vehicle accident (MVA) and reported pain due to accident-related injuries (n=183). Structural equation modeling was used to develop two models hypothesizing a relationship between PTSD symptomatology, pain severity, and perceived life control. Separate models were constructed for psychosocial and physical functioning, based on the hypothesis that pain and PTSD would be differentially related to disability in these two domains. Results suggested that more severe PTSD symptoms and greater pain complaints were related to psychosocial impairment, however, only pain was significantly related to impairment in physical functioning. Perceptions of life control were shown to further explain these interrelationships.

Is the concept of "repression" useful for the understanding chronic PTSD?

Theories concerning the value of avoiding versus attending to trauma-related thoughts provide mixed support for specific coping strategies such as repression. The goal of this study is to examine the usefulness of the concept of repression in understanding chronic Posttraumatic Stress Disorder (PTSD). One hundred and fifty individuals who had been in a motor vehicle accident were included. Participants were classified into four groups (repressors, low anxious, high anxious, and defensively high anxious) based on methodology introduced by Weinberger et al. [J. Abnormal Psychol. 88 (1979) 369]. These four groups were compared on measures of PTSD symptomatology, anxiety, depression, and where appropriate, perceived pain and disability. Results revealed a fairly consistent pattern of group differences such that repressors reported fewer PTSD symptoms, fewer additional anxiety disorders, less depression, and less physical disability due to pain relative to the high anxious and defensively high anxious groups. Regression analyses examining the separate and interactive effects of anxiety and social desirability to predict PTSD symptomatology showed that the majority of the variance was explained by anxiety. In many respects, these data suggest that repression may not be a useful concept for understanding chronic PTSD.

Quality of life and post trauma symptomatology in motor vehicle accident survivors: the mediating effects of depression and anxiety.

We examined the respective contributions of depression, anxiety, and post-trauma symptoms, as these factors reduce quality of life (QOL) in 111 individuals who had experienced a serious motor vehicle accident. Correlations and structural equation modeling were used to evaluate whether the severity of posttraumatic stress disorder symptoms influences QOL directly, and whether depression and anxiety mediated this relationship. Results indicated that post trauma symptomatology has a negative effect on QOL, which is mediated by depression and anxiety.

Psychometric Properties of the Posttraumatic Cognitions Inventory (PTCI): a replication with motor vehicle accident survivors.

This study examined the factor structure, internal consistency, concurrent validity, discriminant validity, and discriminative validity of the Posttraumatic Cognitions Inventory (PTCI; E. B. Foa, A. Ehlers, D. M. Clark, D. F. Tolin, and S. M. Orsillo, 1999) in a sample of 112 individuals who had experienced a serious motor vehicle accident. Results generally supported the 3-factor structure of the PTCI: (a) Negative Cognitions About Self, (b) Negative Cognitions About the World, and (c) Self-Blame. Subscales reflecting negative thoughts of the self and world showed adequate internal consistency, as well as good concurrent, discriminant, and discriminative validity. However, difficulties with the subscale representing self-blame emerged, specifically poor concurrent and discriminant validity. Potential reasons for this finding are discussed. The PTCI seems to be a promising measure of negative and dysfunctional posttrauma cognitions, which deserves continuing attention.