Prolonged exposure for pain and comorbid PTSD: a single-case experimental study of a treatment supplement to multiprofessional pain rehabilitation

Abstract

Objectives It is unclear how to address PTSD in the context of chronic pain management. Here we examine the potential benefits of an addition of prolonged exposure (PE) therapy for PTSD for adults attending multidisciplinary CBT for chronic pain. Methods Four adults seeking treatment for chronic pain from a specialized pain rehabilitation service were offered PE for PTSD using a replicated, randomized, single-case experimental phase design, prior to commencing a 5-week multidisciplinary CBT program for chronic pain. Pre-, post-, follow-up, and daily measures allowed examination of PTSD and pain outcomes, potential mediators, and the trajectory of these outcomes and potential mediators during the subsequent pain-focused CBT program. Results Visual inspection of the daily data demonstrated changes in all outcome variables and potential mediators during the PE phase. Changes came at different times and at different rates for the four participants, highlighting the individual nature of putative change mechanisms. Consistent with expectation, PE produced reliable change in the severity of PTSD symptoms and trauma-related beliefs for all four participants, either by the end of the PE phase or the PE follow-up, with these gains maintained by the end of the 5-week pain-focused CBT program. However, few reductions in pain intensity or pain interference were seen either during the PE phase or after. Conclusions Although “disorder specific” approaches have dominated the conceptualising, study, and treatment of conditions like PTSD and chronic pain, such approaches may not be optimal. It may be better instead to approach cases in an individual and process-focused fashion. Ethical committee number 2013/381.

New generation psychological treatments in chronic pain

“…The treatment for PTSD in chronic pain has been evaluated in a single case experimental design study (n=4) but has not been further examined. In the single case study, each of the four cases showed clinically relevant improvements in symptoms of PTSD and beliefs related to trauma 71. These new approaches that include comorbid problems are not “one size fits all” packages of treatment components delivered as a whole for everyone meeting entry criteria for treatment.…”

“…For the latter, the focus is on behavioral activation for depression in the context of chronic pain, 70 a combination of ACT plus mindfulness based prevention of relapse in problematic opioid use, 49 or the addition of prolonged exposure to traumatic reminders for people with chronic pain and post-traumatic stress disorder (PTSD). 71 The clinical trial for the study focused on depression is registered and recruitment has started (ClinicalTrials.gov, NCT04140838). For the treatment focused on problematic opioid use in chronic pain, an initial feasibility and preliminary efficacy study (n=35) has been completed and compares the integrated treatment with treatment as usual in military veterans.…”

“…In the single case study, each of the four cases showed clinically relevant improvements in symptoms of PTSD and beliefs related to trauma. 71 These new approaches that include comorbid problems are not "one size fits all" packages of treatment components delivered as a whole for everyone meeting entry criteria for treatment. The developments are not entirely new treatments with novel mechanisms of change, but they do represent new modular designs built from known components.…”

“…Emerging trends in psychological treatments for chronic pain include attempts to design treatments based on the most effective component methods,69 or they focus on comorbid conditions associated with chronic pain. For the latter, the focus is on behavioral activation for depression in the context of chronic pain,70 a combination of ACT plus mindfulness based prevention of relapse in problematic opioid use,49 or the addition of prolonged exposure to traumatic reminders for people with chronic pain and post-traumatic stress disorder (PTSD) 71. The clinical trial for the study focused on depression is registered and recruitment has started (ClinicalTrials.gov, NCT04140838).…”

An updated audit of the patient selection process for pain management programmes in a speciality care service before and during the COVID-19 pandemic

“… 28 , 29 There is a growing body of research showing the benefits of simultaneously treating post-traumatic stress and chronic pain in particular. 30 - 35 Given synergies in cognitive-behavioural treatments for pain and mental health, research is needed to better understand how best to integrate treatments for both of these difficulties to further promote inclusion. 29 …”