The purpose of this study is to examine the efficacy of an integrated treatment for Veterans
with comorbid chronic pain and posttraumatic stress disorder (PTSD). It is hypothesized that
Veterans who receive the integrated treatment will report more positive outcomes than
individuals who are assigned to treatment as usual, pain treatment, or PTSD treatment.
Chronic pain and post-traumatic stress disorder frequently co-occur and are associated with
a significant level of affective distress, physical disability, and treatment resistance.
However, no empirical studies have been conducted investigating the efficacy of a treatment
tailored specifically for individuals with comorbid chronic pain and PTSD.
The primary objective of this study is to evaluate the efficacy of a cognitive-behavioral
therapy approach for comorbid chronic pain and PTSD. A secondary objective of this study is
to examine potential mechanisms of action that might mediate treatment outcome. It is
1.a) Participants receiving integrated cognitive-behavioral treatment for chronic pain and
PTSD will report significantly greater improvements on measures of pain, affective distress,
and physical functioning from pre-treatment to post-treatment than participants in the
Cognitive Behavioral Treatment for chronic pain, Cognitive Processing Therapy (CPT) for
PTSD, or Treatment as Usual (TAU) conditions
1.b) All active treatments will be more effective at promoting improved outcomes than
Treatment as Usual
2) Participants receiving integrated cognitive-behavioral treatment for chronic pain and
PTSD will report decreased symptoms of PTSD from pre-treatment to post-treatment when
compared to participants in the other conditions.
3) Participants receiving integrated cognitive-behavioral treatment for chronic pain and
PTSD will report greater maintenance of change, and greater improvements on measures of
Pain, Affective Distress, Physical Functioning, and PTSD at 6 months following the
completion of treatment than participants in the other three conditions
4) As a secondary/exploratory hypothesis, the researchers will examine potential mechanisms
of action in treatment.
It is hypothesized that changes in these potential mechanisms will mediate treatment
outcome. The proposed study is a four-treatment condition by three-evaluation period
(pre-treatment, post-treatment, and 6-month follow-up) repeated measures factorial design
with multiple dependent measures. Participants will be 136 patients with co-morbid chronic
pain and PTSD receiving care in the VA Boston Healthcare System. Participants in the active
treatment conditions will complete 11 weekly outpatient therapy sessions. A clinical
psychologist with specialized training in providing both PTSD and chronic pain treatment
protocols will conduct therapy in an individual format, 90 minutes in duration. Participants
assigned to the TAU condition will not receive treatment beyond that provided by their
primary care provider and other healthcare providers. The Cognitive Behavioral Therapy-PAIN
condition will follow an adaptation of a manualized treatment protocol used by Kerns and
colleagues that emphasizes identifying and modifying maladaptive thoughts and behaviors
related to the experience of chronic pain. Participants in the Cognitive Processing Therapy
- PTSD condition will receive a manualized treatment protocol that includes several
empirically supported techniques including cognitive restructuring, exposure therapy, and
skills training. Participants in the Cognitive Behavioral Therapy - Integrated condition
will receive an integrated treatment for comorbid pain and PTSD including components of the
pain and PTSD treatments described above.
The proposed study will address the specific objectives of the National Pain Management
Strategy by helping to assure that clinicians practicing in the VA healthcare system are
adequately prepared to assess and manage chronic pain effectively, especially when comorbid
with PTSD. Knowledge gained from the proposed study could potentially be utilized by
psychologists and other healthcare providers across the VA system nationwide who are
currently engaged in Cognitive Behavioral Therapy treatment programs for chronic pain and
PTSD. Given that Cognitive Behavioral Therapy has been shown to be efficacious for pain and
PTSD, but not for comorbid pain and PTSD, it is imperative that a new integrated treatment
be evaluated that has the potential to address the unmet needs of this large population.
Thus, this study will have important implications for the delivery of pain management
services to veterans and others with chronic pain and PTSD.
- Patients will be eligible for participation if they have chronic pain, defined as
constant pain of at least six months duration with a neurologic or musculoskeletal
etiology. Patients must also meet criteria for PTSD.
- Stability of pain and anxiety medications will be required for two months prior to
study entry and during the active treatment and TAU phase.
- Patients with life threatening or acute physical illness (e.g., cancer).
- Current alcohol or substance abuse or dependence. Veterans who have a history of
alcohol or drug dependence but who have not had problematic use in the last six
months will be included in the study.
- Current psychosis or suicidal ideation.
- Individuals seeking pain treatment such as surgical interventions will be excluded.