Catastrophizing and Pain in Military Personnel

Transcription

1 Curr Pain Headache Rep (2011) 15: DOI /s Catastrophizing and Pain in Military Personnel Christopher Spevak & Chester Buckenmaier III Published online: 26 January 2011 # Springer Science+Business Media, LLC (outside the USA) 2011 Abstract Combat-related injuries have been well documented for centuries. More recently, injuries suffered by US service members in Iraq and Afghanistan have resulted in a high number of survivable conditions. Polytrauma care in this setting must take into account both the physical and psychological injuries suffered by returning wounded warriors. Catastrophizing may occur when previously healthy individuals are faced with impairment and disfigurement. This is compounded with repeated operative procedures. Early detection and treatment of catastrophizing contributes to improved care of the wounded warrior. This article describes our experiences at Walter Reed Army Medical Center with catastrophizing in US service members returning from the current military operations in Iraq and Afghanistan. Keywords Pain. Catastrophizing. Trauma. Injuries. Posttraumatic stress disorder. Cognitive therapy. Behavioral therapy. Hypervigilance. Mental defeat. Coping Introduction Battlefield injuries as well as noncombat injuries account for significant pain and suffering in military personnel. The C. Spevak (*) Georgetown University Hospital, Washington, DC, USA cs25@georgetown.edu C. Buckenmaier III Acute Pain Medicine Service, Walter Reed Army Medical Center, Washington, DC, USA Chester.Buckenmaier@us.army.mil American Civil War surgeon Dr. S. Weir Mitchell chronicled the psychological effects of pain from combat injuries: Perhaps few persons who are not physicians can realize the influence which long continued and unendurable pain may have on body and mind under such torments the temper changes, the most amiable grow irritable, the bravest soldier becomes a coward, and the strongest man is scarcely less nervous than the most hysterical girl [1]. Catastrophizing has been broadly defined as an exaggerated negative orientation toward pain stimuli and pain experiences [2]. Catastrophizing influences the perception of pain and is a predictor of future pain and disability. This article describes our experiences at Walter Reed Army Medical Center (WRAMC) with catastrophizing in US service members returning from the current military operations in Iraq and Afghanistan. Pain and Mental Health in US Military Personnel The most common causes of chronic pain in service members during the current military conflicts in Iraq and Afghanistan are common conditions such as accidents and musculoskeletal injuries [3]. Heavy body armor, vibratory conditions, and other combat factors likely lead to these musculoskeletal issues in soldiers [4 6]. While body armor certainly protects against missiles and blasts, the protection comes at a biomechanical cost. This is well described in an epidemiological study at two military pain management centers where the presentation, diagnosis, mechanisms of injury, and treatment of soldiers injured in Operation Iraqi Freedom are described. Low back pain was found to be the primary pain complaint (53%) followed by extremity pain (23%). In that study, 107 patients were seen at WRAMC and 55 were treated in Landstuhl, Germany. The authors

2 Curr Pain Headache Rep (2011) 15: concluded that possible steps to improve treatment and return to duty in soldiers injured during combat include prompt and aggressive treatment of factors known to exacerbate pain, such as fear, anxiety, and depression [7]. In another study, neck pain in military helicopter pilots was found to be a significant occupational problem and thought to be a consequence of longer exposure to flying. They reported 1-year prevalence of any neck pain of 43% and continuous neck pain of 20% [8]. Neck pain is well known to respond to cognitive behavioral measures targeting muscle tension, such as mindfulness and progressive muscle relaxation, which are discussed below. In addition, multiple studies have been published on the mental health of service members. The Millennium Cohort Study of 77,047 US service members from 2001 to 2003 reported that the baseline mental and physical health for service members was better than the general population [9]. Mental health surveys completed immediately upon return from deployment to Iraq, followed by 3 and 6 months after return, identified increased percentages of interpersonal conflicts, posttraumatic stress disorder (PTSD), depression, and overall mental health disorders [10]. In addition, midterm health and personnel outcomes of recent combat amputees found a 66% percent rate of mental health diagnoses, with anxiety and adjustment disorder prevailing [11 ]. Data analyzed from the 2008 Department of Defense Health Behavior Survey, which included all active-duty military personnel, measured stress, anxiety, depression, PTSD, suicidal ideation, and suicide attempts. The study found that about 1 in 7 personnel met screening criteria for needing further anxiety evaluation and about 1 in 5 met criteria for needing further depression evaluation. Not surprisingly, those deployed during Operation Iraqi Freedom, Operation Enduring Freedom, or other combat theaters are more likely to need further anxiety evaluation. Likewise, suicidal ideation was higher among those who had been combat deployed [12]. The incidence rate of hospitalizations for new-onset bipolar I disorder among military personnel using the defense medical epidemiology database inpatient data concluded that, in the US military, psychiatric illness is the second leading cause of hospitalizations after injury and poisoning for men, and after delivery-related hospitalizations for women [13]. It should be noted that the healthy worker effect due to preaccession medical examination as well as periodic personnel and medical evaluations while in the military may impact data interpretation. Pain and Mental Health during Combat Physical and mental health injuries resulting from traumatic battlefield injuries have been reported in multiple studies. The Department of Defense s Casualty Classification System reports death and injury rates of US military personnel in Iraq. Casualty rates were lower than in prior conflicts; however, a greater proportion of troops wounded in Iraq survived their injuries [14 ]. A prospective longitudinal analysis of injuries sustained by a large combat forward-deployed maneuver unit was consistent with prior studies describing battlefield injuries [15]. There was a significantly higher proportion of head and neck wounds compared with prior conflicts. This is most likely to be due to advancement in body armor technology and development. Belmont et al. [16] described disease and nonbattle injuries sustained by a large combat-deployed maneuver unit during operation Iraqi Freedom. Musculoskeletal injuries and psychiatric disorders accounted for 74% of total casualties. Historically, disease and nonbattle injury resulted in significantly more hospitalizations and time loss than battle injuries as a result of the hospital combat environment. Psychiatric hospital admissions of US Army soldiers in Iraq and Afghanistan were for common behavioral health disorders including mood, adjustment, and anxiety disorders (including PTSD). Combat units in Iraq demonstrated higher risk of mental disorder and anxiety problems compared to support units [17]. The strongest predictors of postdeployment psychiatric disorders in deployed marines were low pay grade, hospitalization during deployment, low education, smoking, and PTSD at deployment conclusion [18]. Catastrophizing and Combat Injuries Catastrophizing as described previously is an exaggerated negative orientation toward pain stimuli and pain experiences. The Pain Catastrophizing Scale is an instrument developed to broadly quantify catastrophizing and consists of rumination, magnification, and helplessness subscales [19]. Catastrophizers do not share many common demographics; however, catastrophizing is associated with less formal education [20]. This relationship was demonstrated in a study where pain-related cognitions in individuals with lower levels of education correlated with maladaptive pain beliefs and coping strategies [21]. Two related factors to catastrophizing are hypervigilance and mental defeat. Pain hypervigilance is described as a strong attentional biased toward pain and is a powerful predictor of subjective acute postoperative pain [22]. Mental defeat, on the other hand, has been found to be an important psychological reaction to painful trauma. Mental defeat is described as an assault on a person s life and sense of identity and results in giving up efforts to retain identity and self will in the face of uncontrolled traumatic events [23]. These behaviors both trigger and contribute to catastrophizing. In addition,

3 126 Curr Pain Headache Rep (2011) 15: emerging research involves the association of mental defeat with PTSD [23]. Catastrophizing behavior, as reflected in high catastrophizing scores, is predictive of increased postoperative pain in multiple studies [24 26]. Predictors of moderate to severe pain during the immediate postoperative period include preoperative pain, expectations of pain, fear of surgery, and pain catastrophizing [27]. Patients with chronic pain with catastrophizing behaviors report more pain intensity, are more disabled by the pain problem, and experience more psychological distress independent of the level of physical impairment [28]. In addition, catastrophizing was related to a longer duration of pain in patients with spinal cord pain [29]. A recent study by Ciccone et al. [30 ] evaluated 2995 US National Guard troops before deployment to determine if catastrophizing was associated with psychiatric morbidity. The study also assessed whether catastrophizing could account for individual differences in psychological distress and impaired physical function in the presence of acute and chronic pain. In National Guard members reporting pain symptoms, frequent catastrophizing was associated with higher rates of depression, PTSD, alcohol dependence, and somatization-like illnesses. Higher catastrophizing rates also were associated with chronic as opposed to acute pain. Results from this study are not dissimilar from the general population. The Walter Reed Army Medical Center Experience Wounded warriors requiring tertiary care transported to WRAMC from Iraq and Afghanistan frequently present with extensive polytrauma requiring repeated surgical interventions. Comorbid conditions include PTSD and traumatic brain injury as well as anxiety and fear of limb loss and disfigurement. These comorbidities are unique to combat-related injuries. Our treatment at WRAMC involves both a multidisciplinary and a multimodal approach of both physical and psychosocial injuries, beginning on the inpatient wards and continuing as outpatient therapy by members of the behavioral health department. Service members are evaluated for underlying behavioral health comorbidities and assessed for their knowledge of pain, its etiology, and its impact on their lives and relationships. Catastrophizing behaviors are identified early and aggressively treated. Treatment plans are tailored to the wounded warrior, taking into account the comorbidities noted above. We have found that treatment focused on psychological adaptation, including cognitive restructuring of automatic thoughts and cognitive distortions with reframing and coping strategies, improves pain and quality of life of the wounded warrior. Treatment progresses through stages of assessment, reconceptualization, skills development, application, and generalization of learned skills. Cognitive restructuring techniques begin with education regarding the impact of negative thinking followed by cognitive reappraisal. Soldiers are led through exercises to help with compartmentalization with traditional techniques of selective attention. Meditation and prayer are also encouraged. Relaxation training techniques utilized include progressive muscle relaxation, visualization, hypnosis, meditation, and systemic desensitization. Maladaptive pain behavior patterns are addressed with functional rehabilitation, stressing timecontingent medication regimes as well as decreasing avoidant and self-focused behavior by increasing interests. Likewise, stress-management techniques include relaxation training, physical therapy, and occupational therapy. Stress inoculation is employed to help a person gain confidence in his ability to cope with anxiety and fear. Soldiers are engaged in effective pain-coping strategies as well. Coping is defined as a person s cognitive and behavioral efforts to reduce, minimize, master, or tolerate the internal and external demands that tax or exceed a person s resources [31]. Treatment of catastrophizing includes validation of the individual s experience of pain and acknowledgment that the pain creates a foundation for improved coping. After initial fulfillment of dependency needs, attention is gradually withdrawn from the pain. Emotion-focused avoidance coping strategies decrease the relation between pain intensity and psychological functioning [32]. The soldiers are encouraged to communicate anxiety and fears and explore psychosocial stressors while actively participating in choices and managing issues that are out of their control. As body image issues play a significant role in polytrauma injuries, soldiers are encouraged to grieve the loss of function as well as disfigurement. Techniques to facilitate identification of distortions and encouragement of self-acceptance are utilized. Decreasing negative beliefs about the self in relation to pain is essential to reduce information-processing bias, which interferes with coping. This is one of the most difficult issues for the soldiers as well as caregivers. Continued treatment occurs when soldiers are discharged to the outpatient Warrior Clinic, or transferred to another medical treatment facility either in the Department of Defense or Veteran s Health Care System. As discussed previously, polytrauma injuries often result in multiple operative procedures, resulting in further impairment as an outpatient as well. We routinely screen for catastrophizing and intervene early with treatments as described above. A recent study looking at outcomes of an integrated health clinic from a Veteran s Administration Hospital utilizing nonpharmacologic biopsychosocial interventions, including mind body skills and complementary and alternative medicine therapies, revealed

4 Curr Pain Headache Rep (2011) 15: improvement in chronic nonmalignant pain, depression, anxiety, and health-related quality of life [33]. Conclusions The available evidence and our experience suggest that early detection of catastrophizing behaviors and prompt treatment benefits the rehabilitation and recovery of wounded soldiers. Our population is distinct from the civilian studies in that most wounded warriors are young and healthy before suffering major polytrauma. Outcome measurement includes improvement in physical and occupational rehabilitation as well as standardized pain scores. Additional study is needed in this patient population with concurrent traumatic brain injury and PTSD to determine the most effective cognitive and behavioral treatments in the acute setting. In addition, the benefits of an integrated behavioral health team member on an acute pain service need further exploration. Disclosures No potential conflicts of interest relevant to this article were reported. 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