International Society for Traumatic Stress Studies

Physical and Mental Battle Wounds: OEF/OIF/OND Veterans’ Physical Pain is Associated with Their PTSD Symptoms Severity But Not Their Physical Head Injuries

Posted 16 September 2015 in JOTS Highlights by Margaret Powell

At the Translational Research Center for TBI and Stress Related Disorders (TRACTS), a VA Rehabilitation Research and Development, TBI Center of Excellence, we assess physiological, psychological, cognitive and brain changes in a large sample of OEF/OIF/OND Veterans. The objective of this study was to characterize which clinical variables were most associated with reports of physical pain in our cohort of Veterans. When conducting cognitive and psychological assessments of our participants we noticed, from anecdotes in the context of our assessments or casual conversation, that many of them were affected by significant physical pain. In some cases, their pain seemed to be intense enough that it was a struggle to complete daily tasks, let alone our comprehensive study. We began to wonder how our participants’ psychological suffering might be influencing their physical suffering.

Results from previous studies corroborated our suspicions; they show that many Veterans returning from Iraq and Afghanistan are experiencing a great deal of debilitating physical pain (Gironda, Clark, Massengale, & Waler, 2006; Lang, Veazey-Morris, & Andrasik, 2013; Lippa, et al., 2015). For some, this pain is chronic, lasting months and even years (Kerns, Otis, Rodenburg, & Reid, 2003; Mersky, 1994). Often, it co-occurs with other physical and psychological conditions, such as PTSD, TBI, depression, anxiety, substance abuse, and impaired sleep, making it difficult to isolate or treat on its own (Capaldi, 2011; Cifu, et al., 2013, Tan et al., 2009). Much research has been done that shows that chronic pain, PTSD and mTBI (otherwise known as the poly trauma triad) are more likely to be seen together than to occur in isolation (Otis, Fortier, & Keane, 2012). However, these studies often rely on evaluations done in isolation, self-report measures and information obtained from medical records.

In contrast, our study benefited from a wide breadth of recorded psychological and physical factors (sleep quality, alcohol use, gender, close blast exposure, lifetime TBI, combat exposure, PTSD severity) and utilized a new and validated clinical-administered tool to assess for TBI. Importantly, the TRACTS sample overall (n=450), as well as our sub-sample of 171 OEF/OIF/OND Veterans reported in this study is highly representative of the current population of OEF/OIF/OND Veterans, motivating us to get at the root of the psychological-to-physical pain association. Our findings showed that current physical pain intensity was associated with PTSD severity, sleep quality, and alcohol use, but not physical head injuries (mTBI), as previously shown in other studies Specifically, PTSD symptoms involving re-experiencing the trauma (nightmares, intrusive thoughts) were associated with reports of current pain, leading us to wonder if re-experiencing a psychological and/or physical trauma causes your current physical pain to flare up. We feel these results suggest that past psychological trauma drives how much pain people are in presently, even more so than physical brain injury (mTBI). Importantly, these findings hold true for people with a history of chronic pain, as well as those who are suffering from pain currently.

Moving forward, it will be important for research to continue exploring the connection between PTSD, sleep, and pain. More broadly, such research would contribute to understanding the relationship between physical and psychological health as it relates to treatment and rehabilitation.

JTS Reference Article: 

Powell, M. A., Corbo, V., Fonda, J. R., Otis, J. D., Milberg, W. P., & McGlinchey, R. E. (2015). Sleep quality and reexperiencing symptoms of PTSD are associated with current pain in US OEF/OIF/OND Veterans with and without mTBIs. Journal of traumatic stress, 28(4), 322-329.

Discussion Questions

  • Are there identifiable alterations to brain structure and function that can help explain the relationship between re-experiencing symptoms and current pain levels?
  • Can understanding how trauma influences the perception of pain inform the development of new therapies to alleviate pain?

Author biography

Margaret (Megan) Powell
, B.A. (Colgate University ’12) is a Research Assistant focusing on neuropsychological assessment, group therapy and project management at the Translational Research Center for TBI and Stress Related Disorders (TRACTS) at the VA Boston Healthcare System. Her research interests include comorbid disorders and mind-body connections. Megan will be pursuing her Masters in Clinical Social Work beginning this fall.


Capaldi, V., Guerrero, M., William, Killgore. (2011). Sleep disruptions among returning combat veterans from Iraq and Afghanistan. Military Medicine, 176(8), 879-888.

Cifu, D. X., Taylor, B. C., Carne, W. F., Bidelspach, D., Sayer, N. A., Scholten, J., et al. (2013). Traumatic brain injury, posttraumatic stress disorder, and pain diagnoses in OIF/OEF/OND Veterans. J Rehabil Res Dev, 50(9), 1169-1176. doi: 10.1682/JRRD.2013.01.0006

Gironda, R. J., Clark, M. E., Massengale, J. P., & Walker, R. L. (2006). Pain among veterans of Operations Enduring Freedom and Iraqi Freedom. Pain Med, 7(4), 339-343. doi: PME146 [pii]

Kerns, R. D., Otis, J., Rosenberg, R., & Reid, M. C. (2003). Veterans' reports of pain and associations with ratings of health, health-risk behaviors, affective distress, and use of the healthcare system. J Rehabil Res Dev, 40(5), 371-379.

Lang, K. P., Veazey-Morris, K., & Andrasik, F. (2013). Exploring the Role of Insomnia in the Relation Between PTSD and Pain in Veterans With Polytrauma Injuries. J Head Trauma Rehabil. doi: 10.1097/HTR.0b013e31829c85d0

Lippa, S. M., Fonda, J. R., Fortier, C. B., Amick, M. A., Kenna, A., Milberg, W. P., et al. (2015). Deployment-Related Psychiatric and Behavioral Conditions and Their Association with Functional Disability in OEF/OIF/OND Veterans. J Trauma Stress, 28(1), 25-33. doi: 10.1002/jts.21979

Mersky, H., Bogduk, H. (1994). International Association for the Study of Pain Task-Force on Taxonomy (pp. 209-214). Seattle: IASP Press.

Otis, J. D., Fortier, C. B., & Keane, T. M. (2012). The management of chronic pain in the context of comorbid PTSD and mTBI. In R. B. J Vaterling, T. Keane (Ed.), PTSD and Mild Traumatic Brain Injury. New York, NY: Guilford Publications. Inc.

Tan, G., Fink, B., Dao, T. K., Hebert, R., Farmer, L. S., Sanders, A., et al. (2009). Associations among pain, PTSD, mTBI, and heart rate variability in veterans of Operation Enduring and Iraqi Freedom: a pilot study. Pain Med, 10(7), 1237-1245. doi: PME712 [pii]