Other Challenges in Pain Assessment

• The Behavioral Pain Rating Scale (BPRS) (Mateo, Krenzischek, 1992)

• The Behavioral Pain Scale (BPS) (Payen, Bru, Bosson, et al., 2001)

• Pain Behavior Assessment Tool (PBAT) (Puntillo, Morris, Thompson, et al., 2004)

• Critical-Care Pain Observation Tool (CPOT) (Gelinas, Fillion, Puntillo, et al., 2006)

• Pain Assessment and Intervention Notation (PAIN Algorithm) (Puntillo, Miaskowski, Kehrie, et al., 1997)

• Nonverbal Pain Scale (NVPS) (Odhner, Wegman, Freeland, et al., 2003).

• The hierarchy begins with an attempt to obtain a self-report. If that fails, the following indicators should be assessed, and one can assume pain is present (APP) if any of the measures indicates pain. Again, the abbreviation APP may be used for documentation if approved by institutional policy and procedure.

• Potential causes of pain, such as procedures or existing painful conditions, are next on the hierarchy. These should include noting that pain at rest can cause aching and that the following procedures have been found to be painful: turning (the most painful of this group), wound drain removal, tracheal suctioning, femoral catheter removal, placement of a central venous catheter, and nonburn wound dressing change.

• Following assessment for causes of pain, clinicians look for patient behaviors that may indicate pain. This is the point at which a behavioral pain assessment tool is used, and we recommend using the CPOT for critically ill patients.

• Next, reports of pain or observations of behaviors that might indicate pain are elicited, when possible, from people who know the patient well, such as caregivers and family members. They may know of previously existing painful conditions such as arthritis that have been causing pain.

• Finally, when in doubt about the presence of pain or when wanting to confirm the suspicion of pain, an analgesic trial may be helpful. The analgesic trial is used as the basis for developing the pain treatment plan once pain has been confirmed. (See Boxes 3-9 and 3-11, pp. 123 and 126, for more ideas about using the analgesic trial.)

• Try to obtain a self-report. A large majority of adults with IDs achieve a sixth grade level of academic skill and may be able to use some of the self-report scales mentioned in the section on self-report tools for adults who have difficulty with the commonly used tools such as the 0 to 10 NRS (pp. 92-95).

• Identify pathologic conditions and procedures that commonly cause pain, paying particular attention to those sources of pain characteristic of the type of ID. For example, individuals with cerebral palsy or autism often experience gastrointestinal discomfort such as gastroesophageal reflux. Individuals with Down syndrome are prone to developing leukemia, with all the usual pain associated with the disease and its treatment. Chronic pain is very common, one source being musculoskeletal pain in cerebral palsy.

• Observe behaviors indicative of pain. Changes in facial expression, especially brow lowering and chin raising, are probably the most frequently cited indicators of pain in persons with IDs, and they do not seem to vary with the level of cognitive functioning. Numerous other behaviors are cited in research into pain in adults with IDs. Some behaviors indicative of pain are unconventional, such as kicking others, picking at own skin, or freezing. Consider using the CPS-NAID (see Form 4-2) to assess chronic pain in adults with IDs.

• Physiologic indicators such as vital signs are not usually very helpful in assessing pain, but in the ID literature physiologic indicators often refer to the following behaviors, which may be helpful in assessing individuals with severe or profound IDs: gasping for breath, vomiting, and becoming red in the face.

• Obtaining information from caregivers who know the patient well, sometimes over a period of years, is a common way of assessing pain in individuals with IDs and is high on the hierarchy of pain assessment.

• Finally, when in doubt about the presence of pain or when wanting to confirm the suspicion of pain, an analgesic trial may be helpful. Assess for changes in behavior following use of an analgesic. (See Box 3-11, p. 126, for suggestions concerning analgesic trials.)

Schizophrenia

The extent of apparent insensitivity to pain in patients with schizophrenia can be extreme, as revealed in some clinical case reports. One such example is a patient with diagnosed schizophrenia for 20 years who burned his arm so severely it had to be amputated (Virit, Savas, Altindag, 2008). The patient explained, “I put my hand on the burning flames of the LPG (liquefied petroleum gas) cylinder in order to get warm…. I did not feel any pain” (p. 384).

Insensitivity to pain by schizophrenic patients has been suggested for more than 100 years, and failure to respond to pain is clearly associated with increased morbidity and mortality rates. A literature review of physical diseases in patients with schizophrenia documented the long-held observation that many types of physical illness, such as CV diseases, HIV infections, and dental problems, are more common in these patients than in the general population (Leucht, Burkard, Henderson, et al., 2007). This is thought to be caused in part by the stigma attached to patients with schizophrenia; it leads to undertreatment. Further, the tendency to ascribe patients’ expressions of physical illness to the mental illness sometimes leads to missing a medical diagnosis. In addition, patients themselves simply fail to report symptoms of physical illness. It appears that patients with schizophrenia who fail to respond to pain also seek medical care at later stages of disease. For example, in a small study of 55 patients with schizophrenia undergoing appendectomy, 34 appendixes were perforated and 9 were gangrenous (Cooke, Magas, Virgo, et al., 2007).

In a literature search for studies of postoperative complications in seriously mentally ill patients, 10 studies relating to patients with schizophrenia were identified (Copeland, Zeber, Pugh, et al., 2008). Of the studies, 9 had fewer than 100 patients, but one large retrospective study included 466 patients with schizophrenia and 338,257 patients without schizophrenia (Daumit, Pronovost, Anthony, et al., 2006). Those with schizophrenia had higher rates of postoperative complications, such as respiratory failure and deep-vein thrombosis, than did patients without schizophrenia. Again, it appears that patients with schizophrenia are insensitive to pain and seek medical care at later stages of disease.

One small study of 50 schizophrenic patients and 25 controls found that those with schizophrenia reported significantly lower pain intensity postoperatively and consumed 60% less analgesic medication (Kudoh, Ishihara, Matsuki, 2000). This shows that schizophrenic patients seem to be less responsive to postoperative pain. Nevertheless, postoperative pain in schizophrenic patients is a risk factor for postoperative confusion (Kudoh, Takahira, Katagal, et al., 2002), which occurs more commonly in schizophrenic patients than in those without schizophrenia. Although pain scores do not reflect very much conscious awareness of pain, adequate postoperative pain relief is necessary to prevent postoperative confusion (Kudoh, 2005).

The lack of responsiveness to pain of schizophrenic patients is poorly understood. One way of comprehending the denial of pain and the low pain ratings in the presence of noxious stimuli that ordinarily cause severe pain is that the mental illness overwhelms the patient’s thought processes (e.g., hallucinations, intrusive thoughts), and the patient simply does not focus on pain. Patients with schizophrenia also may be preoccupied with their psychotic symptoms and may suffer from fatigue and a lack of drive, consequently failing to seek help for physical symptoms (Leucht, Burkard, Henderson, et al., 2007). Some studies find that patients with schizophrenia, when compared to healthy controls, have higher sensory perception thresholds, such as the perception of warmth and the onset of thermal pain. This trait seems to be caused by abnormalities in information processing (Jochum, Letzsch, Greiner, et al., 2006). The tests for these sensations required sustained attention, and the researchers noted that the patients had difficulty focusing. A review of 12 studies of individuals with schizophrenia revealed that their responses to experimental pain were diminished (Potvin, Marchand, 2008).

Antipsychotic medications have sometimes been thought to have analgesic effects, and that could help explain seeming decreased sensitivity to pain in individuals with schizophrenia. However, in the previously mentioned study, antipsychotic medications did not alter the finding of high sensory thresholds. Drug-free patients also had hypoalgesic responses. Therefore, hypoalgesia could not be explained solely by the effects of antipsychotic drugs (Potvin, Marchand, 2008).

Another explanation for hypoalgesia is derived from a review of the literature that suggests that seeming pain insensitivity may be a familial trait rather than a function of the psychotic state (Singh, Giles, Nasrallah, 2006). One study compared the responses to finger pressure by college students who did not have diagnoses of schizophrenia, but who had relatives who did, with the responses of students with no family history of schizophrenia (Hooley, Delgado, 2001). Pain threshold and tolerance were higher in the healthy adults who had relatives diagnosed with schizophrenia, suggesting that pain insensitivity may be a familial trait.

To summarize, apparent insensitivity to pain in patients with schizophrenia may reflect a true lack of pain sensitivity or may be caused by other factors such as failure to focus on pain or respond to pain in the presence of a psychotic state. Unfortunately, a review of the literature did not produce sufficient evidence of whether hypoalgesia is present in schizophrenic patients when they are stable as well as during acute phases of psychosis (Potvin, Marchand, 2008).

More recently, researchers have questioned whether some patients with schizophrenia are insensitive to pain or just seem insensitive to pain because of communication impairments that accompany schizophrenia (Bonnot, Anderson, Cohen, et al., 2009). A review of the scientific literature on pain in patients with schizophrenia yielded 431 articles, of which 57 were considered relevant to examining sensitivity to pain. These included 9 case reports, 23 clinical studies, 20 experimental research, and 5 review articles. Only 1 experimental study used a neurophysiologic measure of pain reactivity, and it showed a normal pain threshold in schizophrenia. Misconceptions about patients with schizophrenia being insensitive to pain are probably derived from observations that many of these patients show reduced pain reactivity in the form of decreased behavioral responses and self-reported pain.

How can pain be assessed in patients who do not report pain or report low intensities of pain? A survey was conducted of 74 staff members of a geriatric psychiatry service to explore pain assessment and management issues in that population (Stolee, Hillier, Esbaugh, et al., 2007). Part of the survey consisted of a list of 37 potential indicators of pain, and staff were asked to rate the extent to which they agreed or disagreed that these could be indicators of pain. Those pain indicators that were endorsed most often were facial grimacing or wincing, verbal pain complaints, diagnoses of painful conditions (such as arthritis), body positioning, and groaning or moaning. The accuracy of these indicators of pain was not assessed. Also, in this population of patients both mental illness and cognitive impairment existed, so the extent to which each condition influenced the perception of pain is unknown. However, the majority of respondents (more than 80%) were not so much interested in specific behaviors but rather in identifying changes in usual behaviors as indicators of pain in patients with mental illness. This preliminary research provides a clue to the assessment of pain in patients with schizophrenia, namely, notation of changes in the patients’ usual behaviors.

Many behaviors, such as personality changes, sleep disturbances, and fatigue, may occur as the result of either pain or exacerbations in mental illness (McCaffery, Pasero, 2001; Rutledge, Donaldson, 1998). Because apparent insensitivity to pain and impaired pain responsiveness are common in mental illness, it is recommended that such behaviors be interpreted as potential indicators of pain and that the pain be treated first, before attempting to determine whether the behaviors are a result of a mental disorder.

The finding of the appearance of insensitivity to pain in many, but not all, patients with schizophrenia presents clinicians with assessment challenges. In some ways assessment is comparable to that in previous recommendations that pain in nonverbal patients and those unable to respond with behavioral indicators should be assumed and treated when usually painful underlying pathologies or procedures are present. Because pain is rarely experienced as a hallucination (Watson, Chandarana, Merskey, 1981), any report of pain should always be taken seriously.

The assessment of pain in patients with schizophrenia should not differ from the assessment of pain in mentally healthy individuals. For example, if an institution’s policy recommends assessment of pain during every shift, it should also be done on units caring for patients with mental illness, bearing in mind that a patient with schizophrenia may deny pain, even in the presence of a disease known to be painful such as an infected appendix.

For the assessment of pain in adult patients with schizophrenia, information from the previous discussion can be applied to the hierarchy-of-pain assessment techniques, Box 3-9 (p. 123), as follows:

In conclusion, when addressing the problem of pain in patients with serious mental illness, two important considerations are (1) patients with chronic pain who also have mental disorders have a poorer quality of life than those without mental disorders; and (2) better treatment outcomes are likely when both pain and the mental illness are treated than when only one or the other is treated (Nicholas, 2007). Thus, whether the mental illness causes pain or is a consequence of pain, both pain and the mental illness should be treated.

Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is an anxiety disorder that can occur following an extremely traumatic event that involves being threatened by or witness to a situation that involves death or injury (APA, 1994). Traumatic events may include military combat, physical attacks, torture, or severe automobile accidents. The prevalence rates of individuals’ at risk for developing PTSD, such as combat veterans and victims of criminal violence, range from 3% to 58%.

Soldiers returning from the Iraqi war report very high levels of combat exposure, with 90% describing being shot at and a high percentage report handling dead bodies, knowing someone who was injured or killed, or killing an enemy combatant (Hoge, Castro, Messer, et al., 2004) Research has shown that soldiers with extensive combat exposure are four times more likely to develop PTSD than those with low combat exposure (Kulka, Schlenger, Fairbank, et al., 1990). In a convenience sample of Iraqi veterans, 71% had pain, 57% had PTSD, and 64% had mild traumatic brain injury; 36% had all three (Tan, Fink, Dao, et al., 2009). This population also displayed compromised autonomic nervous system function, suggesting that autonomic abnormality may contribute to, result from, or be a useful marker of symptoms of pain in traumatic brain injury and PTSD.

Soon after a traumatic event, “psychic numbing” or “emotional anesthesia” occurs; it is a symptom of decreased responsiveness to the external world (APA, 1994). Symptoms of PTSD usually begin within the first 3 months of the precipitating event, and approximately half of patients experiencing such symptoms completely recover within 3 months, whereas many others have persistent symptoms for longer than 12 months. PTSD is characterized by distress or impairment in functioning, socially or occupationally; persistent anxiety; sleep disturbances; and recurrent nightmares about the traumatic event. The patient may develop hypervigilence, irritability, exaggerated startle responses; and difficulty concentrating. When persons are exposed to events that are reminders of the original traumatic event, extreme psychologic distress or physiologic reactions commonly occur. Usually, they make deliberate efforts to avoid all reminders.

The prevalence of PTSD has been estimated to be between 6% and 9% or more in the general population of the United States (Breslau, 2001). Unfortunately, PTSD is much more common and is often underdiagnosed in primary care and mental health settings. For example, in a study of 295 psychiatric outpatients, 46% had PTSD but only 7% were diagnosed as such by physicians (Villano, Rosenblum, Magura, et al., 2007).

The presence of high levels of pain during the peritrauma period has been associated with increased risk for the development of PTSD (Norman, Stein, Dimsdale, et al., 2008). Related to this finding is a study of 24 children admitted to the hospital for acute burns (Saxe, Stoddard, Courtney, et al., 2001). The children were assessed for PTSD while in the hospital and 6 months after discharge. All children received morphine, but those who received higher doses of morphine showed greater reduction in PTSD symptoms over 6 months. It is interesting that in another study, of 147 soldiers in Iraq who were treated in a military treatment center for burns and had had at least one surgery, 119 who had received ketamine during surgery were compared with 28 who had not (McGhee, Maani, Garza, et al., 2008). The prevalence of PTSD was 27% in those who had received ketamine and 46% in those who had not received ketamine despite the fact that their burns were larger and their injury severity scores higher. A pilot study of placebo versus 40 mg of propranolol (Inderal) four times a day following acute, psychologically traumatic events found that propranolol had a preventive effect on subsequent PTSD (Pitman, Sanders, Zusman, et al., 2002). This offers the hope that ketamine, propranolol, morphine, or perhaps some other medications can be used soon after trauma or injury to prevent or reduce the symptoms of PTSD.

When PTSD involves a physically painful injury, it has been suggested that pain may be a flashback to the original traumatic injury (Asmundson, Coons, Taylor, et al., 2002). Therefore, it may be possible to prevent or minimize the development of pain-related PTSD flashbacks by assessing pain and treating it with analgesics at an early stage. Another small study (N = 6) of veterans with both chronic pain and PTSD examined the effects of using components of cognitive processing therapy for PTSD and cognitive behavioral therapy for chronic pain (Otis, Keane, Kerns, et al., 2009). A 12-session integrated treatment for veterans with both chronic pain and PTSD was developed and used by the participants. Although half the participants withdrew from the study, participants appeared to benefit from the treatment, and further research is being conducted to evaluate the efficacy of this approach.

PTSD and chronic pain often occur together and are frequently observed within the Department of Veterans Affairs health care system (Otis, Keane, Kerns, 2003). When patients with PTSD are being assessed, chronic pain is commonly identified, regardless of the nature of the traumatic experience, and vice versa; when patients with chronic pain are being assessed, PTSD is commonly found too (Asmundson, Coons, Taylor, et al., 2002; Schwartz, Bradley, Penza, et al., 2006). In a study of 295 psychiatric outpatients, 24% had both PTSD and chronic severe pain (Villano, Rosenblum, Magura, et al., 2007). In another study of 85 veterans seeking treatment for PTSD, 66% had chronic pain diagnoses (Shipherd, Keyes, Jovanovic, et al., 2007).

Unfortunately, because of the stigma placed on seeking psychiatric help, most veterans do not seek help from this source. If they develop painful conditions, they are more likely to seek help from pain clinics (DeCarvalho, Whealin, 2006). Because PTSD may hamper treatment for chronic pain, pain specialists should know about the possibility that PTSD can coexist with chronic pain and should watch for symptoms, such as being easily startled, hypervigilence, isolation, and use of alcohol or other substances to deal with PTSD or pain. An appropriate screening tool for PTSD should be used.

Studies have reported both increased and decreased sensitivity to pain in individuals with PTSD (Geuze, Westenberg, Jochims, et al., 2007). Decreased sensitivity to pain in patients with PTSD has been documented in only a few experimental studies. In a small study of 12 veterans with PTSD and 12 without PTSD, neuroimaging was done while each group was exposed to heat stimuli (Geuze, Westenberg, Jochims, et al., 2007). Subjects rated pain using an NRS of 0 to 100. Compared to controls, individuals with PTSD rated the heat stimuli as being significantly less painful, and neuroimaging revealed an analgesic response and altered pain processing in certain brain areas.

In another small, double-blind, crossover study, eight Vietnam veterans with PTSD and a control group of eight veterans without PTSD, matched for combat severity, watched a videotape of dramatized combat (Pitman, van der Kolk, Orr, et al., 1990). None were receiving opioid analgesics. The tape was viewed by each group while under the effects of naloxone hydrochloride or placebo. In the placebo condition, those with PTSD experienced a 30% decrease in pain ratings, but no decreases in pain ratings occurred in the naloxone condition, which suggests that naloxone blocked endogenous opioid analgesia. The veterans without PTSD showed no decrease in pain ratings under either condition. It appeared that veterans with PTSD had opioid-mediated analgesic responses (endogenous opioids). Thus, decreased sensitivity to pain in patients with PTSD appears to occur briefly when a patient is exposed to acute pain or something that triggers memories of or reminds the patient of the original trauma.

Patients with PSTD and chronic pain tend to have increased sensitivity to pain. The mechanisms most often proposed to understand the cooccurrence of chronic pain and PTSD are shared vulnerability and mutual maintenance (Asmundson, Coons, Taylor, et al., 2002). For example, in terms of the concept of shared vulnerability, it seems possible that anxiety sensitivity is shared by patients with both PTSD and chronic pain. With respect to the concept of mutual maintenance, it seems possible that certain cognitive or affective components of chronic pain exacerbate symptoms associated with PTSD and that certain affective and behavioral components of PTSD exacerbate symptoms associated with chronic pain.

Analysis of pain intensity was compared in three groups, all members of which had chronic pain; but one group had accident-related pain and high PTSD symptoms, one group had accident-related pain and few or no symptoms of PTSD, and the third group had pain that was not accident related and had no symptoms of PTSD (Geisser, Roth, Bachman, et al., 1996). Patients with accident-related pain and strong PTSD symptoms reported higher levels of pain than did the other two groups.

To examine sensitivity to pain, three groups of subjects—32 outpatients with combat- and terror-related PTSD, 29 outpatients with anxiety disorder, and 20 healthy individuals—were compared (Defrin, Ginzburg, Solomon, et al., 2008). The first two groups were randomly selected from an outpatient psychiatric clinic and contacted by telephone to request participation in the study. Higher rates of chronic pain, more intense chronic pain, and more painful body regions were found in the subjects with PTSD than in the other two groups. Further, the greater the severity of PTSD, the greater the severity of chronic pain.

A review of the literature also confirms this finding (Smith, Egert, Winkel, et al., 2002). In addition to being at high risk for PTSD, individuals with persistent pain who do develop PTSD are also likely to experience more intense and pervasive pain than those who do not develop PTSD.

In the study by Defrin and others (2008), differences emerged when the groups were tested for measurement of warmth, cold, light touch, and heat-pain thresholds and for responses to acute suprathreshold heat and mechanical stimuli. Although the patients with PTSD were less sensitive to thresholds for warmth, cold, touch, and heat-pain than the other two groups, they found the suprathreshold heat and mechanical stimuli much more intense than did the other groups. The researchers offered several possible explanations for this paradoxical finding, such as altered sensory processing in subjects with PTSD, and recommended further research. Other researchers suggest that the increased sensitivity to suprathreshold pain may reflect in part that the subjects were exposed to this type of pain for a longer time (repeated painful stimuli) in the experimental situation than when tested for the heat-pain threshold in which they were simply asked to identify the point at which the heat stimulus became painful (Asmundson, Katz, 2008).

A study of 145 individuals with diagnoses of HIV/AIDS who also had persistent pain was conducted to examine the relationship between PTSD and pain (Smith, Egert, Winkel, et al., 2002). In this sample, approximately half (51.8%) had diagnoses of PTSD. Individuals with PTSD reported higher levels of pain at its worst, worse physical and mental health, and higher levels of pain that interfered with daily activities and mood than did those without PTSD. One obvious implication of the study is that individuals with HIV should be assessed for symptoms of PTSD.

A study of 93 patients diagnosed with the chronic pain condition of fibromyalgia syndrome (FMS) was undertaken to determine the prevalence of PTSD-like symptoms (not the diagnostic category of PTSD) and to evaluate the relationship between PTSD symptoms, FMS symptoms, and disability (Sherman, Turk, Okifuji, 2000). More than half (56%) of the sample reported significant levels of PTSD-like symptoms, and this group reported significantly greater levels of pain, interference with life, emotional distress, difficulty adapting to FMS, depressive symptoms, and disability than did individuals without clinically significant levels of PTSD symptoms. Another study of PTSD and FMS yielded similar results. The frequency of occurrence of PTSD was examined in 77 patients with FMS, and 57% were found to have significant levels of PTSD symptoms (Cohen, Neumann, Haiman, et al., 2002). The most frequently reported traumatic event associated with PTSD was the unexpected death of a loved one (as is true for the other patients with PTSD). These patients did not regard their FMS as a traumatic event.

Clearly PTSD symptomatology is prevalent in individuals with FMS and probably has a negative impact on coping with FMS, suggesting that interventions for the treatment of PTSD, such as stress management, may be helpful for patients with FMS. These interventions overlap with interventions for persistent pain and probably can be incorporated easily in a pain management program for patients with FMS.

The relationship between analgesic use and PTSD was studied in 173 African-Americans who were outpatients at a mental health center (Schwartz, Bradley, Penza, et al., 2006). Those with PTSD, 43.5% of the sample, used significantly more opioid and nonopioid analgesic medications than did those who did not have PTSD. Of the patients with PTSD, 68% were prescribed analgesics, and 59% received opioids, whereas only 51% of patients without PTSD received analgesics, 42% of them receiving opioids. (Pain ratings were not reported in this article.) Patients receiving opioids had the highest severity of PTSD symptoms. PTSD was notably underdiagnosed in this group of patients; only 6.5% of the total sample had documented diagnoses of PTSD.

Chronic pain and PTSD often coexist, and PTSD exacerbates chronic pain but is frequently underdiagnosed. It is therefore critical to assess patients with chronic pain for the symptoms of PTSD and to assess patients with PTSD for chronic pain. This makes it possible to recognize and arrange for both the pain and the PTSD to be addressed. A convenient screening tool for PTSD in the primary care setting is the Primary Care PTSD (PC-PTSD) screen shown in Form 4-3 (Prins, Quimette, Kimerling, et al., 2003). It is psychometrically sound, identifying PTSD in 78% of 188 men and women in a primary care setting at the Veterans Administration. It is brief, written at an eighth grade reading level, and easy to score. It consists of four yes/no questions, and a positive answer to two or more items suggests the need for further assessment of PTSD.

Based on the previous discussion of PTSD, suggestions for assessment of pain and PTSD, along with possible prevention of or decrease in symptoms of PTSD are as follows:

To summarize the implications of these assessment suggestions, when PTSD or PTSD symptomatology and pain cooccur, a cognitive-behavioral therapy program is appropriate but will have to be modified to address both problems (Asmundson, Coons, Taylor, et al., 2002). No data yet exist to suggest that either PTSD or chronic pain should be treated first when they cooccur. Thus, treating the conditions simultaneously seems indicated.

Specific treatment of coexisting pain and PTSD is beyond the scope of this chapter, but DeCarvalho and Whealin (2006) suggest additional practical ideas that can be quickly initiated after PTSD is suspected. Educate the patient about the symptoms of PTSD, and provide written materials when possible. One short patient education sheet about chronic pain and PTSD can be obtained from http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_chronic_pain_and_patients.html?opm=1&rr=rr102&srt=d&echorr=true. When possible, give returning service members with pain and possible PTSD the option of attending a military or a civilian pain clinic. This may reduce their fear of stigmatization. Relaxation therapy may be helpful, although some patients find that it allows for disturbing intrusive thoughts.

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