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Cited by 27Mindfulness and Compassion InterventionsMusculoskeletal pain and rehabilitationPosttraumatic Stress Disorder Research

Acceptance and Commitment Therapy for Chronic Pain: Does Post-traumatic Stress Disorder Influence Treatment Outcomes?

Open access
Herbert, Matthew S, Malaktaris, Anne L, Dochat, Cara, Thomas, Michael L, Wetherell, Julie Loebach, Afari, Niloofar·2019·Pain Medicine
DOI 10.1093/pm/pny272
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Abstract

Objective The aim of this study was to determine whether post-traumatic stress disorder (PTSD) moderates treatment outcomes in Acceptance and Commitment Therapy for chronic pain. Design Longitudinal. Setting Veterans Affairs San Diego Healthcare System. Subjects A total of 126 veterans with chronic pain participating in an Acceptance and Commitment Therapy intervention for chronic pain. A structured clinical interview was used at baseline to designate PTSD-positive (N = 43) and -negative groups (N = 83). Methods Linear mixed-effects models to determine whether PTSD moderated change in pain interference, pain severity, pain acceptance, depressive symptoms, or pain-related anxiety at post-treatment and six-month follow-up. Results Participants with co-occurring PTSD reported greater pain interference, pain severity, depressive symptoms, and pain-related anxiety at baseline. PTSD status did not moderate treatment effects post-treatment. Rather, there were significant improvements on all study measures across groups (P < 0.001). PTSD status moderated change in depressive symptoms at six-month follow-up (P < 0.05). Specifically, participants with chronic pain alone demonstrated improvement in depressive symptoms compared with pretreatment levels, whereas participants with PTSD regressed to pretreatment levels. Conclusions PTSD status did not significantly affect treatment outcomes, with the exception of depressive symptoms at six-month follow-up. Overall, Acceptance and Commitment Therapy for chronic pain appears helpful for improving outcomes among veterans with co-occurring PTSD; however, veterans with co-occurring PTSD may experience fewer long-term gains compared with those with chronic pain alone.

Integrity signals

Registry

Crossref · 10.1093/pm/pny272

Cites

47 of 47 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

4 of 17 cited sources checked · 4 supported · 0 flagged

  • Premisecitation

    Higher pain-related acceptance is associated with better physical and psychological functioning among trauma-exposed individuals.

    “higher pain-related acceptance has been associated with better physical and psychological functioning among traumaexposed individuals [25].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [25] Cook, 2015, Chronic pain acceptance incrementally predicts disability in polytrauma-exposed veterans at baseline and 1-year follow-up, Behav Res Ther source
  • Premisecitation

    The mutual maintenance model of CP and PTSD, which suggests that CP and PTSD reciprocally exacerbate the symptoms and distress associated with each condition, is supported by several studies.

    “Several studies have supported the mutual maintenance model of CP and PTSD [4,39], which suggests that CP and PTSD reciprocally exacerbate the symptoms and distress associated with each condition [40].”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [4] Asmundson, 2002, PTSD and the experience of pain: Research and clinical implications of shared vulnerability and mutual maintenance models, Can J Psychiatry source
    • cites [39] Cho, 2011, Daily functioning in chronic pain: Study of structural relations with posttraumatic stress disorder symptoms, pain intensity, and pain avoidance, Korean J Pain source
    • cites [40] Sharp, 2001, Chronic pain and posttraumatic stress disorder: Mutual maintenance?, Clin Psychol Rev source
  • Findingown data

    Among participants with co-occurring PTSD, PTSD symptom severity significantly improved from baseline through post-treatment.

    “Among participants with co-occurring PTSD, PTSD symptom severity significantly improved from baseline through post-treatment, with the greatest improvements on the avoidance subscale.”
    • Also stated in: § Discussion · plain
      “In our exploratory analyses, we found that PTSD symptom severity was significantly decreased at post-treatment among participants with co-occurring PTSD.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Participants with co-occurring PTSD reported greater PTSD symptom severity at baseline compared with participants with chronic pain alone.

    “At the baseline assessment, participants with co-occurring PTSD reported greater pain interference, pain intensity, depressive symptoms, pain-related anxiety, and PTSD symptom severity compared with participants with CP alone (P < 0.05).”
    Quote in the paperNot a substantial claim
  • Findingown data

    Veterans with co-occurring PTSD in this sample did not report greater opioid use relative to those with CP alone.

    “Contrary to some past findings [14] but consistent with others [19], veterans with co-occurring PTSD in this sample did not report greater opioid use but did report greater psychotropic medication use relative to those with CP alone.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 13
  • May combine two claims. 17
  • The quote only partly states this claim. 1

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The PHQ-9 is a reliable and valid indicator of depressive symptom severity.

    “The measure is a reliable and valid indicator of depressive symptom severity with good internal consistency (Cronbach's alpha ¼ 0.89) and concurrent validity with measures of functional impairment [34].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [34] Kroenke, 2001, The PHQ-9: Validity of a brief depression severity measure, J Gen Intern Med source

  • May combine two claims.

    Premisecitation

    A previous investigation examined change in quality of life among adults with chronic pain and probable PTSD participating in a multidisciplinary pain rehabilitation program; however, PTSD diagnosis was not confirmed via structured clinical interview, no pain-specific outcomes were reported post-treatment, and the varied components of a multidisciplinary treatment make it difficult to compare with

    “A previous investigation examined change in quality of life among adults with chronic pain and probable PTSD participating in a multidisciplinary pain rehabilitation program; however, PTSD diagnosis was not confirmed via structured clinical interview, no pain-specific outcomes were reported post-treatment, and the varied components of a multidisciplinary treatment make it difficult to compare with”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [19] Andersen, 2014, Chronic pain patients with possible co-morbid post-traumatic stress disorder admitted to multidisciplinary pain rehabilitation-a 1-year cohort study, Eur J Psychotraumatol source

  • May combine two claims.

    Findingown data

    When considering individual items, the largest decreases were found for physical reactions to traumatic memories (question 5), loss of interest in enjoyable activities (question 9), and worry about the future (question 12).

    “When considering the individual items, the largest decreases were found for physical reactions to traumatic memories (question 5), loss of interest in enjoyable activities (question 9), and worry about the future (question 12).”
    Quote in the paperNot a substantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    There were no significant differences between participants with and without co-occurring PTSD on improvements in pain interference, pain severity, pain acceptance, depressive symptomology, or pain-related anxiety during the treatment period.

    “There were no significant differences in outcomes between participants with and without co-occurring PTSD at post-treatment.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The moderating effect of PTSD diagnostic status on change in pain-related anxiety approached significance, with follow-up tests showing a similar pattern of greater improvement in the PTSD-negative group relative to the PTSD-positive group.

    “We also found that the moderating effect of PTSD diagnostic status on change in painrelated anxiety approached significance, with follow-up tests showing a similar pattern of greater improvement in the PTSD-negative group relative to the PTSD-positive group.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    We observed the strongest impact on the avoidance subscale, followed by the re-experiencing and hyperarousal subscales.

    “We observed the strongest impact on the avoidance subscale (B ¼ -1.74, SE ¼ 0.73), followed by the re-experiencing (B ¼ -0.89, SE ¼ 0.48) and hyperarousal subscales (B ¼ -0.73, SE ¼ 0.47).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Although veterans with PTSD evidenced relatively smaller gains in pain acceptance, this interaction was not statistically significant.

    “Although veterans with PTSD evidenced relatively smaller gains in pain acceptance, this interaction was not statistically significant.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Participants with PTSD were significantly younger and more likely to use psychotropic medications.

    “Participants with PTSD were significantly younger and more likely to use psychotropic medications.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    PTSD status did not significantly affect treatment outcomes, with the exception of depressive symptoms at six-month follow-up.

    “PTSD status did not significantly affect treatment outcomes, with the exception of depressive symptoms at six-month follow-up.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    We considered therapist effects in post hoc analyses, and results remained consistent.

    “We considered therapist effects in post hoc analyses, and results remained consistent.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    There were no group differences in sex, race/ethnicity, education, treatment delivery type, opioid use, NSAID use, muscle relaxant use, type of pain condition, or attrition.

    “There were no group differences in sex, race/ethnicity, education, treatment delivery type, opioid use, NSAID use, muscle relaxant use, type of pain condition, or attrition (PTSD positive: N ¼ 12, 28%; PTSD negative: N ¼ 30, 36%).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The PCL-C has high test-retest reliability and validity for diagnosis of PTSD using the SCID.

    “The PCL-C has high test-retest reliability (0.96) and validity (kappa ¼ 0.64) for diagnosis of PTSD using the SCID [38].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [38] Weathers, 1993 source

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Analyses were conducted with an intent-to-treat (ITT) sample.

    “Analyses were conducted with an intent-to-treat (ITT) sample, defined as participants who were randomized to a treatment condition and completed the baseline assessment.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The PASS-20 is a valid and reliable measure of anxiety symptoms in pain populations.

    “The PASS-20 is a valid and reliable measure of anxiety symptoms in pain populations with high internal consistency (Cronbach's alpha ¼ 0.81) and an excellent correlation between the short and long form (r ¼ 0.97) [36].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [36] Roelofs, 2004, Psychometric evaluation of the Pain Anxiety Symptoms Scale (PASS) in chronic pain patients, J Behav Med source

  • May combine two claims.

    Interpretationreasoning

    The change in PTSD symptom severity associated with ACT for CP was either at the lower end of clinically meaningful or not clinically meaningful, depending on the criteria.

    “Thus, depending on the criteria, the change in PTSD symptom severity associated with ACT for CP was either at the lower end of clinically meaningful or not clinically meaningful.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The Brief Pain Inventory Short Form Interference Scale and pain severity subscale show high internal consistency and are sensitive to treatment change.

    “Both subscales show high internal consistency (Cronbach's alpha: pain severity ¼ 0.85; pain interference ¼ 0.88) and are sensitive to treatment change [32].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [32] Tan, 2004, Validation of the Brief Pain Inventory for chronic nonmalignant pain, J Pain source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The CPAQ has good internal consistency.

    “The CPAQ measures how much patients have adjusted to pain as part of their identity and lifestyle and consists of 20 items scored on a seven-point Likerttype scale with good internal consistency [33].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [33] McCracken, 2004, Acceptance of chronic pain: Component analysis and a revised assessment method, Pain source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Self-report measures were administered by trained research assistants blinded to each participant's treatment condition.

    “Self-report measures were administered by trained research assistants blinded to each participant's treatment condition at baseline, midtreatment, post-treatment, three-month follow-up, and six-month follow-up.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Participants meeting eligibility requirements were randomly assigned to receive either in-person or videoteleconferencing ACT for CP.

    “Participants meeting eligibility requirements were then randomly assigned to receive either in-person or videoteleconferencing ACT for CP.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    A recent study suggested a meaningful clinically important difference on the PCL between 5.7 and 10.2 points with a midpoint of 7.9 points, whereas other studies have used a cutoff of 10-12 points.

    “A recent study suggested a meaningful clinically important difference on the PCL between 5.7 and 10.2 points with a midpoint of 7.9 points [43], whereas other studies have used a cutoff of 10-12 points [44].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [43] Stefanovics, 2018, Minimal clinically important differences (MCID) in assessing outcomes of post-traumatic stress disorder, Psychiatr Q source
    • cites [44] Steenkamp, 2015, Psychotherapy for military-related PTSD: A review of randomized clinical trials, JAMA source

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    This is a reasonable outcome for an intervention that focuses on increasing activity in the service of values.

    “This is a reasonable outcome for an intervention that focuses on increasing activity in the service of values.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Depression and PTSD frequently co-occur.

    “Depression and PTSD also frequently co-occur [41], and depression exacerbates adverse outcomes among veterans with PTSD [42].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [41] Roth, 2008, The relation of post-traumatic stress symptoms to depression and pain in patients with accident-related chronic pain, J Pain source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The study did not use the gold standard for the diagnosis of PTSD, the Clinician Administered PTSD Scale-IV.

    “Finally, we did not use the gold standard for the diagnosis of PTSD, the Clinician Administered PTSD Scale-IV.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The study sample consisted entirely of veterans with CP, and therefore results may not completely generalize to civilian samples.

    “Second, the study sample consisted entirely of veterans with CP, and therefore results may not completely generalize to civilian samples.”
    Quote in the paperNot a substantial claim
24 of 24

  • The paper relies on this without support.

    No study has assessed the influence of PTSD in a standalone psychosocial intervention for CP, nor determined whether PTSD symptom severity is reduced in such an intervention.

    “To the best of our knowledge, no study has assessed the influence of PTSD in a standalone psychosocial intervention for CP, nor has a study determined whether PTSD symptom severity is reduced in a standalone psychosocial intervention for CP.”

  • The paper relies on this without support.

    The observed improvements in outcomes are attributable to ACT treatment rather than to other factors such as natural recovery or regression to the mean.

    “Overall, Acceptance and Commitment Therapy for chronic pain appears helpful for improving outcomes among veterans with co-occurring PTSD; however, veterans with co-occurring PTSD may experience fewer long-term gains compared with those with chronic pain alone.”
2 of 2

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

  • PTSD-positive muscle-relaxant percentage is incorrect

    Minor

    The table lists 14 muscle-relaxant users among 43 PTSD-positive participants, which is 32.56%, not 17%.

    Reported 17 · recomputed 32.55814

  • PTSD-negative muscle-relaxant percentage is incorrect

    Minor

    The table lists 12 muscle-relaxant users among 83 PTSD-negative participants, which is 14.46%, not 28%.

    Reported 28 · recomputed 14.457831

2 of 2

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Weathers, 1993, The PTSD Checklist (PCL): Reliability, Validity, and Diagnostic Utility. Annual Convention of the International Society for Traumatic Stress Studies

Cited by

Sorted by citations

Related

Authors
Herbert, M. S., Malaktaris, A. L., Dochat, C., Thomas, M. L., Wetherell, J. L., & Afari, N.
Affiliations
  • University of California San Diego (US)
  • San Diego State University (US)
Corresponding author
Herbert, Matthew S
ORCID
Venue
Pain Medicine
Publisher
Oxford University Press (OUP)
Published
2019-01-02
Volume
20
Issue
9
Pages
1728-1736
ISSN
  • 1526-2375 (ISSN-L)
  • 1526-4637
DOI
10.1093/pm/pny272
OpenAlex
W2906884691
Semantic Scholar
0d11f3289a9e1c78da089bc965989e0eee5c0daf
Cited by
27
References
44
Citations by year
2026: 5 · 2025: 4 · 2024: 1 · 2023: 6 · 2022: 3 · 2021: 3 · 2020: 5
FWCI
2.34
Type
journal article
Language
en
Open access
Licence
academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model (vor, 365 d)
Locations
  • Pain Medicine (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • Veterans Affairs Rehabilitation (F6891R)
  • Office of Academic Affiliations, Department of Veterans Affairs
Topics
  • Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
  • Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
  • Social Sciences › Psychology › Clinical Psychology › Posttraumatic Stress Disorder Research
Keywords
acceptance and commitment therapy, chronic pain, post-traumatic stress disorder, veterans, treatment moderators, pain interference, pain intensity, pain acceptance, depressive symptoms, pain-related anxiety
MeSH terms
Adult, Aged, Female, Humans, Longitudinal Studies, Male, Middle Aged, Stress Disorders, Post-Traumatic, Veterans, Chronic Pain, Pain Management, Acceptance and Commitment Therapy

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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

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