Staff Voices - Chronic Pain and PTSD in the Military

Staff Voices - Chronic Pain and PTSD in the Military

Former Army Captain Darisse Smith was deployed to Iraq from 2005-2006 as a Kiowa helicopter pilot. “I lived in pain the entire time that I was deployed,” Smith said in a blog she created about her experiences. “My lower back was hurting, mostly due to the vibrations of the aircraft I was flying and inadequate seating.” Smith ended up with four back surgeries, followed by a spinal cord stimulator implant.

Smith is not alone in her experiences. Chronic pain is a significant problem in military populations, especially for service members who have deployed in support of Operations Iraqi Freedom and Enduring Freedom.

  • Chronic pain is the most common reason for OIF and OEF medical evaluation .
  • Spinal pain is the most common reason for medical boards across military services.
  • Of veterans that entered the VA system between 2005 and 2008, 48% reported chronic pain.

Risk factors for the development of chronic pain in deployed service members include heavy packs that create shearing forces that cause lower back pain, operational driving and flight (especially all-terrain vehicles and rotary wing aircraft), and the psychological risks of combat.

Chronic pain and posttraumatic stress disorder frequently occur together in military and civilian populations.  A recent study of veterans receiving treatment for PTSD found that 66 percent also had chronic pain diagnoses. Similarly, 47 percent of OIF/OEF veterans seeking care for neck and back pain also met diagnostic criteria for PTSD.

One model that has been proposed to explain the comorbidity between the two disorders is that of shared vulnerability. The shared vulnerability model suggests that certain individuals may be genetically predisposed to develop both PTSD and chronic pain because of heightened anxiety sensitivity. Anxiety sensitivity refers to a tendency to fear anxiety symptoms based on the belief that they have harmful consequences (e.g., viewing shortness of breath as indicative of a heart attack). Anxiety sensitivity has been found to be elevated in patients with PTSD and in some samples of patients with chronic pain.

Another model that has received support is the mutual maintenance model. This model proposes that certain components of chronic pain maintain or exacerbate PTSD symptoms, and that some components of PTSD symptoms worsen chronic pain. For example, a patient with combat-related PTSD and chronic back pain described experiencing severe back spasms after seeing a trash bag at the side of the road that reminded him of an IED. In this instance, his PTSD caused an exacerbation of his chronic pain.

In military populations, another factor that often links PTSD and chronic pain is the presence of traumatic brain injury (TBI). A recent study of OIF/OEF veterans receiving treatment at a polytrauma rehabilitation center found that 42 percent had PTSD, chronic pain, and persistent postconcussive symptoms. It was more common for patients to have all 3 disorders combined than to have any one in isolation. The researchers called this combination the Polytrauma Clinical Triad. The ways in which the three disorders interact require further study in order to provide the most effective treatment.

Many patients with chronic pain and PTSD turn to prescription pain medication abuse to cope with their symptoms. A recent study of OIF/OEF veterans with pain found that veterans with PTSD were significantly more likely to be prescribed opioid medications, as well as to report risky use of this medication (for example, taking more than prescribed or taking combinations of opioids and benzodiazepines). Veterans with PTSD who received opioid medications were also more likely to experience adverse outcomes, such as accidents, overdoses, and suicide.

Darisse Smith, who developed PTSD  and depression after her pain persisted, explained, “I swallowed lots of pills—Oxycontin, Vicodin, all kinds of opiates—and I just hid all the negative emotions I was having. PTSD symptoms started to creep up, and I hid them with pills. Depression, thoughts of suicide, plans for suicide, very close to ending my life, and I just used pills against it.”

Some military medical centers are beginning to design treatment programs that address PTSD and pain simultaneously. The South Texas Research Organizational Network Guiding Studies on Trauma and Resilience (STRONGSTAR) Consortium recently began a clinical trial to examine the efficacy of a combined Prolonged Exposure (PE) for PTSD and chronic pain treatment in an active duty military population. Their protocol integrates an abbreviated PE treatment protocol into pain treatment for orthopedic  trauma patients with comorbid pain and PTSD.

Darisse Smith received effective treatment for her pain, depression, and PTSD. Now a civilian, she shares her story around the country. “I vowed to get the word out about my personal story so that others facing similar troubles could be encouraged and so that medical professionals could see the impact of injury and mental illness,” said Smith.

For further information on chronic pain and related psychological issues, military members and veterans can go to


Asmundson, G, Coons, M.J., Taylor, S., & Katz, J. (2002). PTSD and the experience of pain: research and clinical implications of shared vulnerability and mutual maintenance models. Canadian Journal of Psychiatry, 47, 930-937.

Cohen, S.P., Brown, C., Kurihara, C., Plunkett, A., Nguyen. C., & Strassels, S.A. (2010). Diagnoses and factors associated with medical evacuation and return to duty for service members participating in Operation Iraqi Freedom or Operation Enduring Freedom: a prospective cohort study. Lancet, 375, 301-309.

Cohen, S.P., Gallagher, R.M., Davis, S.A., Griffith, S.R., & Caragee, E.J. (2011). Spine-area pain in military personnel: A review of epidemiology, etiology, diagnosis, and treatment. The Spine Journal, in press. Epub ahead of print retrieved July 1, 2012 from

Dunn, A.S., Julian, T., Formolo, L.R., Green, B., & Chicone, D.R. (2011). Preliminary analysis of posttraumatic stress disorder screening within specialty clinic setting for OIF/OEF veterans seeking care for neck or back pain. Journal of Rehabilitation Research & Development, 48, 493-502.

Lew, H.L., Otis, J.D., Tun, C, Kerns, R.D., Clark, M.E, & Cifu, D.X. (2009). Prevalence of chronic pain, posttraumatic stress disorder and persistent postconcussive symptoms in OIF/OEF veterans: Polytrauma clinical triad. Journal of Rehabilitation Research and Development, 46, 697-702.

McGeary, D., Moore, M., Vriend, C., Peterson, A., & Gatchel, R.J. (2011). The evaluation and treatment of comorbid pain and PTSD in a military setting: An overview. Journal of Clinical Psychology in Medical Settings, 18, 155-163.

Seal, K.H., Shi, Y., Cohen, G., Maguen, S., Krebs, E.E., & Neylan, T.C. (2012). Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. Journal of the American Medical Association, 307, 940-947.

Shipherd, J.C., Keyes, M., Jovanovic, T., Ready, D.J., Baltzell, D., Worley, V. Gordon-Brown, V., Hayslett, C., & Duncan, E. (2007). Veterans seeking treatment for posttraumatic stress disorder: What about chronic pain? Journal of Rehabilitation Research & Development, 44, 153-166.

Smith, Darisse. (2010, January 7) Army vet talks chronic pain. [Video file]. Retrieved from

Smith, Darisse (2012, May 24). Email correspondence.