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Posttraumatic Stress Symptoms and the Diathesis-Stress Model of Chronic Pain and Disability in Patients Undergoing Major Surgery

Martin, Andrea L. MA*; Halket, Eileen RN; Asmundson, Gordon J.G. PhD; Flora, David B. PhD*; Katz, Joel PhD* †

doi: 10.1097/AJP.0b013e3181e15b98
Original Articles

Objectives: To (1) use structural equation modeling (SEM) to examine relationships proposed in Turk's diathesis-stress model of chronic pain and disability as well as (2) investigate what role, if any, posttraumatic stress symptoms (PTSS) play in predicting pain disability, relative to some of the other factors in the model.

Methods: The study sample consisted of 208 patients scheduled for general surgery, 21 to 60 years of age (mean age=47.18 y, SD=9.72 y), who reported experiencing persistent pain for an average of 5.56 years (SD=7.90 y). At their preadmission hospital visit, patients completed the Anxiety Sensitivity Index, Pain Catastrophizing Scale, Pain Anxiety Symptoms Scale-20, Pain Disability Index, posttraumatic stress disorder Checklist, and rated the average intensity of their pain (0 to 10 numeric rating scale). SEM was used to test a model of chronic pain disability and to explore potential relationships between PTSS and factors in the diathesis-stress model.

Results: SEM results provided support for a model in which anxiety sensitivity predicted fear of pain and catastrophizing, fear of pain predicted escape/avoidance, and escape/avoidance predicted pain disability. Results also provided support for a feedback loop between disability and fear of pain. SEM analyses provided preliminary support for the inclusion of PTSS in the diathesis-stress model, with PTSS accounting for a significant proportion of the variance in pain disability.

Discussion: Results provide empirical support for aspects of Turk's diathesis-stress model in a sample of patients with persistent pain. Findings also offer preliminary support for the role of PTSS in fear-avoidance models of chronic pain.

*Department of Psychology, York University

Department of Anesthesia, The University of Toronto, Toronto, Ontario

Department of Psychology, University of Regina, Regina, Sakatchewan, Canada

Supported by a CIHR Canada Research Chair in Health Psychology (J.K.); a CIHR Investigator Award and NET Grant (G.J.G.A.); as well as a CIHR Doctoral Award and a CIHR Strategic Training Fellowship in Pain: Molecules to Community (A.L.M.).

Reprints: Joel Katz, PhD, Department of Psychology, Behavioral Sciences Building, York University, 4700 Keele Street, Toronto, Ontario M3J 1P3, Canada (e-mail:

Received for publication June 4, 2009; revised February 15, 2010; accepted February 17, 2010

© 2010 Lippincott Williams & Wilkins, Inc.