Psychology
2011. Vol.2, No.7, 700-705
Copyright © 2011 SciRes. DOI:10.4236/psych.2011.27107
Combat Posttraumatic Stress Disorder and Chronic Pain
Braš Marijana1, Ana Havelka Meštrović2, Mladen Havelka3,
Morana Bilić3, Zoran Lončar4
1Department of Psychiatry, University Hospital Zagreb, Zagreb, Croatia;
2Department of Psychiatry, University Hospital Dubrava, Dubrava, Croatia;
3Department of Health Psychology, University of Applied Health Studies, Zagreb, Croatia;
4Department of Traumatology, University Hospital Zagreb, Zagreb, Croatia.
Received May 26th, 2011; revised July 4th, 2011; accepted August 8th, 2011.
Objective: chronic post-traumatic stress disorder (PTSD) is commonly accompanied by depression and anxiety
as comorbidity. The psychological states, such as depression and anxiety, can increase pain symptoms. A num-
ber of recent research results have shown that chronic post-traumatic stress disorder and chronic pain frequently
co-occur and similar mechanisms have been identified that sustain both conditions. Method: the data were col-
lected from medical records of 184 Croatian war veterans diagnosed with chronic PTSD and chronic pain as
co-morbid condition. On the basis of medical records, interviews and different types of self-assessment ques-
tionnaires the inter-relationship between chronic pain and chronic PTSD was analysed. PTSD was assessed by
CAPS (Clinical Administered Posttraumatic Scale) and M-PTSD (Mississippi Scale for combat PTSD), whereas
pain was measured by Melzack-McGill Pain Questionnaire—short form (MPQ-SF) and Visual Analogue Scale
(VAS). Results: the combat veterans with PTSD reported in descending order the following: pain in the head,
back pain, widespread pain and limb pain. The patients with chronic PTSD had significantly higher total pain
scores as well as affective and sensory pain components when compared to the patients without PTSD. Anxiety
and depression were also highly correlated with pain. The relation between pain severity and depression was
mediated by the severity of PTSD. Conclusion: our findings are directed towards the need for multidisciplinary
approach in the treatment of patients with chronic PTSD and co-morbid chronic pain, which will optimize
treatment and result in more cost-effective care.
Keywords: Chronic Pain, Posttraumatic Stress Disorder, Melzack-McGill Pain Questionnaire, Depression,
Anxiety
Introduction
Posttraumatic stress disorder (PTSD) includes psychological
imbalance and neurophysiologic dysfunctions resulting in be-
haviour changes that significantly affect the relation between an
individual and his social and natural environment. Clinically,
the disorder is manifested through the triad of symptoms, i.e.
repetition, avoidance and excitation, commonly accompanied
by anxiety and depression. Based on the IASP (International
Association for the Study of Pain) pain is defined as a discom-
forting sensory and emotional experience related to the actual
or possible tissue damage or mere description of such a damage
(Keefe et al., 2004). Pain can appear even when there is no tis-
sue injury, it can be experienced as intense in minor injuries, or
can be mild upon sustaining massive injuries. The influence of
psychological factors on pain experience is referred to as psy-
chogenic pain, the pain that should by no means be differenti-
ated from the so-called “real” pain, i.e. the one caused by inju-
ries or pathological processes in tissues. Significant correlation
has been found between chronic pain and psychological disor-
ders. The model of the development of chronic pain is similar
to the model that describes the CNS plasticity in its response to
psychological trauma and is therefore strongly related to
chronic PTSD (Otis et al., 2003). Similar to chronic PTSD, there
is an increasing evidence indicating the patient’s hereditary
predisposition to the development of chronic pain, which, fol-
lowing the continuing and strong nociceptive stimuli from the
periphery resulting in neuroplastic changes in the basal ganglia
and the cortex, can also serve as a model for the development
of chronic posttraumatic stress disorder. The most recent stud-
ies have shown that pain is one of the most common symptoms
in PTSD patients, regardless of the nature of traumatic experi-
ence. Sudden change in life habits upon sustaining a trauma,
together with the possible posttraumatic reaction, can signify-
cantly affect the ability of coping with pain. Geuze et al. in their
study of 12 veterans with PTSD and 12 veterans without PTSD
find diminished sensitivity to pain in PTSD patients (Geuze et
al., 2007), specifically in terms of altered processing of pain in
brain regions related to affective and cognitive pain processing,
e.g. the insula, the hypocampus, the amygdala and the ventro-
lateral prefrontal cortex. Other studies have reported about
similar findings (Nemeroff et al., 2006; Lanius et al., 2003;
Shin et al., 2005). However, there are also studies showing that
in individuals with borderline personality structure the sensi-
tiveity to pain is altered, although not in PTSD patients
(Schmahl et al., 2008). Defri et al. have recently reported about
the first systematic and quantitative evaluation of the perception
of pain in PTSD (Defrin et al., 2008). The PTSD patients
showed higher levels of chronic pain, much more intense
chronic pain, and greater number of painful regions in the body
than the control study group. The severity of PTSD symptoms
correlated with the severity of painful symptoms. The pain
threshold in PTSD patients was higher than in the control and
anxiety patient groups, but the pain stimulus above the pain
threshold was experienced much more intensely than by other
study group subjects. The question is raised here whether it is
about the altered sensory processing or the way in which the
PTSD patients interpret and respond to painful stimuli. The

B. MARIJANA ET AL. 701
extent of PTSD in our study patients was measured by
M-PTSD questionnaire. For reasons of assessment of correla-
tion between the PTSD extent, pain and other co-morbid states,
the patients were divided into two groups: the group with
strongly expressed PTSD (above the cut-off point in the M-
PTSD questionnaire), and those without pain, although all of
the patients have been for several years psychiatrically treated
for PTSD. The assumption is that in a certain number of Croa-
tian war veterans the therapy has resulted in diminishing of
symptoms and the fact has also been taken into consideration
that the PTSD is a chronic disorder with exacerbations and that
not all the patients are in the same mental states at the same
time. Other studies have also shown that the PTSD symptoms
occur more often in individuals with headaches when compared
with the general population, assuming that PTSD is a risk factor
for chronic headache (Peterlin et al., 2008). Low back pain is
particularly interesting, since many studies have provided evi-
dence of how psychological variables affect the low back pain
sensations. In a study of low back pain patients six years after
their traffic accident it was observed that pain did not correlate
with the severity of sustained injury and socio-demographic
factors, but rather with the presence of PTSD. The conclusion
was that the psycho-social factors rather than the physical ones,
were predictors of symptomatic low back pain following major
physical trauma (Harris et al., 2007). Besides, the correlation
between pain in the whole body and the fibromyalgia symptom
is of particular interest, since in a significant number of patients
with fibromyalgia the presence of traumatic stressors and PTSD
symptoms has been found (Näring et al., 2007). The studies
report about three basic dimensions of anxiety sensitivity: fear
that the anxiety reactions will be publicly noticed; fear from
losing cognitive control; and fear from somatic sensations. It
has been shown that these are increased in PTSD patients
(Taylor et al., 2001), but only in a limited number of chronic
pain patients. It has also been found that the severity of anxiety
sensitivity is positively correlated with the severity of PTSD
symptoms (Fedor et al., 2000). The aim of our study was to
explore the link between PTSD and chronic pain and comorbid
diagnosis, such as depression and anxiety.
Method
Subjects
The total number of 184 patients participated in the study.
All patients were diagnosed with chronic war induced PTSD
based on DSM-IV and ICD-10. They were treated at Osijek
Clinical Hospital, Department of Psychiatry and all of them
also suffered from co-morbid chronic pain, as defined accord-
ing to the IASP criteria (International Association for the Study
of Pain). The study subjects with the diagnosis of war induced
PTSD were treated from 2004 to 2006. In their medical history
they all reported direct participation in military activities of
Croatian Army, at least for three continuous months, and re-
peated exposure to life threatening situations or wounding dur-
ing the 1991-1995 war. In the selection of study subjects the
following painful syndromes were taken into consideration:
chronic primary pain in the head, chronic lumbo-sacral syn-
drome, chronic cervico-brachial syndrome, chronic peripheral
neuralgia, polyneuropathy, and generalized pain in the whole
body. The sample was randomised by random selection of pa-
tients of both sexes who signed the informed consent for par-
ticipation in the study. There were 21 (11.41%) female and 163
(88.58%) male study subjects. The average age of the study
subjects was 40.54 years, while most of the subjects were 39
years of age. The average age for male study subjects was
40.71 years and it was 39.24 years for the female study sub-
jects.
Study Objectives
The principal study objective was to define the relation be-
tween chronic PTSD and its co-morbid diagnoses, i.e. depress-
sion and anxiety, and co-morbid manifestations of chronic pain,
like for instance lower back pain, pain in the cervical spine,
pain in the head, generalised pain in the entire body and pain in
the extremities.
Methods
Through the psychiatric interview, questionnaires and self-
assessment scales information was collected about different
categories of experience and other characteristics that could con-
tribute to the development of clinical manifestations of PTSD
and chronic pain. The principal characteristics of PTSD clinical
manifestations and chronic pain are the following: increased
sensitivity and excitability of CNS to external stimuli, stressor
features, socio-economic factors following the trauma, social
support, family support, occupational status (employed or re-
tired), sex, age when traumatic event was experienced. It has
been assumed that each of the above factors can affect the in-
creased or decreased risk for the development of chronic PTSD
and chronic pain.
The data were collected retrospectively, except those con-
cerning PTSD symptomatology, actual level of anxiety, depress-
sion and subjective pain experience.
Instruments
1) Specialized structured non-standardized questionnaire for
collection of data on socio-economic status, psychiatric therapy
and duration and treatment of chronic pain.
2) Detailed psychiatric examination of war veterans and
analysis of the available medical records for the purpose of
diagnosing the war induced PTSD based on ICD - 10 (Interna-
tional Classification of Diseases) for mental disorders; M-PTSD
questionnaire (Keane, Caddell, & Taylor, 1986 Mississippi
PTSD questionnaire) for the assessment of the level of PTSD
symptoms. The M-PTSD measures the degree of PTSD expres-
sion following traumatic experience and it consists of 36 Likert
type items.
3) The state of anxiety and its characteristics were measured
by State Trait-Anxiety Inventory Questionnaire (STAI). STAI
(Spilerberger, 1977) scale measures the degree of anxiety as a
state and anxiety as a personality trait and it contains the total
of 40 Likert type items.
4) The assessment of the degree, or level, of depression was
made by Beck depression questionnaire (BDI—Beck Depres-
sion Inventory), containing 21 questions answered only by one
of the 4 offered answers. The instrument contains items that
refer to symptoms, such as hopelessness and irritability, the
feeling of guilt or punishment, and also the physical symptoms
(e.g. fatigue, weight loss, diminished interest in sex, etc.).
5) The assessment of psycho-pathology by SCL-90 ques-
tionnaire (Product Symptom Checklist, Derogatis, 1965)—in-
cludes the test that contains 90 Likert type items and is used as
a measurement of psychological problems and symptoms of
psycho-pathology; for instance, somatisation, obsessive-com-
pulsive disorders, panic attacks, inter-personal sensitivity, de-

B. MARIJANA ET AL. 702
pression, anxiety, hostility, paranoid ideas, psychotic character-
istics.
6) The Melzack-McGill Pain Questionnaire was used for the
assessment of single components of pain, qualitative descrip-
tion of chronic pain and degree of pain intensity (McGill Pain
Questionnaire, MPQ, Melzack, 1975). Today it is one of the
most commonly used instruments in pain studies. Besides
qualitative and quantitative characteristics of pain, the ques-
tionnaire provides insight into the sensory and affective com-
ponents of subjective pain experience.
Statistics
Descriptive statistical analysis was made by the method of
grouping the obtained data, mean values, dispersion values
(standard deviation), correlation coefficients and regression
analysis.
Results
The obtained results showed that the majority of the study
subjects (64.67%) started noticing their mental disturbances
only after the end of the war. Most of them began with the
treatment also after the war, although 48% of the study subjects
reported to have experienced some kind of psychological dis-
orders already during the war. The smallest number of patients,
i.e. only 17 of them, became aware of the problem and com-
menced with the treatment for their disorders already during the
war. The majority of them were 2 to 3 times hospitalized in
psychiatric departments during their treatment. It is interesting
to note that the patients have complained of long-term chronic
pain; some of them have presented with one painful syndrome
and some with more simultaneous painful syndromes; a sig-
nificant number of patients (22.8%) have reported painful sen-
sations in the entire body. These patients are particularly inter-
esting because of neuro-biological and clinical relations be-
tween PTSD symptoms, fibromyalgia, chronic fatigue and de
pression. Pain in the lumbar spine was reported by 47.28% of
study subjects, pain in the cervical spine by 17.93%, pain in the
head by 54.9% and pain in the limbs by 5.4% of study subjects.
With regard to the beginning of mental problems the patients
are divided into 2 groups. The first group are the patients in
whom the disorders started during the war, at some time be-
tween 1990 and 1995, and the second group are those in whom
the disorders appeared after the war, i.e. between 1996 and
2004. The questions about the beginning and location of chronic
pain were treated separately. The patients were also divided
into the group in whom the chronic pain started during the war
and the group in whom it started after the war.
It may be observed that most of the study subjects (75%) re-
port the beginning of chronic pain after the war.
Anxiety is small but significant extent related to pain loca-
tion in the head (r = 0.16; p < 0.05), while the correlation with
pain variables is insignificant. The results further show no sig-
nificant correlation between PTSD and pain location (p > 0.05)
(Table 1).
The study results show also statistically significant positive
relation between the expression of PTSD and different types of
psychological disorders. The more expressed the PTSD symp-
toms the greater is the tendency toward somato-vegetative dis-
orders (r = 0.686; p < 0.01); i.e. the problems pertaining to
anxiety (r = 0,790; p < 0.01) and depression (r = 0.806; p < 0.01)
prevail together with obsessive-compulsive (r = 0.697; p < 0.01)
and phobic disorders (r = 0.643; p < 0.01). Hypersensitivity (r =
0,658; p < 0.01), paranoid (r = 0,542; p < 0.01), and hostile
tendencies (r = 0.742; p < 0.01) increase with the increased
intensity of disorders pertaining to PTSD syndrome. Sleeping
difficulties are also associated with increased intensity of PTSD
syndrome (r = 0.553; p < 0.01).
Affective pain is significantly negatively correlated with the
pain in the whole body (r = –0.21; p < 0.05), and insignificantly
with other pain location variables.
As shown in the above table, sensory pain is significantly
negatively correlated with the location of pain in the whole body
(r = –0.23; p < 0.05), and insignificantly with all other variables
of pain location (Table 2).
As shown in Table 3. The predictor criteria for “sensory
pain”, the “pain in the whole body” has been found as the best
predictor (B = –6.66; p < 0.05), followed by depression (B =
0.26; p < 0.05). The applied set of predictors accounts for
31.4% of criteria variance (R² = 0.314; F = 3.061, p < 0.05).
In defining the predictor criteria for the “affective pain”, pain
in the whole body (B = –2.88; p < 0.05) and depression ranked
highest (B = 0.13; p < 0.05) (Table 4). The applied set of pre-
dictors accounts for 28.0% of criteria variance (R² = 0.280; F =
2.599, p < 0.05). The study subjects reporting about the pain in
the whole body also show higher levels of PTSD, depression
and anxiety; they also report higher intensity of sensory and
affective pain experience and have greater difficulties in social
and family relations.
Table 1.
Correlation coefficient between PTSD, anxiety and pai n l oca ti on.
VARIABLE PAIN IN THE
LUMBAR SPINE
PAIN IN THE
CERVICAL SPINE
PAIN IN
THE HEAD
PAIN IN THE
WHOLE BODY
PAIN IN THE
LIMBS (M-PTSD)
(STAI 1)
ANXIETY
AS A STATE
PAIN IN THE LUMBAR SPINE 1.00
PAIN IN THE CERVICAL SPINE 0.37* 1.00
PAIN IN THE HEAD –0.02 –0.25* 1.00
PAIN IN THE WHOLE BODY –0.48* –0.25* –0.60* 1.00
PAIN IN THE LIMBS –0.19* –0.11 0.17* –0.13 1.00
(M-PTSD) –0.03 –0.07 0.15 –0.14 –0.08 1.00
(STAI 1) ANXIETY AS A STATE –0.02 –0.03 0.16* –0.14 –0.02 0.64* 1.00

B. MARIJANA ET AL. 703
Table 2.
Correlation coeffic ient between affective and sensor y pain component (McGill) and its location.
VARIABLE
PAIN IN THE
LUMBAR
SPINE
PAIN IN THE
CERVICAL
SPINE
PAIN IN
THE
HEAD
PAIN IN THE
WHOLE
BODY
PAIN IN
THE
LIMBS
(MCGILL)
AFFECTIVE
COMPONENT OF PAIN
(MCGILL)
SENSORY COMPONENT
OF PAIN
PAIN IN THE
LUMBAR SPINE 1.00
PAIN IN THE
CERVICAL SPINE 0.37* 1.00
PAIN IN THE HEAD –0.02 –0.24* 1.00
PAIN IN THE
WHOLE BODY –0.48* –0.25* –0.59*1.00
PAIN IN THE LIMBS –0.18* –0.12 0.16* –0.13 1.00
(MCGILL) AFFECTIVE
COMPONENT OF PAIN 0.09 0.08 0.07 –0.21* –0.03 1.00
(MCGILL) SENSORY
COMPONENT OF PAIN 0.03 0.09 0.11 –0.23* 0.06 0.71* 1.00
Note: *p < 0.05.
Table 3.
Contribution of predictors in th e p rognosis of “sensory pain” criteria.
PREDICTORS B SE Beta t p
PAIN IN THE LUMBAR SPINE –2.84 2.05 –0.18 –1.39 0.17
PAIN IN THE CERVICAL SPINE 0.90 2.10 0.05 0.43 0.67
PAIN IN THE HEAD –3.09 2.10 0.20 –1.47 0.14
PAIN IN THE WHOLE BODY –6.66 3.15 0.36 –2.12 0.04
PAIN IN THE LIMBS –2.18 3.35 0.06 –0.65 0.52
PTSD 0.01 0.05 0.03 0.19 0.85
ANXIETY AS A STATE 0.15 0.12 0.21 1.30 0.20
ANXIETY AS PERSONALITY TRAIT –0.03 0.15 –0.03 –0.21 0.84
DEPRESSION 0.26 0.11 0.36 2.30 0.02
PHYSICAL HEALTH –0.13 0.29 –0.05 –0.44 0.66
PSYCHOLOGICAL HEALTH 0.55 0.33 0.25 1.66 0.10
SOCIAL RELATIONS 0.20 0.49 0.05 0.41 0.68
ENVIRONMENT –0.17 0.20 –0.11 –0.85 0.40
Table 4.
Contribution of predictors in th e p rognosis of “affective pain” criteria.
PREDICTORS B SE Beta t p
PAIN IN THE LUMBAR SPINE –0.86 0.92 –0.13 –0.94 0.35
PAIN IN THE CERVICAL SPINE –0.22 0.94 –0.03 –0.24 0.81
PAIN IN THE HEAD –1.57 0.94 –0.24 –1.67 0.10
PAIN IN THE WHOLE BODY –2.88 1.41 –0.35 –2.04 0.04
PAIN IN THE LIMBS –1.59 1.50 –0.10 –1.06 0.29
PTSD 0.00 0.02 0.03 0.20 0.84
ANXIETY AS A STATE 0.07 0.05 0.23 1.38 0.17
ANXIETY AS PERSONALITY TRAIT –0.07 0.07 –0.16 –0.99 0.32
DEPRESSION 0.13 0.05 0.42 2.64 0.01
PHYSICAL HEALTH –0.03 0.13 –0.03 –0.21 0.84
PSYCHOLOGICAL HEALTH 0.09 0.15 0.10 0.62 0.53
SOCIAL RELATIONS 0.13 0.22 0.08 0.58 0.56
ENVIRONMENT 0.00 0.09 0.00 0.02 0.99

B. MARIJANA ET AL. 704
Discussion
The patients have presented with long duration of chronic
pain; some of them with only one painful syndrome, some with
multiple simultaneous painful syndromes, and a significant
number of them with pain in the whole body (22.8%). The lat-
ter ones are interesting for study purposes because of neuro-
biological and clinical relations between the PTSD symptoms,
fibromyalgia, chronic fatigue and depression. The pain in lum-
bar spine was reported by 47.28% of study subjects, pain in the
cervical spine by 17.93%, headache by 54.9%, and pain in the
extremities by 5.4% of the study subjects. A significant num-
ber of our study subjects report about pain in the head, but fur-
ther research is needed for more thorough analysis of these
types of pain. A certain number of studies have shown that
PTSD symptoms are more expressed in individual suffering
from different types of headaches when compared with the
general population. The assumption is that PTSD is a risk factor
for chronic headache (Peterlin et al., 2008). As has already been
discussed, the assumption of specific interest is that of relation
between the pain in the whole body and the symptoms of fi-
bromyalgia, since in a significant number of patients with fi-
bromyalgia the existence traumatic stressors and PTSD symp-
toms has been (Naring et al., 2007). Another interesting issue is
the relation between anxiety as a state, or diagnosed condition,
personality traits and PTSD level. By noticing the correlation
between the PTSD degree measured by the above described
study instruments and anxiety, depression and sensory and
affective pain components, it can be concluded that there is a
statistically significant correlation between the above tests (Ta-
ble 4) The significant positive correlations between the degree
of PTSD symptoms and anxiety as a personality trait and con-
dition are particularly interesting as it the PTSD degree and
sensory and affective pain components. The importance of de-
pression intensity has been noticed in terms of its significant
positive correlation with painful experience and degree of
PTSD. All of these can be discussed in terms of common vul-
nerability. In reference literature the term “anxiety sensitivity”
is used as a disposing sensitivity for anxiety reactions and fear
from the very anxiety symptoms because of belief that they can
cause harmful effects (Sharp et al., 2001). Our study results
support the model of common sensitivity. With regard to the
PTSD relation to pain, depression has proved as an important
factor. It is possible that the changes resulting from depression
(fatigue, diminished activity, etc.) lead to aggravation and sus-
taining of symptoms, both of pain and of PTSD, and of a gen-
eral disability. The obtained results indicate that PTSD does not
significantly correlate with any of the pain sites (p > 0.05).
Anxiety as a state shows low but significant correlation with
headache (r = 0.16; p < 0.05), and insignificant correlation with
other variables. The results have also shown that anxiety as a
personality trait does not significantly correlate with any vari-
able of the site of pain (p > 0.05). The best predictors of sen-
sory pain criteria have shown to be pain in the whole body (B =
–6.66; p < 0.05) and depression (B = 0.26; p < 0.05). The em-
ployed set of predictors provided for 31.4% of criteria variance
(R² = 0.314; F = 3.061, p < 0.05). The best predictors of affect-
tive pain criteria have shown to be pain in the whole body (B =
–2.88; p < 0.05) and depression (B = 0.13; p < 0.05). The em-
ployed set of predictors provided for 28.0% of criteria variance
(R² = 0.280; F = 2.599, p < 0.05). Based on our study results it
may be seen that the patients with pain in the whole body have
greater levels of PTSD, depression, anxiety, experience greater
sensory and affective pain and have greater difficulties in their
social relations. The correlation mechanisms between depress-
sive symptoms and the symptoms of PTSD, although interest-
ing and extensively studied, have not yet been fully clarified.
(Maruta et al., 1976; Leo, 2005; Arnow et al., 2006; McWilliams
et al., 2003). The recent study carried out by Roth et al. has
investigated three models of correlation between pain, PTSD
and depression. The results indicate the correlation between the
symptoms of depression with pain and PTSD. It has also been
shown that the PTSD symptoms independently and directly
affect the severity of depression and that the degree of depress-
sion directly and indirectly affects the intensity of pain (Roth et
al., 2008). In reference literature the idea of sensitivity to anxi-
ety is usually discussed as a predisposing sensitivity to anxious
reactions and fear from the mere symptoms of anxiety, assume-
ing they might cause damaging effects (Sharp & Harvey, 2001).
Their study shows that there is mutual vulnerability for both
disorders and that the symptoms are mutually supported. It is of
utmost importance for clinicians to be aware of this fact when
treating such patients, no matter in which department or prac-
tice they are being treated. There is also a need for physicians
who are assessing the PTSD levels in patients to ask them about
the presence of painful symptoms (e.g. fibromyalgia or chronic
musculoskeletal pain), including the questions about the nature
and location of pain and its effects on the activities of daily
living. It may simply be done by tests such as McGill’s or struc-
tured clinical interviews. Furthermore, in centres for the treat-
ment of chronic pain assessment should be made of the possible
PTSD symptoms and depression using clinical interview or self-
assessment questionnaires. Patients should also be monitored
for sensitivity to anxiety and presence of depression. As regards
the treatment, it is important to modify the therapeutic protocols
in cases where both disorders are present, which is actually
supported by the fact that increased use of combined protocols
for both disorders can be seen worldwide.
Study Strenghts an d Limitations
One of the main strengths of our study is in the use of data
from clinical samples with diagnosed combat PTSD. The sam-
ples provide unique opportunity to investigate combat PTSD
symptoms and pain related disorders which can co-occur with
other comorbidity diagnoses. However, more research is needed
to explain the theoretical models of coexistence of the two dis-
orders, and more thoroughly controlled studies to investigate
the efficacy of the treatment methods for co-morbid conditions.
Our study is limited by its cross-sectional nature due to which
we cannot interfere with causality. Methodological limitations
of our study refer to retrospective data collection. The patients
were selected from our hospital, implicating that they came by
themselves, which might be scientifically limited. Also, the se-
condary gain motivation and possibility of exaggerated symp-
toms cannot be excluded because the scales for PTSD meas
urement and pain questionnaires are prone to subjectivity.
Conclusion
Our study results have shown a significant degree of PTSD
symptoms to persist in war veterans despite long-term treatment.
The relation has been confirmed between the tests used for the
assessment of PTSD, anxiety, depression and sensory and af-
fective components of pain, leading to the conclusion that there
is statistically significant correlation between all the applied tests.
Positive correlation between the PTSD symptom levels and

B. MARIJANA ET AL. 705
anxiety as a personality trait and as a state are of particular
interest, and so are the PTSD levels and sensory and affective
components of pain. The importance of the intensity of depress-
sion has been noticed, especially for its significantly positive
correlation between pain experience and PTSD level.
There is significant relation between posttraumatic stress
disorder and chronic pain syndromes, which in clinical practice
occur together with negative interaction in terms of the course,
outcome, and treatment of each individual disorder. It is as-
sumed that when compared with acute stressful stimulus the
chronic stress disorder has similar pattern of development as
does the chronic neuropathic pain in relation to peripheral
painful stimulus. The study has confirmed the assumption about
the relation between PTSD and chronic pain.
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