Psychology of Pain: Focus on the Veteran with Chronic Pain

Post-Deployment Chronic Pain Comorbidities Luz S. Vasquez, MD

Disclosure Information

Nothing to Disclose

Learning Objective Describe how to apply effective treatment approaches to enhance the recovery of our Veterans who have both chronic pain and posttraumatic stress disorder

Case Study #1

Jerry is a 28 yr old who presents to your office because his wife insisted that he see a doctor. She claims he has not been himself since he returned from Afghanistan. It has now been one year since Jerry has returned home from deployment. He was deployed for multiple tours. His wife is distraught because Jerry has been irritable. He insists on sleeping on the floor. He refuses to socialize with their friends. He is drinking heavily and had his license suspended for a DWI. He can’t find a job and feels out of sorts. He feels he doesn’t fit in any more. He admits that he hasn’t been much fun to be with since his return. He feels jumpy, and is quick to anger but feels that his wife doesn’t understand where his “heads at”

Jerry has just come back from a one year deployment as a member of the Army National Guard. While in Afghanistan, he worked as a radio operator as part of a quick reaction force. He was in a lot of fire fights and was exposed to several improvised explosive device (IED) blasts. On several occasions these were so close that he felt his head ringing and momentary disorientation, but he never lost consciousness. He did see some of his friends blown up. His living conditions were very sparse in Afghanistan. He was around a lot of smoke and fumes from the burn pits where they burned garbage, chemicals, and plastic

He aches all over, especially his shoulders, knees, and back. He says he feels like an old man. . He thinks this is pretty normal after what he has been through and it doesn’t really bother him. He doesn’t sleep well waking up with violent nightmares and has been drinking more because it helps him feel less edgy.

He drinks a six pack of beer every day and maybe once a week gets drunk. He started smoking during his first deployment and currently smokes one pack a day. He doesn’t like taking pills but a friend offered him some hydrocodone a few weeks ago and that really helped him feel better, and he would like a prescription. He denies the use of any illicit drugs

His physical examination is remarkable for pain in his knees, shoulders and back. He has full range of motion of these joints. There is no edema or erythema present He tells you that he does not want to see a psychiatrist, because he does not want that on his medical record

Case Study #2

Janet is a 32 yr old Hispanic female. She comes to your office with a chief complaint of headaches and back pain. She was well until her deployment to Iraq. While in Iraq she routinely had to wear full body armor. On patrol she fell into a ditch and injured her back. Since this fall she notes chronic low back pain. She describes this a an electric shock type of pain that occurs continuously. There are no positions in which this pain is relieved. She has consulted a civilian MD about this pain who told her to try physical therapy for this pain and prescribed oxycodone to use when the pain was severe. She went to a few physical therapy sessions but it make her pain worse so she stopped going

 Since she has returned home from deployment, she notes that she has little energy and no ambition to do any of her household duties. She claims she goes to work each day but feels she is in a cloud. She can not relate to her coworkers  She has an 8 year old daughter. Her daughter was living with her mother while she was deployed. She feels her mother has spoiled her. She finds her daughter too demanding and “tiresome”. When she has to spend time with her daughter, she finds herself to be a hard disciplinarian and does not enjoy spending time with her child  She also suffers from daily headaches which she describes as a pulling sensation that starts in her neck and spreads throughout her entire scalp

 Due to her debilitating headaches she spends most of her time laying in bed in a dark room. She claims she takes ibuprofen “around the clock” and she will often double the dose with minimal relief from her pain  Since returning from deployment she has gained 60 lbs. She attributes this to pain when moving, which limits her ability to exercise. She describes eating as the only thing that gives her joy and admits to a diet of mostly fast food  She had a CT Scan of her head done by her civilian MD which was normal. She also had an MRI of her spine which was unremarkable

 On physical exam she has difficulty rising from a chair, she has a positive straight leg test on the right. She weighs 182 lbs and is 5 feet tall  In your office she becomes tearful, she states she is ashamed of her weight gain. She feels useless and doesn’t see how she can continue to manage her full time job and the care of her daughter  She states the headaches and back pain have taken over my life . They interfere with everything. I need to be rid of this pain  She tells you if she has to continue her life with this level of pain, she would rather die

Case Study #3

 Jenna is a 30 yr old recently returned from a tour in Afghanistan. When she returned from Afghanistan she noted that she had become socially isolated and was depressed. She went to see a civilian MD, who diagnosed her with clinical depression. She was started on Fluoxetine. She was initially compliant with the medication and noted some relief of her symptoms. Subsequently she decided she did not want to “ put chemicals in her body” so she stopped taking the medication  She complains of diffuse body pain. She has multiple areas of her body where she feels intense shooting pain. She is concerned that she has fibromyalgia

She has been prescribed multiple medications for this pain, including naprosyn , cyclobenzaprine, and oxycodone. She finds that these help for short periods of time but the pain relief wears off quickly. Her physical exam is unremarkable She is a newlywed. She states her husband feels that she should be more energetic. He doesn’t understand the extent of her pain and how it limits her movement She is interested in getting pregnant and has recently stopped taking her oral contraceptive