PTSD as a Mediator in the Relationship Between Post-Concussive Symptoms and Pain Among OEF/OIF/OND Veterans

Kimberly M. Avallone, Erin R. Smith, Sean Ma, Sean Gargan, Katherine E. Porter, Caitlin C. Authier, Brian Martis, Israel Liberzon, Sheila A.M. Rauch

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


Introduction: Traumatic brain injury (TBI), pain, and post-traumatic stress disorder (PTSD) commonly co-occur in Veteran populations, particularly among Veterans returning from the recent conflicts in Iraq and Afghanistan. Extant research indicates that both TBI and PTSD can negatively impact pain broadly; however, less is known about how these variables impact one another. The current study examines the impact of self-reported post-concussive symptoms on both pain severity and pain interference among Veterans with PTSD who screened positive for a possible TBI, and subsequently, evaluates the potential mediating role of PTSD in these relationships. Materials and Methods: Participants were 126 combat Veterans that served in Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn who were being evaluated for participation in a multisite treatment outcomes study. As part of an initial evaluation for inclusion in the study, participants completed several self-report measures and interviews, including the Brief Traumatic Brain Injury Screen, Neurobehavioral Symptom Inventory, Brief Pain Inventory, and the Clinician Administered PTSD Scale, which were utilized in these analyses. Results: For pain severity, greater post-concussive symptoms significantly predicted increased pain severity with a significant indirect effect of postconcussive symptoms on pain severity through PTSD (indirect effect = 0.03; 95% confidence interval = 0.0094-0.0526). Similar results were found for pain interference (indirect effect = 0.03; 95% confidence interval = 0.0075-0.0471). Conclusions: These findings replicate and extend previous findings regarding the relationship between TBI, pain, and PTSD. Self-reported post-concussive symptoms negatively impact both pain severity and pain interference among Veterans with probable TBI, and PTSD serves as a mediator in these relationships. Clinically, these results highlight the importance of fully assessing for PTSD symptoms in Veterans with a history of TBI presenting with pain. Further, it is possible that providing effective PTSD treatment to reduce PTSD severity may provide some benefit in reducing post-concussive and pain symptoms.

Original languageEnglish (US)
Pages (from-to)E118-E123
JournalMilitary medicine
Issue number1-2
StatePublished - Jan 1 2019


  • PTSD
  • TBI
  • pain
  • veterans

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health


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