Uncontrolled pain following physical injury as the core-trauma in post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a psychiatric diagnostic category characterized by "the development of characteristic symptoms following a psychologically traumatic event that is generally outside the range of usual human experience". Research shows that the prevalence of PTSD among injured survivors of stressful events is higher than that of survivors without physical injury, thus suggesting that secondary stressors (e.g., severe uncontrolled pain, a prolonged state of acute anxiety, uncertainty regarding the immediate future, loss of control, and inability to monitor contact with the environment) may play an important role in the formation of PTSD. However, pain has never been suggested or recognized as a direct cause of PTSD. We present the case of a patient who lost an eye under traumatic circumstances and was later diagnosed as suffering from PTSD. Upon evaluation in a psychophysiological laboratory, this patient's core-trauma was discovered to be 7 h of severe uncontrolled pain while waiting for surgery, rather than the moment when he lost his eye during military service. The case suggests that pain, although not "generally outside the range of usual human experience", may be a strong enough stressor in traumatic circumstances to cause the development of PTSD, thus highlighting the importance of prompt and adequate pain management in hospitalized survivors of traumatic injury.