Dr. Zayfert is assistant professor of psychiatry and director of the Anxiety and Posttraumatic Stress Disorder Treatment Program in the Department of Psychiatry at Dartmouth Medical School in Hanover, NH.

Dr. Gillock is clinical associate in the Department of Psychiatry at Dartmouth Medical School.

Dr. Mellman is associate professor of psychiatry and director of the Psychopharmacology Program in the Department of Psychiatry at Dartmouth Medical School.

Acknowledgments: The authors would like to thank Carolyn Black Becker for her helpful comments. The authors report no financial, academic, or other support of this work.


 

Abstract

Why is it important to detect posttraumatic stress disorder (PTSD) in medical settings and how can physicians help these patients obtain effective treatment? PTSD often manifests through physical symptoms and might be associated with a variety of medical problems. Unaware that such symptoms may be related to PTSD, many patients seek medical care only. This article discusses the critical role of medical professionals in ameliorating the deleterious effects of PTSD on physical and emotional well-being. Patients who present in medical settings often do not readily comprehend the complex role posttraumatic stress reactions can play in their health problems and are often reluctant to discuss their traumatic experiences. Thus, physician identification and management of PTSD is crucial for many patients. However, addressing PTSD presents unique challenges even for physicians skilled in addressing other mental health concerns. These challenges include recognizing signs of PTSD and developing effective strategies for communicating with patients about the role of PTSD in their overall health.

 

Introduction

Recent epidemiologic data indicate that a substantial majority of Americans have experienced traumatic events.1 Posttraumatic stress disorder (PTSD) is a potentially debilitating anxiety disorder that affects many who are exposed to trauma. The current prevalence of PTSD in the general United States population is estimated to be 5%,2 and approximately 8% of the population meet criteria for PTSD at some point in their lives.3 However, the prevalence of PTSD among medical populations is substantially higher.4,5

The high rates of PTSD observed in medical populations are not surprising given that PTSD has been linked to poor health outcomes and functioning in a variety of domains. Studies have shown an association between PTSD, increased physical complaints, and poor overall health.6,7 PTSD has also been associated with an increased risk for medical conditions affecting the circulatory, digestive, musculoskeletal, nervous, respiratory, and immunological systems.8 Finally, available evidence suggests that individuals suffering from PTSD seek medical treatment more often than those without PTSD.7,9

Researchers have developed a variety of models to explain the association between PTSD and poor physical health. However, it is likely that a complex interaction of biological, behavioral, and psychosocial mechanisms leads to seeking of medical treatment among individuals with PTSD. For example, many traumatic events result in physical injury, some with lasting medical sequelae that require ongoing care.7,10 In addition, biologic dysregulation associated with PTSD, principally in the adrenergic and hypothalamic-pituitary-adrenal systems, has been implicated in the development of a variety of medical conditions for which patients seek care.11 PTSD has also been linked to behavioral risk factors (eg, smoking, substance use, poor diet, lack of exercise) for poor health.3,11 Finally, because PTSD involves avoidance of thinking about traumatic experiences, patients may selectively attend to physical symptoms that often accompany PTSD.7,12

In addition to the more straightforward medical presentations, PTSD is also associated with complex syndromes such as irritable bowel syndrome,13 fibromyalgia,14 and chronic fatigue syndrome.15 The primary care provider is in the optimal position to coordinate referrals for the multidisciplinary services that will best serve the needs of these patients. Thus, identification in the primary care setting has a pivotal role in meeting the treatment needs of individuals with PTSD. Even so, PTSD eludes detection in primary care in many cases. Thus, patients frequently present to specialized clinics such as those treating chronic pain, headaches, or epilepsy. Because these patients may be among those least likely to comply with recommendations to seek psychological services, it is important that clinicians become adept at drawing connections between PTSD and other disorders in a persuasive yet nonthreatening manner.

A variety of factors can interfere with identification of PTSD in clinical practice. Unfamiliarity and/or discomfort with the disorder and time constraints on clinicians may impede detection. Detection is also hindered by overlap between PTSD symptoms, diagnosable physical conditions, and the ambiguity in symptom presentation. Because there is often a gap of months or years between traumatic events and the onset of physical symptoms, individuals with physical complaints often do not link them to prior trauma. Many patients are reluctant to disclose traumatic events and discuss psychological symptoms. Avoidance of thoughts or reminders about the traumatic event is a core aspect of PTSD. Cultural influences, such as the belief that psychological symptoms are indicative of weakness, may dissuade some patients from revealing relevant diagnostic information.

Despite obstacles, enhancing detection of PTSD in medical settings is a worthy goal. Identification of PTSD offers physicians the opportunity to refer patients for effective intervention16 and alleviate suffering of those who might otherwise never seek mental health treatment. Thus, the remainder of this article will offer guidance to healthcare providers in meeting the needs of patients suffering from PTSD who present in medical settings.

 

Recognizing PTSD

The criteria for PTSD include the experience of a traumatic event, reexperiencing symptoms, avoidance symptoms, and hyperarousal.17 Events that may lead to PTSD typically involve a threat of serious harm to the individual or someone close to them and produce a sense of intense fear, helplessness, or horror. Clues from the patient’s history, behavior, and self-report are helpful for recognizing PTSD (Table). A diagnosis of PTSD is given when traumatic memories remain disturbing for 1 month or longer and persistently provoke fear, arousal, and avoidance behavior that is very distressing or that greatly interferes with a person’s life. PTSD is often accompanied by physical health complaints and feelings of depression, guilt, or shame.

 

Interviewing Strategies With Traumatized Patients

While there are a number of reasons why providers might be reluctant to ask about trauma, patients often welcome provider’s inquiries about their trauma experiences.18 When providers do not ask about abuse and assault, they can inadvertently send the message that this information is not important. Providers may be more inclined to assess patients’ exposure to trauma if they feel equipped to intervene effectively.

Once trauma has been identified as a significant concern, specialized psychiatric services are often indicated. Guiding patients with PTSD to seek appropriate services is typically a gradual process that takes place over multiple visits. The following strategies may facilitate identification and management of PTSD.
Ask about trauma directly and specifically. Taking the initiative shows that the clinician recognizes that trauma is a health issue. Using behaviorally specific and nonjudgmental questions maximizes the likelihood that the patient will disclose potentially embarrassing experiences such as abuse and assault.18
Interview the patient alone. Disclosure of trauma is sometimes more difficult or embarrassing in the presence of significant others. In addition, providers should alert themselves to the possibility of current abuse and avoid questioning in the presence of a possible perpetrator.
Summarize observations. Describing observations in simple and objective terminology can help the patient draw connections between experiences that previously appeared unrelated. Often, it is helpful to present this to the patient in a tentative manner (eg, “I’ve begun to wonder if what you are experiencing lately might be related to things that happened in your past”).
Normalize and validate posttraumatic reactions. Many patients with PTSD are aware that something is “not right,” but are fearful that their symptoms mean that they are abnormal, losing control, or “going crazy.” Communicating that the symptoms are understandable reactions experienced by many trauma survivors is a powerful method of managing traumatized patients. Validation can smooth subsequent steps, including medical procedures and referrals. Validation may include statements such as, “It’s not unusual to be bothered by stressful experiences long after they are over” and “It makes sense that you feel overwhelmed.”
Link to the presenting complaint. Patients with PTSD who present in medical settings are often concerned that the physician will not take their medical complaints seriously. For a variety of reasons, some patients are not ready to directly address their condition. Establishing a connection to the presenting complaint may enhance willingness to address psychological issues that affect the presenting problem. For example, the physician can make a statement such as, “It might be frightening to think about, yet the stress of ‘unfinished business’ can make it harder to deal with your back pain.”
Emphasize stress reduction. In making a referral for psychological services, it is important to communicate to patients that you take their symptoms seriously and to dispel the impression that you think the symptoms are “in their head.” Emphasize that stress can affect physical health and that a multidisciplinary approach may offer strategies to reduce stress and thereby alleviate suffering related to health concerns.
Offer optimism. PTSD patients often feel they have little control over many areas of their lives. Hopelessness interferes with taking steps to get help. Thus, an important goal of early intervention is to establish a sense of optimism by communicating to the patient that he or she can learn more effective ways of coping with stress. For example, the physician might say, “You can learn other ways to cope with your distress about the past. While we can’t change the awful things that have happened to you, I am hopeful that we will be able to help you feel less stressed by them.”
Enhance control. Using specific strategies to enhance the patient’s feeling of control can increase his or her willingness to adhere to recommendations. In addition to open and collaborative communication, this includes more extensive education about reproductive functioning, medical procedures, and offering choices whenever possible.

 

Screening Instruments

Given the high costs and burden on resources associated with undetected PTSD,19 formal screening processes may have utility in some settings. Several brief screening instruments for PTSD have recently been developed. Breslau and colleagues20 devised a seven-symptom screening tool based on a widely used diagnostic interview. Breslau and colleagues found that interview endorsement of four of the seven symptoms accurately detected 80% of cases classified as lifetime PTSD, based on the full diagnostic interview. However, follow-up assessment is recommended since the rate of false positives with this screening is 29%.

Meltzer-Brody and colleagues21 offered a four-item self-rating scale to screen for current PTSD diagnosis. The Startle, Physiologic arousal, Anger, and Numbness (SPAN) Test correctly identifies 84% of PTSD cases, and has a false positive rate of 11%. The use of these screening tools has the potential to enhance detection of PTSD when used in a population where the prevalence rate is 10% or higher.

 

Detection and Initial Management of PTSD in Populations With Increased Risk

As noted above, PTSD is overrepresented in medical populations and is associated with a higher rate of service utilization. This section reviews considerations relevant to the detection and initial management of PTSD in three populations for which it may be of particular significance: acute injury, obstetrics/gynecology (OB/GYN), and chronic pain clinics.

 

Acute Injury

Settings in which acute injury is treated are unique in that identification and management is aimed at prevention of PTSD soon after a trauma. Traumatic injury is a relatively common antecedent of PTSD.1 Psychiatric sequelae of traumatic injury often take the form of “subthreshold PTSD,” ie, posttraumatic symptoms that cause distress and impairment but fail to meet full PTSD diagnostic criteria.22,23

The significance of psychiatric complications of traumatic injury is underscored by findings that PTSD and depression significantly predict functional status and satisfaction with recovery after controlling for injury severity.24

Although serious injury is highly prevalent, only a minority of injury survivors will develop PTSD.25,26 Therefore, determining who is at future risk based on acute signs and symptoms is an important consideration for targeting interventions. The recently introduced diagnostic category of acute stress disorder emphasizes dissociation and the presence of PTSD symptoms as demarcating early risk for continuing PTSD. However, the data regarding the significance of dissociation for predicting PTSD in the aftermath of severe injury are mixed.23,26 Other factors that have been associated with increased risk for development of PTSD after injury include elevated heart rate within hours of the trauma,27 severity of early PTSD symptoms,26 and avoidant and maladaptive coping styles.22,23

Since it is not feasible for all injured patients at risk for PTSD to receive mental health interventions, it is important that providers in acute trauma settings have a general awareness of issues related to the disorder. Educating injured patients about possible PTSD symptoms is potentially a useful and cost-effective first-line intervention. Patients who begin to experience nightmares or flashbacks are often confused and frightened by their symptoms and can benefit from having a frame of reference for understanding them. The brief screening tools discussed above and patient information materials can provide this framework.

Injured patients who manifest intense reexperiencing, anxiety, sleep disturbance, dissociation, or appear to be trying hard to avoid thinking about what happened warrant the highest priority for mental health intervention. Research on interventions for preventing PTSD soon after trauma is in preliminary stages. Some of the most promising data support a modification of cognitive-behavioral therapy (CBT) for injury survivors.28 This suggests that some of the key components of CBT, such as educating the patient about the nature of PTSD and facilitating expression of trauma-related memories, thoughts, and feelings, are potential strategies for prevention of PTSD.

 

OB/GYN

Women are at high risk for exposure to assaultive violence. Approximately 35% of those assaulted have experienced PTSD during their lifetime,29 warranting a skillful approach to detecting and managing PTSD in the OB/GYN setting. Abuse/assault and subsequent PTSD put women at greater risk for reproductive health problems, including sexual dysfunction, genital or nongenital physical injuries, sexually transmitted diseases,30 chronic pelvic pain (CPP),31 and complications during pregnancy and/or childbirth.32

OB/GYN providers should be especially cognizant of abuse/assault and PTSD because pelvic exams, labor, and delivery procedures can evoke feelings of loss of control and violation. In addition, both pregnancy and childbirth can trigger memories of past abuses, and childbirth itself is a potentially traumatic event.32 Being aware of a woman’s abuse history enables OB/GYN providers to adjust their interactions with the patient to enhance her sense of control and reduce her anxiety and posttraumatic symptoms during medical procedures.

 

Chronic Pain

Traumatic events, particularly sexual and physical abuse, are common experiences of patients seeking help for chronic pain problems. Such events have been implicated in the development and maintenance of chronic pain syndromes.33 Estimates of the prevalence of any form of abuse among patients with chronic pain have been as high as 65%.34,35 Despite the attention to trauma in the development and maintenance of chronic pain, the role of PTSD in chronic pain has only recently been investigated. However, available data suggests that the prevalence of PTSD among patients with chronic pain problems approximates 35%.5 Moreover, the presence of PTSD appears to adversely affect the adaptation to chronic pain.12,36

CPP, in particular, is a complex problem with multiple contributing factors. Approximately 58% of women who present with CPP report a history of assault or abuse,37 yet there is no conclusive evidence that psychological factors have a causative role.38 It is important to identify possible psychological contributions such as PTSD. However, CPP is a multifaceted problem, and communicating to the patient that physical complaints are to be taken seriously regardless of identifiable organic pathology promotes effective management.

 

Conclusion

PTSD is a highly prevalent disorder with pervasive effects on emotional and physical health. Despite this, many individuals do not seek appropriate interventions that can attenuate the aftereffects of trauma. Patients with PTSD present in medical settings with a wide range of physical health concerns, yet show little awareness of the role of their traumatic experiences in their presenting complaints. Attention to the detection of PTSD and the use of strategies suggested above would facilitate effective intervention for PTSD as an important adjunct to the patient’s medical care.  PP

 

References

1.    Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit area survey of trauma. Arch Gen Psychiatry. 1998;55:626-631.
2.    Norris FH. Epidemiology of trauma: frequency and impact of different potentially traumatic events on different demographic groups. J Consult Clin Psychol. 1992;60:409-418.
3.    Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the national comorbidity survey. Arch Gen Psychiatry. 1995;52:1048-1060.
4.    Stein MB, McQuaid JR, Pedrelli P, Lenox R, McCahill ME. Posttraumatic stress disorder in the primary care medical setting. Gen Hosp Psychiatry. 2000;22:261-269.
5.    Asmundson G, Norton GR, Allerdings MD, Norton PJ, Larsen DK. Posttraumatic stress disorder and work-related injury. J Anxiety Disord. 1998;12:57-69.
6.    Clum GA, Calhoun KS, Kimerling R. Associations among symptoms of depression and posttraumatic stress disorder and self-reported health in sexually assaulted women. J Nerv Ment Dis. 2000;188:671-678.
7.    McFarlane AC, Atchison M, Rafalowicz E, Papay P. Physical symptoms in post-traumatic stress disorder. J Psychosom Res. 1994;38:715-726.
8.    Schnurr PP, Spiro A 3rd, Paris AH. Physician-diagnosed medical disorders in relation to PTSD symptoms in older military veterans. Health Psychol. 2000;19:91-97.
9.    Schnurr PP, Friedman MJ, Sengupta A, Jankowski MK, Holmes T. PTSD and utilization of medical treatment services among male Vietnam veterans. J Nerv Ment Dis. 2000;188:496-504.
10.    Beckham JC, Crawford AL, Feldman ME, et al. Chronic posttraumatic stress disorder and chronic pain in Vietnam combat veterans. J Psychosom Res. 1997;43:379-389.
11.    Schnurr PP, Jankowski MK. Physical health and post-traumatic stress disorder: Review and synthesis. Semin Clin Neuropsychiatry. 1999;4:1-11.
12.    Bryant RA, Marosszeky JE, Crooks J, Baguley IJ, Gurka JA. Interaction of posttraumatic stress disorder and chronic pain following traumatic brain injury. J Head Trauma Rehabil. 1999;14:588-594.
13.    Irwin C, Falsetti SA, Lydiard RB, Ballenger JC, Brock CD, Brener W. Comorbidity of posttraumatic stress disorder and irritable bowel syndrome. J Clin Psychiatry. 1996;57:576-578.
14.    Amir M, Kaplan Z, Neumann L, Sharabani R, Shani N, Buskila D. Posttraumatic stress disorder, tenderness, and fibromyalgia. J Psychosom Res. 1997;42:607-613.
15.    Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology: relationship to psychiatric disorders, childhood and adult trauma, and personality traits. Ann Intern Med. 2001;134:917-925.
16.    Foa EB, Keane TM, Friedman MJ, eds. Practice Guidelines From the International Society for Traumatic Stress Studies: Effective Treatments for PTSD. New York, NY: The Guilford Press; 2000.
17.    Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994.
18.    Acierno R, Resnick HS, Kilpatrick DG. Health impact of interpersonal violence. 1: Prevalence rates, case identification, and risk factors for sexual assault, physical assault, and domestic violence in men and women. Behav Med. 1997;23:53-64.
19.    Greenberg PE, Sisitsky T, Kessler RC, et al. The economic burden of anxiety disorders in the 1990s. J Clin Psychiatry. 1999;60:427-435.
20.    Breslau N, Peterson EL, Kessler RC, Schultz LR. Short screening scale for DSM-IV posttraumatic stress disorder. Am J Psychiatry. 1999;156:908-911.
21.    Meltzer-Brody S, Churchill E, Davidson JRT. Derivation of the SPAN, a brief diagnostic screening test for post-traumatic stress disorder. Psychiatric Res. 1999;88:63-70.
22.    Schnyder U, Moergeli H, Klaghofer R, Buddeberg C. Incidence and prediction of posttraumatic stress disorder in severely injured accident victims. Am J Psychiatry. 2001;158:594-599.
23.    Mellman TA, David D, Bustamante V, Fins A, Esposito K. Predictors of PTSD following severe injury. J Anxiety and Depression. 2001;14:226-231.
24.    Michels AJ, Michaels CE, Moon CH, Zimmerman MA, Peterson C, Rodriguez JL. Psychosocial factors limit outcomes after trauma. J Trauma. 1998;44:644-648.
25.    Ursano RJ, Fullerton CS, Epstein RS, et al. Acute and chronic posttraumatic stress disorder in motor vehicle accident victims. Am J Psychiatry. 1999;156:589-595.
26.    Harvey A, Bryant RA. The relationship between acute stress disorder and posttraumatic stress disorder: a 2-year prospective evaluation. J Consult Clin Psychol. 1999;67:985-988.
27.    Shalev AY, Sahar T, Freedman S, et al. A prospective study of heart rate response following trauma and the subsequent development of posttraumatic stress disorder. Arch Gen Psychiatry. 1998;55:553-559.
28.    Bryant RA, Harvey AG, Dang ST, Sackville T, Basten C. Treatment of acute stress disorder: a comparison of cognitive-behavioral therapy and supportive counseling. J Consult Clin Psychol. 1998;66:862-866.
29.    Breslau N, Chilcoat H, Kessler R, Peterson E, Lucia V. Vulnerability to assaultive violence: further specification of the sex difference in posttraumatic stress disorder. Psychol Med. 1999;29:813-821.
30.    Resnick HS, Acierno R, Kilpatrick DG. Health impact of interpersonal violence 2: medical and mental health outcomes. Behav Med. 1997;23:65-78.
31.    Savidge CJ, Slade P. Psychological aspects of chronic pelvic pain. J Psychosom Res. 1997;42:433-444.
32.    Allen S. A qualitative analysis of the process, mediating variables and impact of traumatic childbirth. J Reproductive & Infant Psychol. 1998;16:107-131.
33.    Rapkin AJ, Kames LD, Darke LL, Stampler FM, Naliboff BD. History of physical and sexual abuse in women with chronic pelvic pain. Obstet Gynecol. 1990;76:92-96.
34.    Taylor ML, Trotter DR, Csuka ME. The prevalence of sexual abuse in women with fibromyalgia. Arthritis Rheum. 1995;38:229-334.
35.    Haber J, Roos C. Effects on spouse abuse and/or sexual abuse in the development and maintenance of chronic pelvic pain in women. In: Fields HL, Dubner R, Cervero F, eds. Advances in Pain Research and Treatment. New York, NY: Raven Press; 1985.
36.    Hickling EJ, Blanchard EB, Schwarz SP, Silverman DJ. Headaches and motor vehicle accidents: results of the psychological treatment of post-traumatic headache. Headache Quarterly. 1992;3:285-289.
37.    Walker EA, Gelfand AN, Gelfand MD, Koss MP, Katon WJ. Medical and psychiatric symptoms in female gastroenterology clinic patients with histories of sexual victimization. Gen Hosp Psychiatry. 1995;17:85-92.
38.    Steege JF, Stout A. Chronic gynecologic pain. In: Stewart DE, Stotland NL, eds. Psychological Aspects of Women’s Health Care: The Interface Between Psychiatry and Obstetrics and Gynecology. Washington, DC: American Psychiatric Press; 1993.