Why is it important to be aware of trauma and PTSD in
healthcare settings?
Trauma and trauma-related problems are common
Fifty to ninety percent of all adults and children are exposed
to a psychologically traumatic event (such as a life-threatening
assault or accident, human-caused or natural disaster, or war) at
some point in their lives. As many as 67% of trauma survivors
experience lasting psychosocial impairment, including
posttraumatic stress disorder (PTSD); panic, phobic, or
generalized anxiety disorders; depression; or substance abuse.
Symptoms of PTSD include the persistent, involuntary
re-experiencing of traumatic distress, emotional numbing and
detachment from other people, and hyper-arousal (e.g.,
irritability, insomnia, fearfulness, and nervous agitation).
PTSD affects health
PTSD is linked to structural neurochemical changes in the
central nervous system, which may have a direct biological effect
on health. Such health effects may include vulnerability to
hypertension and atherosclerotic heart disease; abnormalities in
thyroid and hormone functions; increased susceptibility to
infections and immunologic disorders; and problems with pain
perception, pain tolerance, and chronic pain. PTSD is associated
with significant behavioral health risks,including smoking, poor nutrition, conflict or violence
in intimate relationships, and anger or hostility. When trauma
leads to PTSD or other posttraumatic psychosocial problems, this
places great biological strain upon the body and psychological
strain upon the individual and his or her interpersonal
relationships. It is, therefore, not surprising that trauma
survivors, especially those with lasting PTSD symptoms,
frequently report high rates of problems with physical health
.Ê These problems usually involve a variety of bodily
systems including the cardiovascular, pulmonary, neurological,
and gastrointestinal systems.
PTSD affects utilization of services
PTSD and related problems with anxiety, depression, and anger
are also associated with excess rates of healthcare services
utilization. Studies document high medical utilization rates for (1)
both male and female Vietnam and Persian Gulf veterans with PTSD;
(2) survivors of war, political violence, and terrorism; (3)
survivors of earthquakes, hurricanes, and other natural
disasters; (4) crime victims, especially women who have
experienced sexual assault; and (5) survivors of child abuse.
Although research on this subject is currently underway and not
yet completed, clinical observations suggest that the symptoms of
PTSD or associated psychosocial problems often interfere with
healthcare. PTSD symptoms and other psychosocial problems may
cause difficulty in provider-patient communication, reduce
patients' active collaboration in evaluation and treatment,
increase the likelihood of somatization, and reduce patient
adherence to medical regimens.
PTSD is underrecognized by practitioners
Studies show that many patients who seek physical healthcare
have been exposed to trauma and experience posttraumatic stress
symptoms but have not received appropriate mental-health care. As
with other anxiety disorders and depression, most patients with
PTSD are not properly identified and are not offered education,
counseling, or referrals for mental-health evaluation.
What can healthcare providers do?
Recent evidence suggests that psychological assistance can
prevent or greatly reduce the severity of PTSD. Psychological
healthcare is likely to enhance the patient's capacity to benefit
from medical healthcare. Healthcare clinicians do not need
additional training, and their workloads need not be increased,
because specialized PTSD treatment resources are readily
available.
Identify a PTSD consultant
The
first step is to identify a mental-health or PTSD
clinician specialist who is able to provide you with consultation
and your patient with education, assessment, and counseling.
There is a substantial body of published research on PTSD
symptoms and treatment options, and there are expert therapists
from a range of disciplinary backgrounds including psychiatry,
clinical psychology, social work, and psychiatric nursing.
Patients who have had experiences of trauma that raise the risk
of PTSD, or those who present with physical or psychological
symptoms consonant with the disorder, should be referred to one
of these experts. If the PTSD specialist is not a member of your
multidisciplinary healthcare clinic or team, he or she may be
able to participate as an ad hoc consultant or ex-officio team
member. An excellent place to start is with PTSD specialists who
work in VA PTSD Programs and
Vet Centers across the
United States.
Take steps to identify patients who have PTSD
The
second step is to discuss with the PTSD specialist how
best to identify your patients with undetected PTSD. You can
provide educational fact
sheets on stress and trauma for patients to read in clinic
waiting areas. You can also have patients complete a brief (1-to
2-minute) screening questionnaire in the waiting area, on their
own or with the help of clerical or nursing staff. In some cases,
the PTSD specialist may be able to provide on the spot (or
same-day) brief education and counseling for patients who are
experiencing acute psychological distress. Pilot clinical studies
indicate that healthcare patients find these types of
information, screening, and counseling helpful and not
disturbing.
Establish referral procedures
The
third step is to set up a plan for referring to the PTSD
specialist those patients who show signs of potential PTSD and
who are amenable to receiving additional evaluation or
counseling. A few words indicating your awareness of their
possible difficulties with stress, and supportively advising them
that specialized services can be of great help, is almost always
sufficient to motivate patients to accept this referral. You need
not, and in most cases probably should not, attempt to take a
detailed trauma history or make a diagnostic assessment of PTSD.
This can be done by the PTSD clinician specialist.
PTSD clinicians are able to provide a variety of therapeutic
approaches that have been demonstrated to benefit those with
PTSD.Ê These therapeutic approaches include psychodynamic
psychotherapy; exposure therapy; cognitive-behavioral therapy;
pharmacotherapy; group, family, couples, and inpatient treatment;
and combined PTSD and alcohol/substance abuse treatment. No
particular drug has emerged as a definitive treatment for PTSD,
but medication is clearly useful for symptom relief, making it
possible for patients to participate in psychotherapy. Matching
medication to the complex combinations of PTSD and associated
symptoms, beyond palliative care for symptoms of anxiety or
depression, should be done by a PTSD specialist.
Maintain ongoing contact with the PTSD clinician
The
fourth crucial step is to maintain ongoing contact with
the PTSD clinician so that you can monitor your patient's
response to mental-health care. Your observations about your
patient's clinical and functional status at subsequent
appointments provide the PTSD specialist with a valuable source
of feedback and guidance in developing effective PTSD care. In
many cases, your patient's participation in healthcare will
improve.
Brief information about the Department of Veterans Affairs'
network of more than 100 specialized programs for veterans with
PTSD
This fact sheet was based on:
Ford, J.D., Ruzek, J.I., & Niles, B.L. (1996). Identifying
and treating VA medical care patients with undetected sequelae of
psychological trauma and post-traumatic stress disorder.Ê
NCP Clinical Quarterly, 6(4), 77-82.
Friedman, M.J. (1996).
PTSD
Diagnosis and Treatment for Mental Health Clinicians.
Community Mental Health Journal, 32(2), 173-189.
Friedman, M.J. & Schnurr, P.P. (1995). The relationship
between trauma, post-traumatic stress disorder, and physical
health. In M.J. Friedman, D.S. Charney, & A.Y. Deutch (Eds.),
Neurobiological and clinical consequences of stress: From
normal adaptation to post-traumatic stress disorder (pp.
507-524). Philadelphia: Lippincott Raven.
