Trauma, PTSD, and the Primary Care Provider
A National Center for PTSD Fact Sheet
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.
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. 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.
Related Fact Sheets
Screening for PTSD in a Primary Care Setting
A recommended 4-item screen for PTSD symptoms, to be used in primary care
settings.
Discussing
PTSD with your doctor
A useful checklist to help discuss traumatic stress symptoms with primary
care physicians
Primary care and PTSD
-veterans of war in Iraq
What do primary care practitioners need to know about PTSD and the war in
Iraq?
PTSD
and physical health
An overview of recent research confirming that trauma and PTSD affect physical
health
VA PTSD
treatment programs
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. 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.
Schnurr, P.P. (1996). Trauma, PTSD, and
Physical Health. PTSD Research
Quarterly, 7(3), 1-6.
