Trauma, PTSD And Health
By Matthew J. Friedman, M.D., Ph.D. and Paula Schnurr, Ph.D.
NCP Clinical Quarterly 6(4): Fall 1996
In our view, it is no accident that a significant number of patients with undiagnosed PTSD seek treatment in primary care rather than mental health settings. We will present the evidence for this phenomenon. First, we will provide an overview of literature on the relationship between trauma and health. Next, we'll show why we think PTSD is an important mechanism through which traumatic exposure results in poor health. Finally, we'll discuss the implications of this relationship for clinical practice.
We recently reviewed the literature in the PILOTS database on the relationship between trauma and health (1). We identified four categories of trauma: military, sexual, natural disaster and other (torture, accidents, refugee, and hostage situations). We also examined four categories of adverse health outcomes: self-reported health complaints, medical service utilization, morbidity determined by a medical examinations, and mortality. This large, and sometimes methodologically flawed, literature is impressive for the consistency of results showing that exposure to catastrophic stress is associated with more health complaints, greater service utilization, more medical illness, and increased mortality.
We selected four specific studies from this large body of literature to give you the flavor of many of the reported findings. Two particularly noteworthy reports concern coronary heart disease among civilians exposed to war-zone stress. Sibai and associates (2), for example, found that exposure to acute and chronic war stress during the civil war in Beirut, Lebanon was greater among Lebanese patients with coronary angiography (indicative of atherosclerosis) than in patients with normal angiographic findings. Similarly, there was a higher incidence of acute myocardial infarction during the civil war in Croatia than during the same time period one year earlier, before the outbreak of hostilities (3). In the third study, women with a history of childhood or adult sexual abuse seeking treatment in a gastroenterology clinic had greater symptom severity, more surgery and were more functionally disabled than women with no history of sexual abuse (4). In the fourth study, women who had been exposed to criminal victimization, in contrast to a nonvictimized comparison group, made twice as many physician visits and incurred 2.5 times more medical costs in the first year after the assault (5).
Why should exposure to trauma result in poorer health outcomes? In our opinion, PTSD is a major mediator through which this occurs. There aren't too many studies that have directly studied the relationship between PTSD and health, but the few that have been published support this conclusion. Veterans and nonveterans with PTSD have higher rates of health complaints, clinical service utilization, and medical morbidity than those without PTSD. For example, Shalev and associates (6) found that Israeli combat veterans had poorer cardiovascular function as measured by performance on a treadmill, compared with a non-PTSD veteran comparison group. A study by Wolfe, Schnurr, Brown, and Furey (7) illustrates the importance of PTSD, relative to trauma exposure. In female Vietnam veterans, both warzone exposure and PTSD were separately correlated with self-reported health outcomes. However, when both variables were considered simultaneously--by including both as predictors in multiple regression--virtually all the effects of exposure were eliminated. We interpret this to mean that trauma primarily has its effects on health by increasing the likelihood of PTSD.
We believe that there are both physiological and psychological mechanisms through which PTSD exerts its deleterious effects on health. There is a substantial and rapidly expanding experimental literature showing that individuals with PTSD suffer from a number of biological abnormalities, including enhanced cardiovascular reactivity, autonomic hyperarousal, disturbed sleep physiology, enhanced thyroid function, and altered hypothalamic-pituitary-adrenocortical activity. Extrapolating from animal models for PTSD, it seems likely that immunological function, the endogenous opioid system, as well as other homeostatic mechanisms, are also disrupted during the course of PTSD (see [8]) for an extensive review of neurobiological research on PTSD).
In addition to these biological abnormalities, there are a number of psychological and behavioral correlates of PTSD that have been shown to be risk factors for negative health outcomes. Those include hostility, depression, alcohol and substance abuse/dependence, enhanced risk-taking behavior, and impaired coping skills (1).
To summarize, we have shown that trauma exposure and PTSD are linked to adverse health outcomes. We also argued that a significant amount of the association between trauma and poor health is due to the presence of PTSD rather than to trauma exposure itself. We then listed some of the biological and psychological abnormalities associated with PTSD that may explain how PTSD promotes adverse health outcomes. Now we'd like to discuss some of the implications of this relationship between PTSD and health.
We want to emphasize that we are talking about poorer medical health among PTSD patients, not "somatization." There are data showing that individuals with PTSD, especially those exposed to persistent (often childhood sexual) trauma, have an increased likelihood of meeting diagnostic criteria for Somatization Disorder because of their multisystem somatic complaints (9). We do not dispute these findings but believe that they explain a very small portion of the findings on trauma, PTSD, and physical health. We are asserting that people exposed to trauma who develop PTSD are at greater risk than people without PTSD to develop atheroselerotic heart disease, gastrointestinal disorders, endocrine abnormalities, and other diagnosable medical conditions. We also assert that it is because of these diagnosable medical conditions, not because of "somatic complaints," that they are more likely to seek care from primary practitioners and medical specialists rather than from mental health clinicians.
This is why the coordination of primary care and PTSD treatment is so important, as indicated in this issue’s article by Gebhart and Neely. We suggest that a brief questionnaire that inquires about previous exposure to trauma be a routine part of any intake assessment for patients seeking primary or specialty medical care. Patients who report such exposure should receive a more extensive assessment to determine whether or not they have PTSD. Once identified, PTSD patients should be offered appropriate therapy for their PTSD conjointly with their medical treatment. We believe that such an approach will optimize treatment and result in more cost-effective care.
References
1. 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, and A.Y. Deutch (Eds.), Neurobiological and Clinical Consequences of Stress: From Normal Adaption to PTSD (pp. 507-524). Philadelphia: Lippincott-Raven.
2. Sibai, A.M., Armenian, H.K., & Alam, S. (1989). Wartime determinants of arteriographically confirmed coronary heart disease in Beirut. American Journal of Epidemiology, 130, 623-631.
3. Bergovec, M., Mihatov, S., Pepic, H., Rogan, S., Batarelo, V., & Sjerobabski, V. (1992). Acute myocardial infarction among civilians in Zagreb city area. Lancet, 339, 303.
4. Leserman, J., Drossman, D.A., Li, Z., Toomey, T.C., Nachman, G., & Glogau, L. (1996). Sexual and physical abuse history in gastroenterology practice: How types of abuse impact health status. Psychosomatic Medicine 58, 4-15.
5. Koss, M.P., Woodruff, W.J., & Koss, P.G. (1990). Relation of criminal victimization to health perceptions among women medical patients. Journal of Cosulting and Clinical Psychology, 58, 147-152.
6. Shalev, A., Bleich, A., & Ursano, R. (1990). Posttraumatic stress disorder, somatic comorbidity and effort tolerance. Psychosomatics, 31, 197-203.
7. Wolfe, J., Schnurr, P.P., Brown, P.J., & Furey, J.A. (1994). Posttraumatic stress disorder and war-wone exposure as correlates of perceived health in female Vietnam War veterans. Journal of Consulting and Clinical Psychology, 62, 1235-1240.
8. Friedman, M.J., Charney, D.S., & Deutch, Y,A, (1995). Neurobiological and Clinical Consequences of Stress: From Normal Adaption to PTSD. Philadelphia: Lippincott-Raven.
9. Herman, J.L. (1992). Trauma and Recovery. New York: Basic Books.
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