Somatic Symptoms Associated With PTSD: Assessment And Intervention
Cloitre, Marylene, Ph.D.
NCP Clinical Quarterly 7(4): Fall 1997
Recently, I received a request for consultation regarding a 28-year-old woman seeking mental health treatment following a serious procedural error during gynecological surgery. During the course of the, operation, the surgeon sprayed an acidic rather than saline solution on her cervix. The patient sustained second degree burns and was hospitalized for several days. In the ensuing months, she experienced intermittent pelvic pain and burning sensations in her vagina. Moreover, she lost interest in sex and no longer wanted her husband to see her undressed because she felt deformed. The therapist assigned to the case was bewildered by these symptoms. He thought the patient might be suffering from a delusional disorder related to her beliefs about being deformed and what he viewed as tactile hallucinations. A colleague with whom he discussed the case suggested referring the patient to our trauma clinic.
Additional inquiry determined that the woman was experiencing nightmares about the burns, preoccupation about whether she could function sexually and whether she could have a successful pregnancy. These and other symptoms confirmed a diagnosis of PTSD. The initial difficulty in providing an accurate diagnosis reflects the ongoing struggle within general psychiatric settings to educate mental health providers about PTSD and its pertinence following physical trauma. While general practitioners are beginning to link assault victimization (e.g., child abuse, rape, muggings, etc.), to PTSD, there seems to be less consideration of traumatic induced stress when physical injury occurs, especially those occurring in a medical setting. This may be because, as an interpersonal event, there is no intention to do wrong. In this particular case, the referring therapist viewed the patient as having an unusual reaction to an event that lacked malice, an event he believed was mildly distressful. Minimizing the patient’s injury and being unable to recognize her reactions, he missed PTSD Criteria A through D, concluding erroneously that she was delusional.
Fortunately, the woman was re-diagnosed and treated accordingly. Admittedly, accurate diagnoses can be a problem when the most salient symptom is somatic re-experiencing of the trauma, particularly when the patient has not yet achieved a full or the maximum physical recovery The vital question in this case was whether or not the woman's chronic pain had a partial or substantial organic source.
Both therapist and client need to determine as best as possible the extent to which somatic symptoms derive from physical injuries (e.g., pain related scar tissue). Identifying the source of a physical problem is a prerequisite to identifying effective treatment for physical recovery. Furthermore, identifying that some pain is not "just in her head," may help the traumatized woman regain a sense of control via an appropriate health plan. It also reduces uncertainty about her subjective experiences and delimits the domains of problems targeted for psychological intervention.
Women who have been traumatized in a medical setting are typically anxious about returning to a doctor and will need encouragement and support to do so. Ideally, therapists will have a referral network of reliable and sensitive physicians, some of whom may specialize in working with traumatized individuals. Encouraging the client to bring a friend to the doctor’s office or having a friend be present during the evaluation and exam may help reduce the client's anxiety. The friend can be an additional information processor as the client's anxiety may not allow her to assimilate the medical information being presented. In the case of the burn patient, the traumatized woman wanted information about the risks her injuries presented to future pregnancy, but was too upset to find a doctor to whom she could make these inquiries.
Once accurate information about the client's physical condition has been obtained, client and therapist can realistically assess potential problems and plan ways for coping with the physical sequelae of the injuries. Coping strategies should aim to speed physical recovery and enhance the client's sense of physical integrity (e.g., exercising regularly, taking prescribed medications) as well as to increase client's sense of predictability and control over her injuries. Interventions related to the psychological sequelae of the physical trauma should be considered in tandem with the plan for physical recovery.
It may be difficult for the client and the therapist to discriminate somatic symptoms directly related to the injury from psychosomatic symptoms related to the re-experiencing phenomenon. However, standard PTSD interventions such as the emotional processing of the trauma can be implemented with the expectation that such work will reduce re-experiencing as well as other symptoms such as nightmares and intrusive thoughts. In addition, these treatments tend to reduce generalized anxiety and depression. Thus there may be a complementary process in which increased psychological well-being facilitates physical recovery and physical recovery reinforces the psychotherapeutic aims of treatment. Lastly, the therapist should encourage the client to work collaboratively in an ongoing fashion with the physician. This will help keep the client and therapist up-to- date with the changing physical health picture and help the client re-establish a positive working relationship with physicians.
Marylene Cloitre, Ph.D. is Director of the Anxiety and Traumatic Stress Programs at Payne Whitney Clinic, New York Hospital-Cornell Medical Center.
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