Psychiatric Times.
No. 7
Trauma and the Mind-Body Connection
By Phebe Tucker, MD and Elizabeth A. Foote, MD |
June 1, 2007
Dr Tucker is professor of psychiatric education and vice chair of education in the department of psychiatry at the University of Oklahoma Health Sciences Center in Oklahoma City. She teaches and conducts research related to trauma and terrorism, including physiological changes and treatments of PTSD. She has treated and assessed survivors from the Oklahoma City bombing in 1995 and an F-9 tornado in 1999. Dr Foote is a second-year resident in psychiatry at the University of Oklahoma Health Sciences Center. She graduated from the College of Medicine, University of Oklahoma Health Sciences Center. Dr Foote has interests in addiction psychiatry, psychotherapy, psychoanalysis, and academic psychiatry. Dr Tucker reports that she has had research support from Wyeth Ayerst, GlaxoSmithKline, Pfizer, Ortho-McNeil, AstraZeneca, and Bristol-Myers Squibb; she is a consultant for Wyeth Ayerst; and she has received honoraria from Forest Pharmaceuticals. Dr Foote reports that she has no conflicts of interest concerning the subject matter of this article.
Core symptom clusters of PTSD may respond to many of the same medications that are effective in depression. Moreover, these same antidepressants treat common comorbid conditions such as mood and other anxiety disorders. SSRIs are considered first-line medication treatments for PTSD and they are well tolerated.40 Tricyclic antidepressants and monoamine oxidase inhibitors may also help, with a norepinephrine(Drug information on norepinephrine)-serotonin reuptake inhibitor also of potential benefit.41 In addition, anticonvulsants, atypical antipsychotics, α2-adrenergic agonists, and ß-adrenergic blockers as monotherapy or adjunctive therapy may improve symptoms.40 Various forms of cognitive and behavioral psychotherapies can desensitize patients to trauma memories and environmental triggers, with demonstrated efficacy in treating PTSD.40 Empirically supported treatments include exposure therapy42 as well as cognitive therapy,43 interpersonal psychotherapy,44 and prolonged exposure therapy.45,46 Stress inoculation and trauma-focused group therapies may also be useful.40
Formal guidelines for treating somatization disorder are lacking, although successful treatment with cognitive- behavioral therapy (CBT) has been demonstrated.47,48 In a randomized controlled trial of CBT compared with standard medical care and psychiatric consultation, findings showed significant improvement with CBT in somatization disorder, self-reported functioning, and somatic symptoms, with reduced health care costs.48 Mai49 suggests that CBT sessions have realistic treatment goals; foster coping with symptoms and limitations; and promote recreation, relaxation, and a sense of control and autonomy. It is also important to develop a treatment strategy for individuals with trauma histories who have many somatic complaints but who do not meet full criteria for somatization disorder. Walker and associates50 discussed a model for treating patients with multiple medically unexplained symptoms. This model minimizes referral to specialists and encourages clinicians to remain self-aware and to process common feelings of anger and resentment.
Keeping in mind that patients who have been traumatized may somatize to express psychic pain and to elicit a nurturing response in caretakers may help modulate physicians' countertransference, which is often born of frustration. Comprehensive treatment includes patient education, use of psychiatric consultants, and treatment of psychiatric illness and primary medical problems. Just as with somatization disorder, the patient with medically unexplained symptoms should be encouraged to develop stress management skills, social supports, and healthy behaviors. Medications for comorbid anxiety and mood disorders are indicated as described above, while avoiding medications with potential for abuse or dependence.
The following case illustrates successful use of a combination of support, drug therapy, and psychotherapy for a trauma survivor, provided by a primary care physician in cooperation with a psychiatrist.
CASE VIGNETTE
Edna H, a 35-year-old disabled woman, presented for psychiatric care in 1999, 4 years after suffering loss of hearing in one ear and soft tissue injuries in the Oklahoma City bombing. Edna had a history of childhood physical abuse and neglect and reported an episode of mild, untreated depression in her 20s. In addition to having avoided treatment for bombing-related PTSD, major depression, and panic disorder, Edna had not followed up regularly with her primary care physician for preexisting polycystic ovary syndrome, borderline diabetes mellitus, and hypertension, as well as new-onset nonmigraine headaches and unexplained musculoskeletal pain. She believed that her primary care physician did not care about her and he reminded her of her abusing parent. She was referred to an internist whose medical practice included many patients with mental disorders and lifetime histories of trauma. After a protracted time during which trust was repeatedly tested and finally established with her psychiatrist and internist, she began to comply with treatments prescribed by both.
Edna experienced gradual improvement in her PTSD and depression with an SSRI and multimodal psychotherapy. At first a supportive approach built trust and improved stress management skills and socialization. Eventually, therapy combined a psychodynamic approach (exploring past abuse and ensuing trust issues triggered by terrorism and troubled relationships) with a cognitive-behavioral paradigm (identifying and reshaping automatic negative expectations of repeated traumatization as more positive relationships and goals were attained.) Her primary care physician medically managed her diabetes, hypertension, and polycystic ovary syndrome, and encouraged a diet and exercise program designed by Edna to enhance her sense of personal control. Musculoskeletal pain was evaluated but not found to have a medical cause. Edna recognized that her pain was often linked to stress related to trauma reminders and life frustrations. The primary care physician scheduled visits at regular intervals to reinforce health-promoting behaviors and did not refer her to specialists for unsubstantiated physical complaints. Although she did not return to work, Edna reported satisfaction in joining several charitable organizations, making lasting friendships, and pursuing a new hobby of photography.
- Foa EB, Keane TM, Friedman MJ, eds. Effective Treatments
for PTSD: Practice Guidelines from the International
Society for Traumatic Stress Studies. New York:
Guilford Press; 2000.
- Henningsen P, Zimmermann T, Sattel H. Medically unexplained
physical symptoms, anxiety, and depression:
a meta-analytic review. Psychosom Med. 2003;65:
528-533.
References
1. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the national comorbidity survey. Arch Gen Psychiatry. 1995;52:1048-1060.
2. Breslau N, Kessler RC, Chilcoat HD, et al. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit area survey of trauma. Arch Gen Psychiatry. 1998;55:626-632.
3. Kessler RD, Chiu WT, Dernier O, Walters EE. Prevalence, severity and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey replication. Arch Gen Psychiatry. 2005;62:617-627.
4. Perkonigg A, Kessler RC, Storz S, Wittchen HU. Traumatic events and post-traumatic events and post-traumatic stress disorder in the community: prevalence, risk factors and comorbidity. Acta Psychiatr Scand. 2000; 101:46-59.
5. North CS, Nixon SJ, Shariat S, et al. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA. 1999;282:755-762.
6. North CS, Pfefferbaum B, Narayanan P, et al. Comparison of post-disaster psychiatric disorders after terrorist bombings in Nairobi and Oklahoma City. Br J Psychiatry. 2005;186:487-493.
7. Lenze EJ, Miller AR, Munir ZB, et al. Psychiatric symptoms endorsed by somatization disorder patients in a psychiatric clinic. Ann Clin Psychiatry. 1999;11:73-79.
8. North CS. Somatization in survivors of catastrophic trauma: a methodological review. Environ Health Perspect. 2002;110:637-640.
9. North CS, Kawasaki A, Spitznagel EL, et al. The course of PTSD, major depression, substance abuse and somatization after a natural disaster. J Nerv Ment Dis. 2004;192:823-829.
10. Carey PD, Stein D, Zungu-Dirwayi N, et al. Trauma and posttraumatic stress disorder in an urban Xhosa primary care population: prevalence, comorbidity and service use patterns. J Nerv Ment Dis. 2003;191:230-236.
11. de Jong JTV, Komproe IH, Ommeren MV. Common mental disorders in postconflict settings. Lancet. 2003; 361:2128-2130.
12. Henningsen P, Zimmermann T, Sattel H. Medically unexplained physical symptoms, anxiety, and depression: a meta-analytic review. Psychosom Med. 2003;65: 528-533.
13. Smith RC, Gardiner JC, Lyles JS, et al. Exploration of DSM-IV criteria in primary care patients with medical- ly unexplained symptoms. Psychosom Med. 2005;67: 123-129.
14. Gupta MA. Somatization disorders in dermatology. Int Rev Psychiatry. 2006;18:41-47.
15. Tull MT, Gratz KL, Salters K, et al. The role of experiential avoidance in posttraumatic stress symptoms and symptoms of depression, anxiety and somatization. J Nerv Ment Dis. 2004;192:754-761.
16. van der Kolk BA, Pelcovitz D, Roth S, et al. Dissociation, somatization and affect dysregulation: the complexity of adaptation to trauma. Am J Psychiatry. 1996; 153:83-93.
17. McLean LM, Toner B, Jackson J, et al. The relationship between childhood sexual abuse, complex post-traumatic stress disorder and alexithymia in two outpatient samples: examination of women treated in community and institutional clinics. J Child Sex Abuse. 2006;15:1-17.
18. Heim C, Wagner D, Maloney E, et al. Early adverse experience and risk for chronic fatigue syndrome: results from a population-based study. Arch Gen Psychiatry. 2006;63:1258-1266.
19. Waldinger RJ, Schulz MS, Barsky AJ, et al. Mapping the road from childhood trauma to adult somatization: the role of attachment. Psychosom Med. 2006;68:129-135.
20. Clauw DJ, Engel CC Jr, Aronowitz R, et al. Unexplained symptoms after terrorism and war: an expert consensus statement. J Occup Environ Med. 2003; 45:1040-1048.
21. Hoge CW, Terhakopian A, Castro CA, et al. Association of posttraumatic stress disorder with somatic symptoms, health care visits and absenteeism among Iraq war veterans. Am J Psychiatry. 2007;164:150-153.
22. Hassett AL, Sigal LH. Unforeseen consequences of terrorism: medically unexplained symptoms in a time of fear. Arch Intern Med. 2002;162:1809-1813.
23. Nemeroff CB, Bremner JD, Foa EB, et al. Posttraumatic stress disorder: a state-of-the-science review. J Psychiatr Res. 2006;40:1-21.
24. Baker DG, Ekhator NN, Kasckow JW, et al. Plasma and cerebrospinal fluid interleukin-6 concentrations in posttraumatic stress disorder. Neuroimmunomodulation. 2001;9:209-217.
25. Altemus M, Cloitre M, Dhabhar FS. Enhanced cellular immune response in women with PTSD related to childhood abuse. Am J Psychiatry. 2003;160:1705-1707.
26. Pitman RK, Orr SP, Forgue DF, et al. Psychophysiological assessment of posttraumatic stress disorder imagery in Vietnam combat veterans. Arch Gen Psychiatry. 1987;44:970-975.
27. Tucker PM, Pfefferbaum B, North CS, et al. Physiologic reactivity despite emotional resilience several years after direct exposure to terrorism. Am J Psychiatry. 2007;164:230-235.
28. Richardson JD, Elhai JD, Pedlar DJ. Association of PTSD and depression with medical and specialist care utilization in modern peacekeeping veterans in Canada with health-related disabilities. J Clin Psychiatry. 2006; 67:1240-1245.
29. Clancy CP, Graybeal A, Tompson WP. Lifetime trauma exposure in veterans with military-related posttraumatic stress disorder: association with current symptomatology. J Clin Psychiatry. 2006;67:1346-1353.
30. Shariat S, Mallonee S, Kruger E, et al. A prospective study of long-term health outcomes among Oklahoma City bombing survivors. J Okla State Assoc. 1999;92: 178-186.
31. Boscarino JA. Posttraumatic stress disorder and physical illness: results from clinical and epidemiologic studies. Ann N Y Acad Sci. 2004;1032:141-153.
32. Jakovljevi M, Sari M, Nad S, et al. Metabolic syndrome, somatic and psychiatric comorbidity in war veterans with post-traumatic stress disorder: preliminary findings. Psychiatr Danub. 2006;18:169-176.
33. Kang HK, Bullman TA, Taylor JW. Risk of selected cardiovascular diseases and posttraumatic stress disorder among former World War II prisoners of war. Ann Epidemiol. 2006;16:381-386.
34. Kubzansky LD, Koenen KC, Spiro A, et al. Prospective study of posttraumatic stress disorder symptoms and coronary heart disease in the normative aging study. Arch Gen Psychiatry. 2007;64:109-116.
35. Boscarino JA, Chang J. Electrocardiogram abnormalities among men with stress-related psychiatric disorders: implications for coronary heart disease and clinical research. Ann Behav Med. 1999;21:227-234.
36. Spindler H, Pederson SS. Posttraumatic stress disorder in the wake of heart disease: prevalence, risk factors, and future research directions. Psychosom Med. 2005; 67:715-723.
37. Shemesh E, Yehuda R, Milo O. Posttraumatic stress, nonadherence, and adverse outcome in survivors of a myocardial infarction. Psychosom Med. 2004;66: 521-526.
38. Doerfler LA, Paraskos JA. Anxiety, posttraumatic stress disorder, and depression in patients with coronary heart disease: a practical review for cardiac rehabili- tation professionals. J Cardiopulm Rehabil. 2004;24: 414-421.
39. Treating Major Depressive Disorder: A Quick Reference Guide. Based on Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 2nd ed. Arlington, Va: American Psychiatric Association; 2000.
40. Treating Patients With Acute Stress Disorder and Posttraumatic Stress Disorder: A Quick Reference Guide. Based on Practice Guideline for the Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder. Arlington, Va: American Psychiatric Association; 2004.
41. Davidson J, Rothbaum B, Tucker P, et al. Venlafaxine extended release in posttraumatic stress disorder: a sertraline and placebo-controlled study. J Clin Psychopharm. 2006;26:259-267.
42. Foa EB, Keane TM, Friedman MJ, eds. Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. New York: Guilford Press; 2000.
43. Resick PA, Nishith P, Weaver TL, et al. A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. J Consulting Clin Psychol. 2002;70:867-879.
44. Bleiberg KL, Markowitz JC. A pilot study of interpersonal psychotherapy for posttraumatic stress disorder. Am J Psychiatry. 2005;162:181-183.
45. Marks I, Lovell K, Noshirvani H, et al. Treatment of posttraumatic stress disorder by exposure and/or cognitive restructuring: a controlled study. Arch Gen Psychiatry. 1998;55:317-325.
46. Foa EB, Rothbaum BO. Treating the Trauma of Rape. New York: Guilford Press; 1998.
47. Lidbeck J. Group therapy for somatization disorders in primary care: maintenance of treatment goals of short cognitive behavioral treatment one-and-a-half-year follow-up. Acta Psychiatr Scand. 2003;107:449-456.
48. Allen LA, Woolfolk RL, Escobar JI. Cognitive-behavioral therapy for somatization disorder: a randomized controlled trial. Arch Intern Med. 2006;166:1512-1518.
49. Mai F. Somatization disorder: a practical review. Can J Psychiatry. 2004;49:652-662.
50. Walker EA, Unutzer J, Katon WJ. Understanding and caring for the distressed patient with multiple medically unexplained symptoms. J Am Board Fam Pract. 1998; 11:347-356.
|
Five Steps to Improving Patient Access Judy Capko, May 21, 2013 Patient access is getting increased attention through reform initiatives. Here are five steps you can take to make sure patients get appropriate access to care in your office.
SearchMedica SEARCH RESULT
Find peer-reviewed literature and websites for practicing medical professionals
|
