Posttraumatic Stress in Medically Ill Patients

A major physical illness or procedure, such as a myocardial infarction (MI), a transplant operation, or a life-threatening attack of asthma, can be emotionally traumatic,^1,2 but the study of posttraumatic reactions in the medically ill is relatively new. Only in the past 2 decades or so it has been recognized that, in fact, medical illness and its treatment can be traumatic, and only since the publication of DSM-IV in 1994 has medical illness been included as a potentially traumatic event that may lead to the development of posttraumatic symptoms. Consequently, many patients and their physicians are not fully aware of the potential of medical illness and procedures to cause symptoms that are similar to those experienced by victims of other traumas, such as combat- related trauma. It is now known that almost all patients who survive an acute medical illness or procedure report some symptoms of posttraumatic stress, and as many as 30% may meet criteria for a psychiatric disorder related to the experience.^1,3

Rachel is a 55-year-old married woman with 2 adolescent children. She comes to a consultation 1 year after she has had an MI. Since that time, she has not slept well, her appetite has substantially decreased, she thinks that she will die soon, and she has not been able to return to work.

On further evaluation, it seems that Rachel is not sleeping well because of recurrent nightmares about having a second MI. In fact, she reports no less than 10 visits to the emergency department in the past year because she felt as though she was "having it all over again." She believes that she will not be alive next year, and therefore "what is the purpose of continuing to work or caring for my children, if I am going to die soon anyway?" She finds it hard to keep her appointments with the cardiologist because "it is stressful to see these doctors again and again. . . . I just can't handle it anymore. No one understands me. My family is not aware of the things I have gone through, and the doctors treat me as though I am well. They even joke with me about these horrible chest pains."

Rachel is a fictional character, but when she complains of not being understood, she is echoing the complaints of many real-world patients. It is important that we at least try to understand their plight. In this article, the importance of correct recognition and treatment of posttraumatic stress symptoms along with depression and general anxiety in a subset of medical patients who are emotionally traumatized by their illness is emphasized. The discussion will use Rachel's case as a framework to translate theoretical considerations into clinically useful information.

It has been known for at least a decade that depression is common and debilitating in patients with cardiovascular illness,⁴ and indeed the reader might think that Rachel is experiencing a major depressive disorder. However, while depression is possible, the distress that Rachel feels seems to be more consistent with a stress disorder.

The treatment of trauma survivors may be different from the treatment of patients who may have similar symptoms but have not been traumatized in the usual sense of the word. It is important to recognize that medical illness can be traumatic because this understanding could inform specific interventions and the management of symptoms of distress as well as depression in the affected patient. Of note, trauma survivors may suffer from a whole spectrum of symptoms, including depression and anxiety.^1,3 Posttraumatic stress is not the only outcome of traumatization, and it is not even the most common one.

When addressing the traumatic impact of a medical illness or its treatment, the clinician will probably need to manage symptoms that are consistent with depression, anxiety, or even behavioral disturbances (particularly in children). These symptoms are consistent with a diagnosis of major depressive disorder. Indeed, a co-occurrence of symptoms of posttraumatic stress with symptoms of depression is the rule rather than the exception in patients with cardiovascular illness^3,5 and probably other medical illness as well.¹

Whether Rachel has depression, posttraumatic stress, or both may not be easy to discern, but it may not be important to make the distinction. Targeting the impact of the traumatic event could be approached in the same way—whether it has caused depression, distress, or posttraumatic stress.

Trauma-focused treatment directly addresses the cause of the symptoms in addition to the symptoms themselves, with the hope that eliminating the cause would also eliminate the symptoms. In that, it is akin to many medical treatments that strive to correct the root of a problem as opposed to targeting a specific constellation of symptoms. For example, the treatment of hemolytic anemia would strive to identify and correct its cause, whether it manifests with jaundice, fatigue, and so on. Certainly both jaundice and fatigue would be eliminated if the anemia is corrected. Conversely, the treatment of jaundice (a symptom) may be entirely different depending on the cause: if hemolytic, a certain set of possibilities exist, if caused by liver failure, a completely different set of treatments is appropriate. Similarly, the treatment of depression or anxiety in the absence of traumatization may not be the same as the treatment of depression or anxiety in the context of a traumatic experience.⁵