Elizabeth A. Foote, MD

SPECIAL REPORT: TRAUMA IN PSYCHIATRIC PRACTICE

Over half of the population is exposed to at least one lifetime traumatic event, yet relatively few of those exposed have lasting psychiatric sequelae. As psychiatrists, we attend to the needs of those who suffer. In this Special Report, the authors point out that psychiatrists’ clinical practice and trauma research focus more often on disease states and less often on enhancing resiliency factors. They present an approach for identifying trauma exposure within a brief psychiatric evaluation and discuss proposed DSM-5 criteria for developmental trauma disorder in youths.

, describes the problem of extreme stressors that confront individuals who live in violent neighborhoods. He interweaves a case history of an African American patient with trauma underlying her diverse psychiatric chief complaints. He discusses protective and healing factors, such as communities with collective efficacy, and ways that clinicians can help patients develop a sense of mastery over traumatic experiences.

Patricia Watson, PhD, and Yuvall Neria, PhD

, identify constructs of resilience and specific resilience factors related to stress resistance and posttraumatic growth. They suggest psychosocial interventions to promote resilience and emotional growth, drawing from developmental, trauma, and disaster research. The authors further identify biological markers related to resilience and stress responses and touch on current studies of neurochemical systems that may yield pharmacological treatments for PTSD and depression.

Trauma may be experienced throughout life and in many different contexts. Mass shootings and bombings, wars, and natural and man-made disasters all affect large numbers of people and command international media attention. However, much trauma is experienced privately-childhood maltreatment, sexual and physical assault, witnessing violence and death, surviving a life-threatening accident or illness, or suddenly losing a loved one. When problems develop, caregivers need to be sensitive to the pain of exposing raw memories as they explore health and mental health issues associated with extreme stress.

Mental health correlates of trauma include PTSD and other anxiety disorders, mood disorders, and substance use disorders; comorbidity is the rule. Sorting out PTSD symptoms from those of other anxiety, mood, and somatoform disorders is often challenging. Although the type of disaster is not necessarily related to PTSD, North and colleagues

 found that certain demographic factors do predict PTSD, as do a mental health history and being the victim of or a witness to trauma.

Some populations may warrant extra attention by clinicians after trauma exposure. In its consideration of the elderly-who were among the groups at high risk for morbidity after Hurricane Katrina-the American Association of Geriatric Psychiatry noted that the absence of family and other support may be the single most critical factor for adverse outcomes.

 PTSD may be underreported in some older adults as a result of alexithymia. Clinicians should always explore life trauma in the elderly. Because of their emotional salience, traumatic events may be remembered quite well, even in persons with cognitive impairment.

While large-scale epidemiological studies of PTSD in children are lacking, research suggests that children exposed to trauma may have higher PTSD rates than adults.

 PTSD may be overlooked in children, however, because it can present differently than in adults, with disorganized behavior, reenactment of trauma themes in play, and vague dreams.

With respect to race and ethnicity, the prevalence of PTSD was found to be highest among blacks in a large national survey. All minorities were less likely to seek treatment than whites.

Addictive disorders have long been associated with trauma. Traumatic experience, with or without a diagnosis of PTSD, increases the prevalence of later development of substance use disorders. This is especially true of childhood sexual abuse.

 About half of those with PTSD have a comorbid substance use disorder, and one-fourth of adults in substance abuse treatment also carry a diagnosis of PTSD. This subpopulation with comorbid conditions most often misuses alcohol, followed by cocaine, cannabis, and opioids. Those with combined disorders have a worse overall prognosis than do persons with either disorder alone.

 PTSD symptoms themselves are related to increased risk of relapse to substance use and increased severity of use during relapse. Treatment interventions that address both disorders simultaneously provide improved outcomes for both disorders.

Physical health may also be influenced by trauma and PTSD. The role of stressful life events in increasing risk for illness was noted by Holmes in his groundbreaking studies of tuberculosis in the 1950s.

 His group found associations between ketosteroid levels, advanced tuberculosis, and anxiety and depression.

More recent studies have noted diverse changes in the hypothalamic-pituitary-adrenal axis after trauma exposure.

 Alterations in the immune system after psychological stress and in PTSD include changes in cytokines, T cells, and tumor necrosis factor, which may increase susceptibility to infection or trigger inflammatory conditions.

Studies have long documented autonomic nervous system dysregulation, particularly in the cardiovascular system, among PTSD patients and also among trauma survivors, irrespective of PTSD status.

 These changes in bodily homeostasis may contribute to increased rates of health problems noted in trauma survivors. Lauterbach and colleagues

 found that PTSD was predictive of poor health: arthritis, respiratory problems, hypertension, lupus, GI problems, and kidney/liver disease are especially more common.

As psychiatrists, we practice holistic medicine. Our traumatized patients depend on us to uncover their emotional pain delicately, to understand its effects on their minds and bodies, and to recognize and draw on their unique strengths and vulnerabilities as we promote recovery. Our healing art blends talk therapy with often complex pharmacotherapies, with a positive outcome rewarding to both healer and trauma survivor.

North CS, Oliver J, Pandya A. Examining a comprehensive model of disaster-related posttraumatic stress disorder in systematically studied survivors of 10 disasters. 

 Sakauye KM, Streim JE, Kennedy GJ, et al. AAGP position statement: disaster preparedness for older Americans: critical issues for the preservation of mental health. 

Gabbay V, Oatis MD, Silva RR, Hirsch G. Epidemiological aspects of PTSD in children and adolescents. In: Silva RR, ed. 

Posttraumatic Stress Disorder in Children and Adolescents: Handbook.

 Roberts AL, Gilman SE, Breslau J, et al. Race/ethnic differenes in exposure to traumatic events, development of post-traumatic stress disorder, and treatment-seeking for post-traumatic stress disorder in the United States. 

 Triffleman EG, Marmar CR, Delucchi KL, Ronfeldt H. Childhood trauma and posttraumatic stress disorder in substance abuse inpatients.

 Khoury L, Tang YL, Bradley B, et al. Substance abuse, childhood traumatic experience, and posttraumatic stress disorder in an urban civilian population. 

 Lerner BH. Can stress cause disease? Revisiting the tuberculosis research of Thomas Holmes, 1949-1961. 

Klaassens ER, Giltay EJ, Cuijpers P, et al. Adulthood trauma and HPA-axis functioning in healthy subjects and PTSD patients: a meta-analysis. 

 Pitman RK, Orr SP, Forgue DF, et al. Psychophysiological assessment of posttraumatic stress disorder imagery in Vietnam combat veterans. 

 Shalev AY, Peri T, Gelpin E, et al. Psychophysiologic assessment of mental imagery of stressful events in Israeli civilian posttraumatic stress disorder patients. 

 Tucker PM, Pfefferbaum B, North CS, et al. Physiological reactivity despite emotional resilience several years after direct exposure to terrorism. 

 Lauterbach D, Vora R, Rakow M. The relationship between posttraumatic stress disorder and self-reported health problems. 

Articles

Over half of the population is exposed to at least one lifetime traumatic event, yet relatively few of those exposed have lasting psychiatric sequelae. As psychiatrists, we attend to the needs of those who suffer.

Introduction: Mental Health Correlates of Trauma

Traumatic experiences are linked with a continuum of mental disorders and physical complaints. In the United States, posttraumatic stress disorder (PTSD) occurs in approximately 8% of adults during their lifetime, with different trauma types associated with varying rates of illness.

 PTSD is commonly associated with comorbid mental conditions such as depressive disorders, other anxiety disorders, impulse control disorders, and alcohol abuse.

 In addition, trauma survivors often experience physiological changes, onset and exacerbation of medical conditions, unexplained medical symptoms and, less commonly, somatization disorder and other somatoform disorders.

Some comorbid disorders predate trauma and are associated with increased risk for PTSD and some begin after trauma exposure.

 Several of the 3 core symptom clusters of PTSD- re-experiencing, avoidance/numbing, and hyperarousal-may overlap symptoms of major depression. Among the avoidance symptoms in PTSD, diminished interest or participation in activities, restricted affect, and emotional detachment may merge with anhedonic depressive symptoms. The increased arousal symptoms seen with PTSD, including sleep difficulties, irritability, and poor concentration are also characteristic of depression.

Major depression often follows exposure to trauma. In fact, depression is the second most common psychiatric disorder diagnosed by North and colleagues

 in highly exposed survivors of the bombing in Oklahoma City 6 months posttrauma. Perkonigg and colleagues

 noted that in a young German community sample with and without comorbid PTSD, depression commonly occurred after trauma. After a terrorist bombing in Nairobi, depression both predated and occurred after the disaster in highly exposed survivors, second only to PTSD postbombing.

Somatization disorder and unexplained physical symptoms

Somatization disorder (a type of somatoform disorder) is less commonly diagnosed in the general population, occurring in up to 2% of women in the United States and less than 0.2% of men, according to 

. A history of chronic pain and GI, sexual, and pseudoneurological symptoms for which there are no identifiable medical causes are the 

 diagnostic criteria for somatization disorder. This condition has been associated with elevated depressive, manic, and anxiety symptoms.

 Moreover, among the diagnostic criteria for somatization disorder, dissociation may also occur in PTSD, and lack of sexual interest is common with major depression. Studies of individuals with trauma histories vary in their reports of somatization disorder, somatic symptoms, and unexplained medical symptoms, with fully diagnosed somatization disorder being less common.	

 discussed the need for methodological precision in assessing these issues among disaster survivors. Her group noted no cases of somatization disorder in terrorism survivors 6 months postdisaster.

 Similarly, no so- matization disorder was seen in flood survivors, who had few new somatoform symptoms, although PTSD and comorbid depression were diagnosed.

 assessed predominantly poor, single South African females in a primary care setting, who had a high rate of lifetime trauma exposure (94%, n = 189). In this specialized sample, somatization disorder was common (18.4%), and PTSD had high comorbidity with somatization disorder (35%; 

The previously mentioned German sample experienced lower rates of lifetime trauma (21.4%) and an adjusted hazard ratio for any somatoform disorder of 3.85 after traumatic experiences, and of 2.51 in traumatized individuals with earlier PTSD, controlling for trauma characteristics.

 of civilians from postconflict communities in Algeria, Cambodia, Ethiopia, and Palestine reported a significant risk ratio (4.07) for somatoform disorder only in the Palestinian group.

Medically unexplained physical symptoms commonly present in primary care settings and account for a high percentage of disability in the workforce. Symptoms often do not reach the threshold for diagnosis of somatization disorder or other somatoform disorders and can also involve medical syndromes with actual physical findings. Emotional underpinnings have been noted in these conditions. The results of a recent meta-analysis by Henningsen and colleagues

 indicated that 4 somatic syndromes (irritable bowel syndrome, nonulcer dyspepsia, fibromyalgia, and chronic fatigue syndrome) were related to but not fully dependent on depression and anxiety. Findings from another study showed that medically unexplained symptoms were more often associated with depression and anxiety than with somatoform disorders.

 reviewed unexplained cutaneous sensory syndromes as "body memories" of traumatic experiences in PTSD; he focused on the skin as the primary organ of early attachment and communication throughout life that is vulnerable to somatization. The connection between early childhood trauma and somatization has been noted by several groups,

 who saw an association of childhood abuse and the somatic condition, chronic fatigue syndrome. Similarly, Waldinger and associates

 found that childhood trauma was associated with higher levels of somatization and insecure attachment in adults. Unexplained medical symptoms after terrorism and war have also been noted in historical and epidemiological accounts.

Complicating the treatment of traumatized patients, many individuals in whom PTSD develops have measur-able physiological differences compared with individuals without the disorder. These include dysregulation of the hypothalamic-pituitary-adrenal axis,

 differences in brain structure and function,

 and physiological reactivity to trauma reminders.

 Autonomic reactivity may be a consequence of exposure to trauma that is independent of PTSD diagnosis; healthy survivors of terrorism were shown to have higher basal heart rate and heightened autonomic reactivity to trauma reminders than controls many years later, regardless of whether they had PTSD.

 Thus, the question arises: are traumatized individuals with changes in their physiological steady state more aware of internal physical cues that contribute to somatic complaints?

Moreover, do the lasting biological changes noted after trauma contribute to the development of actual medical problems? Veterans with PTSD, especially those with childhood and other trauma, have been shown to have greater medical care utilization.

 noted that up to one third of the survivors of the Oklahoma City bombing reported a worsening of medical conditions 1.5 to 3 years later. Chronic combat PTSD, especially comorbid or complex PTSD, has been associated with a high rate of autoimmune diseases, including rheumatoid arthritis, psoriasis, insulin-dependent diabetes, and thyroid diseases. Boscarino

 proposed that biological mediators of these conditions may be associated clinically with higher T-cell counts, hyperreactive immune responses on delayed cutaneous hypersensitivity tests, higher IgM levels, and lower dehydroepiandrosterone levels. Veterans with PTSD have been noted in some studies to have more medical problems, including the metabolic syndrome.

Cardiovascular morbidity in particular has been noted among veterans with PTSD.

 A large prospective study demonstrated an association between PTSD symptoms and coronary heart disease after controlling for depressive symptoms.

 Chronic sympathetic arousal arising from anxiety may contribute to the progression of coronary heart disease through reduced heart rate variability; increased sympathetic and decreased parasympathetic activity are linked to ventricular arrhythmias and sudden death. PTSD has been associated with a greater risk for cardiovascular disease, atrioventricular conduction defects on ECG, and infarctions, while depression has been associated with arrhythmias.

Although PTSD and depression are often comorbid, their pathophysiology may differ.

 While both are associated with increased levels of corticotropin-releasing factor, PTSD is characterized more by low cortisol levels, whereas depression is characterized more by high levels of cortisol. Cardiac outcome would be most favorable with treatment that targets not only depression but also core PTSD symptoms.

 Patients with PTSD are likely to not adhere to medical treatments

; both treating psychiatrists and primary care physicians caring for patients with cardiac problems must address this problem.

How then can we best help traumatized patients who may present with complex and varying patterns of PTSD, depression, physiological changes, unexplained medical symptoms, and primary medical problems? All patients with psychiatric symptoms, regardless of age or presenting problems, should be asked about past and ongoing trauma. Trauma exposure should be explored over time, even if denied on initial assessment, because patients may not reveal trauma until a trusting bond is established with the clinician. Psychiatrists should consider possible trauma in patients with patterns of anxiety, substance abuse, depression, and unexplained medical complaints. Patients with histories of trauma who present with somatic complaints should be referred to a primary care physician to detect undiagnosed medical problems that may be worsened by ongoing stress. After a thorough medical evaluation, unexplained physical symptoms and subclinical somatization disorder may respond to psychiatric treatments found effective in diagnosed somatization disorder.

Depression following trauma should be managed with evidence-based treatments such as those recommended by the American Psychiatric Association Practice Guidelines.

 The treatment of choice for moderate to severe episodes is antidepressants (or electroconvulsive therapy [ECT]) with antipsychotics added as needed. Psychotherapy alone is recommended in mild to moderate depression if preferred by the patient, or in combination with medication. For moderate to severe depression, psychotherapy may be combined with medication or ECT. Combined antidepressant treatment and psychotherapy may also help depression complicated by a personality disorder or significant psychosocial issues such as past or ongoing trauma or interpersonal problems.

Patient preference and clinician expertise should be taken into account when deciding on psychotherapeutic methods, with choices among cognitive-behavioral, interpersonal, and psychodynamic therapies. Psychodynamic therapy may benefit depression following early childhood trauma and may be especially helpful with personality disorders, problematic adult relationships, and trust issues.

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.

 Tricyclic antidepressants and monoamine oxidase inhibitors may also help, with a norepinephrine-serotonin reuptake inhibitor also of potential benefit.

 In addition, anticonvulsants, atypical antipsychotics, α

-adrenergic agonists, and ß-adrenergic blockers as monotherapy or adjunctive therapy may improve symptoms.

 Various forms of cognitive and behavioral psychotherapies can desensitize patients to trauma memories and environmental triggers, with demonstrated efficacy in treating PTSD.

 Empirically supported treatments include exposure therapy

 Stress inoculation and trauma-focused group therapies may also be useful.

Formal guidelines for treating somatization disorder are lacking, although successful treatment with cognitive- behavioral therapy (CBT) has been demonstrated.

 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.

 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 associates

 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.

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.

 Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the national comorbidity survey. 

 Breslau N, Kessler RC, Chilcoat HD, et al. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit area survey of trauma. 

 Kessler RD, Chiu WT, Dernier O, Walters EE. Prevalence, severity and comorbidity of 12-month 

 disorders in the National Comorbidity Survey replication. 

 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. 

 North CS, Nixon SJ, Shariat S, et al. Psychiatric disorders among survivors of the Oklahoma City bombing. 

 North CS, Pfefferbaum B, Narayanan P, et al. Comparison of post-disaster psychiatric disorders after terrorist bombings in Nairobi and Oklahoma City. 

 Lenze EJ, Miller AR, Munir ZB, et al. Psychiatric symptoms endorsed by somatization disorder patients in a psychiatric clinic. 

 North CS. Somatization in survivors of catastrophic trauma: a methodological review. 

 North CS, Kawasaki A, Spitznagel EL, et al. The course of PTSD, major depression, substance abuse and somatization after a natural disaster. 

 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. 

 de Jong JTV, Komproe IH, Ommeren MV. Common mental disorders in postconflict settings. 

 Henningsen P, Zimmermann T, Sattel H. Medically unexplained physical symptoms, anxiety, and depression: a meta-analytic review. 

 Smith RC, Gardiner JC, Lyles JS, et al. Exploration of 

 criteria in primary care patients with medical- ly unexplained symptoms. 

 Gupta MA. Somatization disorders in dermatology. 

 Tull MT, Gratz KL, Salters K, et al. The role of experiential avoidance in posttraumatic stress symptoms and symptoms of depression, anxiety and somatization. 

 van der Kolk BA, Pelcovitz D, Roth S, et al. Dissociation, somatization and affect dysregulation: the complexity of adaptation to trauma. 

 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. 

Traumatic experiences are linked with a continuum of mental disorders and physical complaints. In the United States, posttraumatic stress disorder (PTSD) occurs in approximately 8% of adults during their lifetime, with different trauma types associated with varying rates of illness. PTSD is commonly associated with comorbid mental conditions such as depressive disorders, other anxiety disorders, impulse control disorders, and alcohol abuse.

Elizabeth A. Foote, MD

Articles

Introduction: Mental Health Correlates of Trauma

Trauma and the Mind-Body Connection