Resultant physiological changes
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,23 altered immunological measures,24,25 differences in brain structure and function,23 and physiological reactivity to trauma reminders.26 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.27 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.28,29 Shariat and colleagues30 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. Boscarino31 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.32
Cardiovascular morbidity in particular has been noted among veterans with PTSD.33 A large prospective study demonstrated an association between PTSD symptoms and coronary heart disease after controlling for depressive symptoms.34 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.35
Although PTSD and depression are often comorbid, their pathophysiology may differ.36 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.37 Patients with PTSD are likely to not adhere to medical treatments38; both treating psychiatrists and primary care physicians caring for patients with cardiac problems must address this problem.39
Diagnosis and treatment
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.40 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.
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