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.1,2 PTSD is commonly associated with comorbid mental conditions such as depressive disorders, other anxiety disorders, impulse control disorders, and alcohol abuse.2 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.3,4 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 colleagues5 in highly exposed survivors of the bombing in Oklahoma City 6 months posttrauma. Perkonigg and colleagues4 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.6
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 DSM-IV-TR. A history of chronic pain and GI, sexual, and pseudoneurological symptoms for which there are no identifiable medical causes are the DSM diagnostic criteria for somatization disorder. This condition has been associated with elevated depressive, manic, and anxiety symptoms.7 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.
North8 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.5 Similarly, no so- matization disorder was seen in flood survivors, who had few new somatoform symptoms, although PTSD and comorbid depression were diagnosed.9 Carey and colleagues10 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%; P < .01).
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.4 The assessment by de Jong and coworkers11 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 colleagues12 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.13
Gupta14 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,15-17 including Heim and colleagues,18 who saw an association of childhood abuse and the somatic condition, chronic fatigue syndrome. Similarly, Waldinger and associates19 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.20-22
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.