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
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