Stress-Related Disorders in Primary Care
June 1, 2022 33 minutes read
AUTHOR
Ellen Feldman, MD, Altru Health System, Grand Forks, ND
PEER REVIEWER
Glen D. Solomon, MD, FACP, Professor and Chair, Department of Internal Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH
EXECUTIVE SUMMARY
More than 80% of U.S. adults can expect to experience a traumatic event during their lifetime.
- The current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) outlines criteria for a newer category of “Trauma and Stress-Related Disorders,” including post-traumatic stress disorder (PTSD), acute stress disorders, adjustment disorders, and unspecified trauma and stressor-related disorders.
- Subpopulations within the United States show higher rates of PTSD, including Native Americans living on reservations, refugee populations, and individuals with military experience.
- Approximately 50% of individuals with PTSD also have major depressive disorder. Other common comorbidities include anxiety disorder and substance use disorder. Heart disease, obesity, and autoimmune disorders also can be related to PTSD.
- Screens in mental health may be helpful in deciding the direction of the interview but are not diagnostic tools. The Primary Care PTSD Screen for DSM-5 perhaps is the most efficient and specific screen for primary care practices.
- Trauma-informed care is an approach that emphasizes developing and supporting an emotionally, physically, and culturally sensitive and safe environment for staff and patients.
- The first step in treatment is identifying target symptoms causing functional impairment. PTSD may be treated with psychotherapy, medication, or a combination of the two.
- Having a disorder of mental health is a general risk factor for suicide attempts and completed suicide. Refer patients with high-risk factors and suicidal intention to a specialist. There is growing evidence that collaborative care models, with a team led by the primary care provider and involving mental health professionals, including psychiatry and case management, lead to efficient and effective care for more complex, higher-risk patients.
Writing this paper, I am transported back to the time when I was a young psychiatrist, fresh out of residency, working on the consult and liaison service of a busy general hospital. There I learned the importance of asking about abuse, neglect, and early traumatic experiences. It was there, next to the beds of patients with chronic pain, uncontrolled diabetes, and heart disease, that I learned to connect the dots between early trauma and adult illness. That was in the 1980s. Since that time, our understanding of “invisible trauma” and its effect on the mind and body has grown, but there remains much to be explained.
More than 80% of U.S. adults can expect to experience a traumatic event during their lifetime. Part of the difficulty in pinpointing a more exact measurement stems from an inconsistent definition of the term “trauma,” patient hesitancy in disclosing traumatic experiences, and provider discomfort recognizing and addressing the aftermath of trauma. Yet, these damaging experiences, especially during early development, contribute to adult morbidity and mortality.1,2
In recognition of the importance of developing a uniform understanding of “trauma,” the Substance Abuse and Mental Health Services Administration (SAMHSA) put forth the following definition of trauma: “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”3
Consider this patient scenario:
Shara, a 32-year-old third-year medical student, presents for evaluation of a sleep disturbance that has begun to interfere with clinical duties. “I have been able to get by with little sleep since age 10,” she says, “but with the demands of medical school and now rotations, I think I need a back-up plan.” A physical examination reveals a meticulously groomed, professional young woman with a benign exam except for the curious finding of numerous well-healed, faint scars horizontally on the plantar aspect of the right forearm and scattered razor-thin cuts on the upper thigh in various stages of healing.
The primary care clinician is presented with a dilemma. A workup for the sleep disturbance is a priority. Yet, the pattern of cuts and scars is not explained by her medical history and are consistent with self-harm. Both self-harm and sleep problems are found in survivors of traumatic events, but neither is pathognomonic.4 An empathic approach to this patient may help develop a more nuanced understanding of the origins of the sleep disturbance and provide expanded treatment options. However, time limits and comfort in broaching and discussing such a relationship are among barriers that prevent many clinicians from pursuing this line of history-taking.5
Implementing universal trauma-informed practice strategies and techniques can assist in addressing situations such as this one in a timely and clinically appropriate manner. Recent studies note both patient satisfaction scores and patient engagement increase after primary care practices adopt strength-based trauma-informed care.5,6
Traumatic events are major risk factors for the development of various chronic diseases, including mental disorders, such as depression, post-traumatic stress disorder, complex post-traumatic stress disorder (a newly recognized condition), substance use disorders, and chronic medical conditions, such as cardiovascular disorders, obesity, and autoimmune disorders. These relationships stem from a complex interplay of factors that come into play following traumatic experiences, including neuroendocrine and epigenetic changes, persistent state of anxiety, stigma (delaying treatment and leading to feelings of shame and self-blame), and unhealthy coping skills.7,8
Our medical education trained most of us to recognize and respond to physical trauma, but the recognition and treatment of the aftermath of emotional trauma is not as clear-cut.
This paper discusses invisible trauma in the practice of primary care, including prevalence, recognition, presentation, and, ultimately, how best to address and manage patients with stress-related symptoms in the primary care setting.
History and Current Research Directions
“If everything is ‘trauma,’ is anything?” asks a recent opinion piece in The New York Times, reflecting the shift in how the word “trauma” has migrated from medical terminology into a mainstream culture “buzz word” with attached social capital. There is concern that without a nuanced approach, diluting the term “trauma” can undermine recognition and treatment.9
Although the social adaptation of trauma into everyday vocabulary is a product of our times, descriptions of symptoms arising after traumatic experiences are found throughout history. Cuneiform tablets from the region of Mesopotamia during the Assyrian dynasty depict soldiers with symptoms, such as slurred speech, nightmares, and flashbacks, who were thought to be haunted by ghosts.10 In 490 B.C., Herodotus described functional blindness in an Athenian soldier after battle.11 Shakespeare, in the 1500s, peppered tales with descriptions of stress symptoms after trauma, perhaps most famously in Henry IV (Part 1), when Lady Percy eloquently notes sleeplessness, nightmares, and disturbance of the “spirit within thee” in her husband who has just returned from battle.12
The term “soldiers’ heart,” coined during the Civil War, described a constellation of symptoms noticed in combatants returning from battle, including heart palpitations, fatigue, and shortness of breath. This may represent one of the earliest recognitions of medical problems arising from trauma.13,14
Toward the end of the 19th century, as the influence of Sigmund Freud and his followers spread, women with unstable emotions post-trauma were labeled with a diagnosis of “hysteria” thought to be gender-specific and, in part, a result of “feminine weakness” (an unfortunate link perhaps still contributing to stigma today). Neurologist Jean-Martin Charcot later broadened the concept to apply to both sexes and modified the term to “traumatic hysteria.”13,14
World War I launched a renewed interest in the effect of wartime trauma. “Shell-shock” described a plethora of symptoms seen in soldiers worldwide, ranging from involuntary tics to functional paralysis to debilitating depression and anger outbursts. Treatments ranged from imposing more discipline on troops to supportive psychotherapy to electric shock therapy, with no comprehensive plan or understanding of the overall syndrome. During World War II, with psychiatrists managing most cases, nearly 4.1 million of the 16.1 million U.S. soldiers serving in this devastating conflict were treated for “combat fatigue.” Ultimately, this diagnosis was responsible for nearly 40% of all discharges.13,14
The first publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952 categorized symptoms of stress after trauma as a type of depression or as a manifestation of another disorder, such as anxiety or psychosis. Unfortunately, without a specific diagnostic category, opportunity for research and further investigation into this syndrome was limited.
However, by 1980, with another wave of veterans needing treatment, post-traumatic stress disorder (PTSD) was recognized and characterized in the third edition of DSM. Twelve years later, in 1992, the International Classification of Diseases (ICD) recognized this disorder as well.13-15
Research since the 1980s has provided an expanded definition and understanding of the aftermath of trauma. Symptoms, such as flashbacks, hopelessness, hyper-reactivity, and hypervigilance, are noted not only in soldiers returning from war, but also in survivors of a range of traumatic experiences, including accidents, assault, abuse, domestic violence, mass shootings, health crisis, and natural disasters. In recognition of the heterogeneity of trauma and the range of reactions to traumatic events, the current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) outlines criteria for a newer category of “Trauma and Stress-Related Disorders,” including PTSD, acute stress disorders, adjustment disorders, and unspecified trauma and stressor-related disorders.15,16
DSM-5 takes a broad-based approach to PTSD. In contrast, the recently released ICD-11 contains a narrower definition of PTSD but adds a new diagnostic category called “Complex PTSD” (CPTSD.) This newly recognized, more impairing disorder represents the understanding that under some circumstances, trauma can significantly affect self-image, emotional regulation, and relationships, and can lead to dysfunction in each of these areas. The development of either PTSD or CPTSD is unrelated to the type of trauma experienced, but prolonged, sustained trauma is more likely to result in CPTSD.15-17
ICD-11 acknowledges that cultural influences may play a role in symptom expression and that predisposing factors, including environment and access to resources, significantly affect outcomes.17,18
Ongoing research in this field conceptualizes systemic racism as a risk factor for the development of PTSD or CPTSD, noting the helplessness and anxiety fueled by microaggressions and intergenerational trauma may shape emotional responses reminiscent of symptoms seen in these disorders.19
Other research stems from the results of the landmark 1990s study involving adverse childhood experiences (ACE), revealing a direct link between the experience of childhood trauma and adult chronic disease in 17,000 patient participants. Notably, this study showed a graded relationship between the number of adverse experiences of childhood and adult-onset disorders of mental health, substance abuse, and chronic illnesses. A higher number of ACEs was associated with a significant elevated risk for multiple health conditions, especially in patients experiencing four or more childhood traumas.20
More recent research is looking into epigenetic changes after trauma, with multiple studies investigating alterations in deoxyribonucleic acid (DNA) methylation, specifically after childhood maltreatment.21
Research focusing on treatment and on best practices to achieve remission of symptoms of PTSD, CPTSD, and other stress-related disorders, emphasizes that a focus on strength and resiliency is key in this area.22
Returning to Shara, the medical student:
The primary care clinician asks Shara more about the characteristics of her sleep, history, and past interventions for sleep. Shara mentions that her routine was to sleep from midnight to 6 a.m., but a recent emergency room rotation disrupted this pattern, and she could not adjust. “I worry that I am not cut out for medicine,” she notes. “Some nights I was so upset by what I saw I couldn’t sleep at all. The stuff that happens to children — that was the worst. It was hard to get up the next day, and a few times I was late.” The provider sees an opening and asks Shara how she coped with emotionally disturbing times in the past. Shara smiles ruefully and holds out her arm with the signs of old cuts.
Diagnostic Criteria
To better understand trauma-related symptoms, it is useful to be familiar with the DSM-5 criteria for PTSD and ICD-11 criteria for PTSD and CPTSD.16,18,23 Table 1 summarizes these two diagnostic systems.
Table 1. DSM-5 and ICD-11 Criteria for Diagnosing Post-Traumatic Stress Disorder |
DSM-5 criteria for a diagnosis of PTSD (6B40):16 |
A. Exposure to a traumatic event. Exposure may be direct, witnessed, or learned (when the traumatic event occurs to a person close to the patient). B. At least one of the following intrusive symptoms: 1. Recurrent distressing memories; 2. Recurrent distressing dreams; 3. Flashbacks, often with dissociation (as if the event was reoccurring;) 4. Psychological distress and/or physiologic reactions after “triggers” or cues that remind the patient of the event. C.Persistent avoidance of reminders of the event as evidenced by avoiding distressing memories and reminders of the event and/or avoiding external reminders (including people, places, situations, etc.) D. Changes in mood and cognition after the event, with at least two of the following present: 1. Inability to remember important details of the event; 2. Persistent negative self-image or negative expectations of others; 3. Persistent distorted conceptualization about cause or consequences of the event; 4. Persistent negative emotional state; 5. Significant decline in interests; 6. Detachment/estrangement; 7. Persistent inability to feel positive emotions. E.Change in arousal and reactivity after the event, with two or more of the following: 1. Aggressive outbursts with little to no provocation; 2. Self-destructive or reckless behavior; 3. Hypervigilance; 4. Excessive startle reaction; 5. Concentration difficulties; 6. Sleep disturbance. F.Duration of criteria A-E is more than one month G. The symptoms cause clinically significant distress or impairment and are not attributable to any other medical condition or to substance use. |
ICD-11 describes PTSD as: Exposure to event(s) of “extremely threatening or horrific nature.” Symptoms occur from the three core categories, last for several weeks or more, and cause impaired functioning. Typically, onset occurs within a few months of the stressor, but may be delayed.17,18 |
Symptom presentation is influenced strongly by cultural factors and age/developmental stage of life, and may include:17,18
Complex PTSD (6B41):
|
DSM-5: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; ICD-11: International Classification of Diseases 11th Revision |
Notes:
- It is worth highlighting points F and G in the DSM-5. The symptoms must have lasted more than one month, cause functional impairment, and not be attributable to another medical condition or substance use.16,23
- When considering ICD-11 criteria for PTSD and CPSTD, note that these diagnoses are mutually exclusive.18
Adjustment disorder is a distinct diagnosis, different than either PTSD or CPTSD, but residing with these in the same general category of stress-related disorders. The DSM-5 and ICD-11 classification systems recognize adjustment disorder as a maladaptive response to a life event(s) with symptoms that resolve within six months of resolution of the stressor. Notably, the precipitating event may or may not be experienced as traumatizing (as opposed to PTSD or an acute stress reaction).16,17
Both classification systems allow leeway to diagnose either unspecified or specified (such as persistent, complex bereavement disorder) trauma- and stressor-related disorder when the full PTSD criteria are not met.
In these cases, there still must be functional impairment from the post-traumatic stress symptoms, such as sleep or concentration disturbances that disrupt the ability to engage in age-appropriate activities and/or relationships and the impairment extends beyond the time of expected resolution of an adjustment disorder (six months from the end of the stressor).17,18,23
Back to Shara:
“My dad was a hard-working, successful lawyer and he was never home. He raised me after my mom left, which in some ways was good (her leaving) because my mom and dad had horrible fights. I still remember the midnight shouting matches, and once the police came. I think when she left my sleep problems started,” says Shara. “It was so quiet and only an older neighbor was with me at night. I always felt alone and scared, and one night I started to cut — it took my mind off being afraid. I stopped cutting in college and didn’t even think about doing it again until a few months ago.”
Epidemiology
Exposure to a traumatic event during a lifetime is common, but research on the prevalence and incidence of PTSD and/or CPTSD is limited.
Several studies have looked at the risk of developing PTSD and/or CPTSD following exposure to trauma. Most of the U.S. studies, conducted with veterans, have found that at least 15% of this population develops long-lasting, impairing symptoms meeting criteria for a PTSD or CPTSD diagnosis.
Other studies among the general U.S. population estimate that about 20% of individuals exposed to trauma will develop symptoms meeting criteria for one of these disorders.24,25
The National Comorbidity Study, conducted from 2001-2003 using DSM criteria, calculated the lifetime prevalence of PTSD among the general adult U.S. population at 6.8%. A 2016 national study calculated the one-year prevalence of this disorder at 3.5% to 4.7%.26
Subpopulations within the United States show higher rates of PTSD, including Native Americans living on reservations, refugee populations, and individuals with military experience.27 Notably, rates of PTSD outside of the United States tend to be lower than within the United States. For example, in 2017, the World Health Organization (WHO), using data from more than 71,000 individuals and 26 populations, found a lifetime prevalence of PTSD of 3.9% of the total and of 5.6% among individuals exposed to trauma. Part of the discrepancy in rates may be the result of differences in methodology and definitions of PTSD.28
Studies looking at the prevalence of PTSD among primary care practices have found a disproportionally high representation of individuals with this diagnosis among patients presenting to a primary care clinician. The location of the clinic and population served often are key in determining the rate of PTSD, with some inner-city clinics seeing the prevalence of PTSD in up to 23% of the practice.29
Popular media is rife with questions, concerns, and “facts” about stress reactions related to the COVID-19 pandemic.30,31 Acute stress reactions after pandemics are well-documented in medical studies, but there is controversy in the literature about the prevalence and risk factors associated with development of a more long-lasting mental health disorder, such as PTSD, during and after infectious disease pandemics.32 With the hope of shedding light on this subject, Yuan et al published a meta-analysis pooling information from 88 studies regarding pandemics of the 21st century (including severe acute respiratory syndrome, H1N1, Ebola, Zika, and COVID-19) and subsequent development of PTSD.33
The findings from this investigation included an elevated prevalence of PTSD to 22.6% of the general population post-pandemic, with prevalence of up to 16.9% in healthcare workers.33 It is likely more information will accumulate in the next few years, as the world deals with the aftereffects of the COVID-19 pandemic. Given these statistics and the widespread effect of the recent pandemic, it is likely the prevalence of patients with PTSD presenting to primary care will increase accordingly.
PTSD Comorbidities
PTSD (and, presumably, CPTSD, although studies are lacking, given the newness of this diagnosis) often presents with a comorbid disorder. Approximately 50% of individuals with PTSD also have major depressive disorder. Sorting out symptoms of each can be challenging; a detailed history is helpful. Recent genetic studies looking at this relationship suggest that PTSD may more accurately be viewed as a subtype of depression.34,35
Other common comorbidities include anxiety disorder and substance use disorder. Again, a detailed history and timeline of the trauma and symptom onset are helpful in sorting out these conditions. Although it may be possible to treat a substance use disorder without addressing the underlying trauma, substance use treatment often is more effective when the trauma also is a focus of treatment and vice versa. Concurrent treatments for these conditions are promising and show safety and efficacy greater than the more traditional sequential treatments.36
Stress-Related Disorders and Association with Chronic Disease
Our bodies respond to stress with release of “stress” hormones: epinephrine, norepinephrine, and cortisol. This response is adaptive and protective in the short run (such as during sports, performance events, or an emergency), but a chronic stress response can be harmful. In the latter case, a cascade of reactions, including dysregulation of circadian cortisol rhythm and dysregulation of the immune response via activation of the hypothalamic-pituitary-adrenal axis, portend a vulnerability to disease states.37
Results of studies looking at stress as a risk factor in chronic illness and disease states are mixed, and research continues in this area. Specifically, diverse methodology of studies are barriers to conclusive evidence of the role of stress in cancer and gastrointestinal illnesses. It is becoming increasingly clear that genes and the environment play important roles in mediating the stress response and the effect on an individual.38-40 The role of stress-related disorders in some of the more well-researched areas are reviewed in the following sections.
Perhaps the most convincing evidence of a link between stress disorders and physical illness comes from studies of PTSD and coronary vascular disorders (CVD). Multiple studies have confirmed a significantly higher risk of heart disease in persons diagnosed with PTSD, even with multifactorial adjustment for confounding variables (such as smoking status and weight).40 Follow-up studies after the Sept. 11, 2001, attacks revealed an elevated risk for CVD of 1.7 times for individuals diagnosed with PTSD vs. persons without this diagnosis. Twin studies have confirmed this association as well.41
Obesity is a major risk factor for numerous disease states and also is intimately connected with stress. Although not every individual with a stress disorder is obese and not everyone with obesity has a stress disorder, the connection between these two conditions seems to be bidirectional and determined in part by biologically determined glucocorticoid sensitivity. The effect of this sensitivity is amplified during a stress response.42
A recent long-term study looked at the risk of autoimmune disorders in more than 100,000 U.S. service members diagnosed with PTSD , adjusted for multiple variables (including combat experience) found a 52% higher risk of developing any of the following: systemic lupus erythematosus, inflammatory bowel disease, rheumatoid arthritis, or multiple sclerosis vs. peers without a PTSD diagnosis. While research is ongoing regarding mechanism and individual risk factors, this study joins others linking stress-related disorders to autoimmune disorders.43
Presentation to Primary Care
Research shows that most any traumatic event can lead to negative health consequences, with or without the development of full-blown PTSD or CPTSD.44 Developing a nuanced view of trauma and its aftermath (sometimes termed a “trauma-focused lens”) allows a provider to look beyond criteria for a specific diagnosis and consider the many ways a patient with a history of experiencing trauma may interact with the health system.
Specific symptoms related to a stress response that may interfere with healthcare include negative expectation of others, hypervigilance, and persistent avoidance of thinking about or talking about the traumatic event. These symptoms make it challenging for patients to establish a trusted relationship with a provider; certainly, it also is challenging for a provider to understand the extent of a traumatic event when a patient actively avoids such a discussion. Notably, effective treatment can begin only once the disorder is recognized.45
Twelve years ago, a 2010 study surveying 800 primary care providers (PCPs) found that only 29.6% of these professionals routinely screened adult patients for past experiences of trauma. Time constraints, personal discomfort, and concerns about patient comfort all were identified as barriers to taking this history.46 Yet, despite the growth of evidence since that time regarding the association between childhood trauma and health, there is little evidence PCP comfort with this topic has increased. In fact, a 2021 survey of 168 family medicine residents identified a gap in resident training about this very issue, with 30% of the residents reporting no knowledge of the findings of the ACE study, 75% reporting discomfort addressing a patient’s history of sexual abuse, and almost half reporting discomfort addressing a patient’s history of witnessing physical abuse. Notably, 84% of the residents indicated they would like more training in this area integrated into the curriculum.47
The perspective of patients with a history of traumatic experiences is equally important to consider. A 2012 study of 23 patients with a history of traumatic experiences revealed that more than half felt “ignored or overlooked” by a family practice provider.48
A more recent study of 152 primary care adult patients (42% with four or more ACEs) in a low-income, predominately Latino neighborhood found that almost all of the respondents were comfortable with providers asking about a history of traumatic experiences and including the history in medical records. More than 70% of these patients endorsed a belief that the clinician was equipped to assist a patient with medical problems associated with ACEs.49
These findings were remarkedly similar to a much earlier (1992) study conducted with higher income, white patients. It appears that patient comfort and willingness to discuss ACEs exceeds current levels of provider training and experience.50
The National Institute for Health Care and Excellence (NICE) in the United Kingdom presents guidelines relevant to the PCP to recognize and treat patients presenting with symptoms related to trauma. Most importantly, the NICE guidelines emphasize the PCP should proactively ask about past trauma, especially in patients presenting with medically unexplained physical symptoms, such as gastrointestinal distress, pain, headache, and sleep problems, as well as general relationship difficulties, obesity, and substance abuse.51 SAMHSA guidelines are similar and encourage the provider to use open-ended questions rather than checklists and aim for a general description of the trauma, rather than details, especially during an initial encounter.52
Along these same lines and with more concrete advice, the University of Washington Advancing Integrated Mental Health Solutions (AIMS) guidelines for clinicians interviewing patients about traumatic experiences include:
- Encourage and accept a brief and concise description of the trauma to understand the context without overwhelming the patient.
- Ask open-ended questions, turn toward the patient (turn away from the computer or a checklist), and listen carefully, with appropriate eye contact.
- If a patient stops talking abruptly, this may indicate dissociation (a coping technique to distance oneself from overwhelming memories). An empathic statement (“I appreciate this is difficult for you”) or gentle touch can provide grounding for the patient.53
Screens in Primary Care
Screens in mental health may be helpful in deciding the direction of the interview but are not diagnostic tools. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) perhaps is the most efficient and specific screen for primary care practices. This is a five-item, binary (yes or no) checklist preceded by a query about exposure to a traumatic event; if there has been no exposure to a traumatic event, the individual is “screened out.” For those patients who continue with the checklist, a score of 3 or higher on the scale is a presumptive positive result.
The five items on the PC-PTSD-5 ask about:
- Nightmares or intrusive thoughts
- Avoidant behaviors
- Hypervigilance
- Feeling numb or detached
- Guilt or self-blame about the event or aftermath54
Shara scores a 2 on the PC-PTSD-5 screen, below the cut-off for PTSD, but she does endorse shame/guilt and avoidant behaviors. She says she is willing to consider that the sleep problems could be connected to traumatic experiences of her youth, stating, “I never considered that before. I just thought I was a poor sleeper, but I always blamed myself for my mother leaving and then the cutting — I never wanted anyone to know that life was tough for me.” Other relevant findings include no history of substance use except for an occasional glass of wine, no suicidal thoughts, a mild decline in concentration and focus, and good grades and excellent feedback so far in her medical school career.
Trauma-Informed Medical Care
The landmark ACEs study in the 1990s, discussed earlier, linked the number and severity of ACEs with adult morbidity and mortality. The authors of this work were among the first to call for coordination and communication among medical specialties and training for providers to effectively recognize and treat patients presenting with psychological trauma and improve medical outcomes.20 Growing from these early roots, with input from trauma survivors, policy makers, and professionals from multiple disciplines, trauma-informed care (TIC) is an approach to medical care that emphasizes thinking about trauma history when diagnosing and treating patients. For example, staff trained in TIC will attempt to shift from thinking about what is “wrong” with a patient to what happened to the patient. This approach emphasizes developing and supporting an emotionally, physically, and culturally sensitive and safe environment for staff and patients alike.5,6,55
The principles of TIC begin with recognizing that trauma is ubiquitous and often invisible. Thus, TIC is recommended to be applied universally; this is not an approach reserved for individuals who have been exposed to traumatic experiences. Concrete examples illustrating the six themes or pillars of a trauma-informed clinic include:
- Safety: A perception of an unsafe environment will heighten anxiety. Review the physical layout and approach to the clinic to ensure it is well-lit and accessible; provide a waiting area that allows space and privacy.
- Trustworthiness and transparency: Patients who have been traumatized often have barriers to establishing trust. Avoid frequent or last-minute changes in provider schedule, long wait times, and/or unexpected charges, and be as open as possible with these issues to build comfort and trust.
- Peer support: All individuals involved in the healthcare system are in a risk group for experiencing trauma; supporting each other can be invaluable. Consider integrating support groups into treatment and taking steps to address the need for providers and staff to process traumatic experiences.
- Collaboration: The power differential in medical care can be re-traumatizing and a set-up for power struggles. Attempt to lessen the differential and elevate the patient role by actively engaging with patients in aspects of care, such as timing of appointments, treatment options, and plan of care. A patient with more input often will take more responsibility.
- Empowerment: Patients with traumatic early experiences may carry a sense of helplessness. Consider patient feedback and/or a patient board to acknowledge the important role of patients in the healthcare system and encourage the sharing of experiences.
- Cultural sensitivity: Patients may present with a history of traumatic experiences involving culture, race, gender, or related issues. Make every effort to train all personnel that the clinic is inclusive. This ranges from being sensitive to the effect of details, such as clinic decor, pamphlets, and available media, to using patient-preferred pronouns and choice of name to understanding any specific privacy issues.55-57
TIC is not unique to medical care and may be applied in a variety of settings, including educational and correctional institutions. However, notes German et al of the Montefiore Medical Group Trauma-Informed Care program in a recent publication, “enthusiasm for developing and implementing TIC has far outpaced the field’s ability to measure the impact of such programs.” This group notes that measurable results from systemwide adoption of TIC in medicine include increases in patient engagement and satisfaction, and that these improvements should eventually affect patient outcomes.57
Using some of the principles of TIC, the provider talks with Shara about several non-mutually exclusive options for treatment, including improvement in sleep hygiene, specific psychotherapy for the trauma-related symptoms, and further evaluation for depression and anxiety, with the possible use of a selective serotonin reuptake inhibitor (SSRI) depending on those results. After discussion, Shara opts for starting with specific psychotherapy when “time permits” but also asks for a medication taken as needed for sleep.
Treatment of Stress-Related Disorders
The first step in treatment is identifying target symptoms causing functional impairment. In the case of Shara, although it does seem likely that the sleep disturbance is connected to past trauma, her priority is making sure she is able to get to sleep during off hours and wake on time for her clinical work. Although she may not feel ready or able to explore her past trauma now, the seed planted in the current visit (linking her past trauma to current sleep problems) may develop over future visits.
One way to understand Shara’s current difficulties is to view the recent deterioration in sleep as an adjustment disorder caused by exposure to intense emotional content (treating children in the emergency room). Her personal history of childhood trauma heightens the risk of her developing more impairing symptoms.
The provider and Shara agree on the need for ongoing symptom monitoring and a return appointment. Together they decide that she will work on establishing a better sleep routine and start low dose hydroxyzine for sleep (10 mg to 20 mg) on a taken-as-needed basis. At the end of the visit, Shara picks up a brochure promoting on-site mindfulness-based group interventions for hospital employees (yoga, meditation, and active stretching held in the hospital courtyard three times weekly). “I could try this,” she says.
PTSD may be treated with psychotherapy, medication, or a combination of the two. Since CPTSD is a new diagnosis, studies regarding treatment are not yet available, but can be extrapolated (to some extent) from the PTSD studies. It may be that some of the heterogeneity in response to treatment in PTSD is the result of treating a combined PTSD and CPTSD patient population.58 Most guidelines consider specialized psychotherapy as first-line treatment for PTSD. In general, evidence points to efficacy for symptom reduction and remission with trauma-focused psychotherapies, such as prolonged exposure therapy, trauma-focused cognitive-behavioral therapy, or cognitive processing therapy. These are structured talk therapy programs that combine efforts to effect changes in thinking (cognitions) and behavior. Generally, these consist of a specified number of weekly, 60-minute sessions over three to four months.58,59
Eye movement desensitization and reprocessing therapy (EMDR) is another form of therapy that has evidence of efficacy in the treatment of PTSD. This therapy involves recalling distressing memories related to the trauma while the therapist guides eye movement in an attempt to process the memory with less distress (“desensitize”).60
Some studies have pointed to the significant difficulty of some patients (especially patients with higher PTSD severity) tolerating the inevitable exposure to traumatic memories involved with the trauma-focused therapies. There is some evidence that non-trauma-based therapy, such as cognitive behavioral therapy, can be effective in the treatment of PTSD in these cases.61 There also is emerging data suggesting benefits of mindfulness-based treatments, such as mindfulness-based stress reduction, an eight-week program helping with emotional regulation and geared toward an accepting internal state, in addressing residual symptoms of PTSD.62 Future research direction includes separating out patients with CPTSD, developing an understanding of patient characteristics that point to response to specific therapies, understanding long-term outcomes, and evaluating the potential of harm.
Notably, there are communities where therapy (especially the more specialized forms) is neither available nor affordable. Recent studies looking at internet-delivered therapy show suggestions of efficacy for treatment of PTSD but, according to a May 2021 Cochrane review, the quality of evidence is too low to draw conclusions.61
When therapy either is not practical or not desired, medication is a reasonable alternative. There is evidence that pharmacotherapy can be effective in symptom reduction. Guidelines include the use of specific agents (following) starting at a low dose, with a gradual increase over four to six weeks to achieve symptom reduction. If remission from symptoms is reached, these agents should be continued for a full year before a taper. 58,63,64
Monotherapy for PTSD:
- Fluoxetine, paroxetine, sertraline (SSRIs): There is no evidence of efficacy for other medications in this class;58,63,64
- Venlafaxine (a serotonin-norepinephrine reuptake inhibitor [SNRI]);58,63,64
- Quetiapine (a second-generation atypical antipsychotic): Given the potential of significant weight gain and metabolic side effects, use only if the patient does not respond to adequate doses of an SSRI or SNRI.58,63,64
There is no evidence of superiority of one of these medications over the other — an interplay of genetics, comorbidities, presenting symptoms, and environment are among the factors determining the response to a particular agent.58,63,64
Adjunct medication may be used when there is a partial response to monotherapy but symptoms remain that can be targeted with specific agents (such as sleep disturbance or hypervigilance). These adjunct agents with evidence for efficacy in symptom improvement in PTSD have been tested primarily with patients after combat (it is unclear if these are generalizable), except for hydroxyzine:58,63,64
- Prazosin: An alpha-1 blocker used in PTSD for sleep disruption and nightmares. There are some conflicting studies regarding efficacy;
- Risperdal: A second-generation atypical antipsychotic used for paranoia and outbursts in PTSD. Be mindful of the potential for weight gain and metabolic side effects, and carefully review the risks and benefits;
- Hydroxyzine: An antihistamine used for treatment (taken as needed) of anxiety and insomnia.
In randomized trials of medication vs. psychotherapy, there appear to be slightly better outcomes and marginally better symptom reduction for psychotherapy alone. However, the methodology of these studies does not allow firm conclusions. A 2019 double-randomized study showed the largest symptom remission in patients who were randomized to a treatment of their choice.65
Benzodiazepines should not be used in the treatment of PTSD. Unfortunately, current estimates are that 30% to 70% of patients with PTSD are prescribed these agents. Several studies have shown a lack of efficacy of benzodiazepines in addressing symptoms of PTSD; the risk of their use includes dependence, abuse, and cognitive dulling, far outweighing any potential benefits. Care should be taken to help patients taper off these medications to prevent the emergence of life-threatening withdrawal symptoms.63,64,66
Notably, symptoms such as anxiety and sleep disturbance emerging directly after an event generally are considered an expected reaction to an abnormal event. Current guidelines recommend educating patients about trauma and expected reactions, and continuing to monitor patients in the immediate months after trauma to determine if functional impairment is resolving. Persistent, disabling symptoms may require referral for psychotherapy or psychopharmacologic intervention.58,63,64
Suicide in Patients with Stress-Related Disorders
Having a disorder of mental health is a general risk factor for suicide attempts and completed suicide. With a goal of understanding the risk of suicide for patients with PTSD, results from an ambitious, long-term Swedish study following a nationally representative cohort of more than 3 million respondents were published in 2019. This group found the risk of suicide in patients with PTSD to be approximately twice that of the general population, with higher risk in women and young adults and in patients with a history of suicide attempts prior to the PTSD diagnosis.67
There is no comparable information regarding the suicide risk in patients with other stress-related disorders, indicating that additional studies are needed to clarify any associations.
A 2017 study revealed nearly one-half of adults completing suicide (regardless of diagnosis) had contact with a PCP within a month before death, and 80% had such contact in the year preceding suicide. Clearly, the PCP can play a role in suicide prevention.68
Patients may be hesitant to express thoughts about suicide directly but often will respond to open-ended queries. Asking patients about suicidal thoughts, plans, or intentions may open a discussion. Screens, such as the Columbia Suicide Severity Rating Scale (C-SSRS), can be useful, but screens cannot replace a careful diagnostic evaluation or stand alone in representing suicidal thinking.68-70
Refer patients with high-risk factors and suicidal intention to a specialist. Regional variation in mental health specialist availability ultimately may determine referral and consultation patterns. There is growing evidence that collaborative care models, with a team led by the PCP and involving mental health professionals, including psychiatry and case management, lead to efficient and effective care for more complex, higher-risk patients. Telemedicine consultation, although less intensive than collaborative care, also has shown evidence of efficacy and can assist in bringing specialty care to previously underserved communities. Regardless of the manner of delivery, it is useful for the PCP to have a strong working relationship with professionals in the mental health community. Also, providing patients with information about local support groups and services, such as suicide hotlines, provides an additional safety net for this population.68,70
Summary
- Patients in primary care practices will present with a myriad of symptoms related to past experiences of trauma.
- The emotional and physiologic response to stress and trauma may lead to the development of chronic medical conditions.
- A provider who proactively asks open-ended questions about traumatic history and/or uses appropriate screens and has adopted trauma-informed principles of care is well situated to recognize symptoms associated with past trauma, address symptoms resulting from trauma, and treat/refer patients as clinically indicated.
- Responses to traumatic experiences vary and emerge from a complex interplay between biologic and environmental factors. The most effective treatment plan is individualized, but often includes psychotherapy, mind-body techniques, and/or pharmacotherapy and follow-up.
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More than 80% of U.S. adults can expect to experience a traumatic event during their lifetime. Traumatic events are major risk factors for the development of various chronic diseases, including mental disorders, such as depression, post-traumatic stress disorder, complex post-traumatic stress disorder (a newly recognized condition), substance use disorders, and chronic medical conditions, such as cardiovascular disorders, obesity, and autoimmune disorders. Implementing universal trauma-informed practice strategies and techniques can assist in addressing these situations in a timely and clinically appropriate manner.
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