Trauma, PTSD, and the Primary Care Provider
A National Center Fact Sheet

From: The National Center for PTSD website

Why are Trauma and PTSD Important in Healthcare?

Trauma and Trauma-Related Problems are common
50%-90% of all adults and children are exposed to a psychologically traumatic event (such as a life-threatening assault or accident, human-CAUSED or natural disaster, or war) IN THEIR LIFETIME. As many as 67% of trauma survivors experience lasting psychosocial impairment, including post-traumatic stress disorder (PTSD); panic, phobic, or generalized anxiety disorders; depression; or substance abuse. Symptoms of PTSD include persistent involuntary re-experiencing of traumatic distress, emotional numbing and detachment from other people, and hyperarousal (irritability, insomnia, fearfulness, nervous agitation).

PTSD Affects Health
PTSD is linked to structural neurochemical changes in the central nervous system which may have a direct biological effect on health, such as vulnerability to hypertension and atherosclerotic heart disease; abnormalities in thyroid and other hormone functions; increased susceptability to infections and immunologic disorders; and problems with pain perception, pain tolerance, and chronic pain. PTSD is associated with significant behavioral health risks, including smoking, poor nutrition, conflict or violence in intimate relationships, and anger or hostility. When trauma leads to PTSD or other posttraumatic psychosocial problems, this places great biological strain upon the body and psychological strain upon personal self-care and interpersonal relationships. Thus it is not surprising that trauma survivors, especially those with lasting PTSD symptoms, frequently report high rates of problems with physical health involving a variety of bodily systems (e.g., the cardiovascular, pulmonary, neurological, and gastrointestinal systems).

PTSD Affects Utilization of Services
PTSD and related problems with anxiety, depression, and anger also are associated with excess rates of healthcare services utilization. Studies document high medical utilization rates for both male and female Vietnam and Persian Gulf veterans with PTSD; survivors of war, political violence, and terrorism; survivors of earthquakes, hurricanes, and other natural disasters; crime victims, especially women who have experienced sexual assault; and survivors of child abuse. Although research on this subject is underway and not yet completed, clinical observation suggests that the symptoms of PTSD or associated psychosocial problems often interfere with healthcare, causing difficulty in provider-patient communication; reducing patients' active collaboration in evaluation and treatment; increasing the likelihood of somatization; and reducing patient adherence to medical regimens

PTSD is Under-Recognized by Practitioners
Studies show that many patients seeking physical health care have been exposed to trauma and experience post-traumatic stress symptoms, but have not received appropriate mental health care. As with other anxiety disorders and depression, most patients with PTSD are neither detected nor offered education, counseling, or referral for mental health evaluation.

What Can the Healthcare Provider Do?
Recent evidence suggests that psychological assistance can prevent or greatly reduce the severity of PTSD. This is likely to enhance the patient's capacity to benefit from medical healthcare. Your role as a healthcare clinician need not involve any additional training or workload, because specialized PTSD treatment resources are readily available.

Identify PTSD Consultant
The first step is to identify a mental health or PTSD clinician specialist who is able to provide consultation to you, and education, assessment, and counseling for patients who show signs of PTSD. There is a substantial body of published research on PTSD symptoms and treatment options, and there are expert therapists from a range of disciplinary backgrounds: psychiatry, clinical psychology, social work, and psychiatric nursing. Patients whose experience of trauma raises the risk of PTSD, or those who present with physical or psychological symptoms consonant with the disorder, should be referred to one of these experts. If the PTSD specialist is not a member of your multidisciplinary healthcare clinic or team, he or she may be able to participate as an ad hoc consultant or ex-officio team member. An excellent place to start is with PTSD specialists who work in VA PTSD Programs and Vet Centers across the United States.

Take Steps to Identify Patients with PTSD
The second step is to discuss with the PTSD specialist how best to identify your patients with undetected PTSD. Educational fact sheets on stress and trauma are available for patients to read in clinic waiting areas. A brief (1-2 minute) screening questionnaire is available for patients to complete in the waiting area, on their own or with the help of a clerical or nursing staff person. In some cases, the PTSD specialist may be able to provide on-the-spot (or same-day) brief education and counseling for patients who are experiencing acute psychological distress. Pilot clinical studies indicate that healthcare patients find these types of information, screening, and counseling helpful and not disturbing.

Establish Referral Procedures
The third step is to set up a plan for referring to the PTSD specialist those patients who show signs of potential PTSD and are amenable to receiving additional evaluation or counseling. A few words indicating your awareness of their possible difficulties with stress, and supportively advising them that specialized services can be of great help, is almost always sufficient to motivate patients to accept this referral. You need not, and in most cases probably should not, attempt to take a detailed trauma history or to make a diagnostic assessment of PTSD -- this can be done by the PTSD clinician specialist.

PTSD clinicians are able to provide a variety of therapeutic approaches that have been demonstrated to be of benefit with PTSD, including psychodynamic psychotherapy; exposure therapy; cognitive-behavioral therapy; pharmacotherapy; group, family, couples, and inpatient treatment; and combined PTSD and alcohol/substance abuse treatment. No particular drug has emerged as a definitive treatment for PTSD, but medication is clearly useful for symptom relief, making it possible for patients to participate in psychotherapy. Matching medication to the complex combinations of PTSD and associated symptoms -- beyond palliative care for symptoms of anxiety or depression -- should be done by a PTSD specialist.

Maintain Ongoing Contact with PTSD Clinician
The fourth crucial step is to maintain ongoing contact with the PTSD clinician, so that you can monitor your patient's response to mental health care. Your observations about your patient's clinical and functional status at subsequent appointments provides the PTSD specialist with a valuable source of feedback and guidance in developing effective care for PTSD. In many cases you will observe improvements in your patient's participation in healthcare.

THIS FACT SHEET WAS BASED ON:

"Trauma, PTSD, and Physical Health," by Paula P. Schnurr, PTSD Research Quarterly 7(3): 1-6 (Summer 1996)

"The Relationship Between Trauma, Post-Traumatic Stress Disorder, and Physical Health," by Matthew J. Friedman and Paula P. Schnurr, in Neurobiological and Clinical Consequences of Stress: From Normal Adaptation to Post-Traumatic Stress Disorder, edited by Matthew J. Friedman, Dennis S. Charney, and Ariel Y. Deutch (Philadelphia: Lippincott-Raven, 1995), pp. 507-524

"PTSD Diagnosis and Treatment for Mental Health Clinicians," by Matthew J. Friedman, Community Mental Health Journal 32(2): 173-189 (April 1996)

"Identifying and treating VA medical care patients with undetected sequelae of psychological trauma and post-traumatic stress disorder," by Julian D. Ford, Josef I. Ruzek, and Barbara L. Niles, NCP Clinical Quarterly 6(4): 77-82 (Fall 1996)

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