Mental Health Care
in individuals with PTSD.
These biologic changes asso-ciated with PTSD may reveal reasons why some individualsrecover from traumatic incidents without problems and oth-ers do not.Certain risk factors also predispose some indi-viduals to develop PTSD.
Exposure to traumatic events is a major risk factor for PTSD.Traumatic events that may precipitate the development of PTSD are war,rape,abuse (usually sexual or physical),ter-rorism,torture,serious medical problems,and natural dis-asters.
Rescue workers and medical providers may alsobe at risk for secondary posttraumatic stress.
Halligan and Yehuda examined four categories offac-tors related to PTSD:environmental,demographic,cogni-tive,and biologic risk factors.
Environmental risk factorsincluded:(a) a history ofprior exposure to a trauma or asignificant stress,especially at a young age;(b) type oftraumaexposure;and (c) family instability.Demographic risk fac-tors include:(a) female gender;(b) lower income and edu-cational levels;and (c) being divorced or widowed.A history ofprior psychiatric disorders as well as the occurrence of dissociation (an unconscious defense mechanism in whichan idea,thought,or emotion is separated from the con-sciousness,usually because it is too disturbing or traumaticfor the mind to process at the time) during the trauma areknown risk factors for the development ofPTSD.Cognitiverisk factors may include lower intellectual functioning aswell as preexisting neurodevelopment impairments knownas neurologic “soft signs,”which are subtle neurologic ab-normalities in language,motor coordination,and percep-tion.Finally,biologic risk factors entail:(a) an elevated andprolonged catecholamine response posttrauma as evidencedby a prolonged increased heart rate;(b) chronically low lev-els ofcortisol;and (c) alterations in the hypothalamic-pitu-itary-adrenal (HPA) axis.
Physical Health Problems
Use ofmedical services increases after a traumatic event.Re-search reveals exposure to significantly stressful and traumaticevents may culminate in detrimental physical symptoms anddisease.Posttraumatic stress disorder is associated with higherrates ofasthma,cancer,obesity,chronic pain,hypertension,fibromyalgia,irritable bowel syndrome,peptic ulcer disease,and ischemic heart disease.
Mechanisms explaining thecause ofpoorer health outcomes in individuals with PTSDinclude biologic aspects (elevated norepinephrine and thy-roid hormone,elevated reactivity ofalpha-2 adrenergic re-ceptors,altered HPA activity,and altered sleep physiology),and psychological and behavioral aspects,such as depression,hostility,poor coping,and poor health habits,such as smok-ing and drinking alcohol.
Individuals suffering from PTSD tend to seek treatmentfor multiple physical complaints,but often do not connectthe current physical symptoms to past trauma.Unfortu-nately,many medical and psychiatric providers do not makethis connection either due to the variability in presentingsymptoms.Furthermore,highly comorbid mental disorders“mask”symptoms ofPTSD and become the focus oftreat-ment.Associated comorbid mental disorders include pho-bias,compulsivity,major depression,anxiety disorders,eating disorders,substance abuse,and delinquent or crimi-nal behavior.
The differentiating factor,the previous oc-currence ofa traumatic event and its relationship to thesymptoms,is often unexplored and untreated.
The con-nection between PTSD and physical health problems re-quires collaboration between primary care and mental healthproviders.
Patients with PTSD have a high rate ofsomatization,so fre-quent use ofmedical services and frequent complaints of multiple unexplained physical problems are clues to recog-nizing PTSD.
Complaints tend to be gastrointestinal,cardio-vascular,neurologic,and musculoskeletal in nature.
Becauseofthe high use ofmedical services among individuals withPTSD,obtaining a trauma history should be an importantaspect in assessing people who make frequent office visits,somatizers,and those who have high emotional distress.Patient self-reported screening questionnaires and med-ical history paperwork are efficient ways to assess for PTSD.Because previous trauma can be a sensitive issue,self-reportquestionnaires are a more comfortable way to introduce thetopic and increase the likelihood that the subject will be dis-
The Nurse Practitioner•March 2006
Detachment (generally numb emotionalresponsiveness)
Reexperiencing the event (nightmares orflashbacks)
Emotional effects (emotional distress,helplessness, fear)
Avoidance (avoiding things that are reminders ofthe event)
Months of duration
Sympathetic hyperactivity and hypervigilance(insomnia, irritability, difficulty concentrating)
Acronym adapted from Lange J, Lange C, Cabaltica R: Primary care treatmentof post traumatic stress disorder.
Am Fam Physician