Trauma, PTSD, and the Primary Care Provider

A National Center for PTSD Fact Sheet (Veterans Affairs Canada Adaptation)
Why is it important to be aware of trauma and PTSD in healthcare settings?

Trauma and trauma-related problems are common

Fifty to ninety percent 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) at some point in their lives. 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 the persistent, involuntary re-experiencing of traumatic distress, emotional numbing and detachment from other people, and hyper-arousal (e.g., irritability, insomnia, fearfulness, and 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 health effects may include vulnerability to hypertension and atherosclerotic heart disease; abnormalities in thyroid and hormone functions; increased susceptibility 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 post-traumatic psychosocial problems, this places great biological strain upon the body and psychological strain upon the individual and his or her interpersonal relationships. It is, therefore, not surprising that trauma survivors, especially those with lasting PTSD symptoms, frequently report high rates of problems with physical health. These problems usually involve a variety of bodily systems including the cardiovascular, pulmonary, neurological, and gastrointestinal systems.

PTSD affects utilization of services

PTSD and related problems with anxiety, depression, and anger are also associated with excess rates of healthcare services utilization. Studies document high medical utilization rates for (1) both male and female Vietnam and Persian Gulf Veterans with PTSD; (2) survivors of war, political violence, and terrorism; (3) survivors of earthquakes, hurricanes, and other natural disasters; (4) crime victims, especially women who have experienced sexual assault; and (5) survivors of child abuse. Although research on this subject is currently underway and not yet completed, clinical observations suggest that the symptoms of PTSD or associated psychosocial problems often interfere with healthcare. PTSD symptoms and other psychosocial problems may cause difficulty in provider-patient communication, reduce patients' active collaboration in evaluation and treatment, increase the likelihood of somatization, and reduce patient adherence to medical regimens.

PTSD is underrecognized by practitioners

Studies show that many patients who seek physical healthcare 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 not properly identified and are not offered education, counseling, or referrals for mental-health evaluation.

What can healthcare providers do?

Recent evidence suggests that psychological assistance can prevent or greatly reduce the severity of PTSD. Psychological healthcare is likely to enhance the patient's capacity to benefit from medical healthcare. Healthcare clinicians do not need additional training, and their workloads need not be increased, because specialized PTSD treatment resources are readily available.

Contact VAC for names of specialists or OSI Clinic in your area.

Take steps to identify patients who have PTSD

The second step is to discuss with the PTSD specialist how best to identify your patients with undetected PTSD. You can provide Educational fact sheets on stress and trauma for patients to read in clinic waiting areas. You can also have patients complete a brief (1 to 2 -minute) screening questionnaire in the waiting area, on their own or with the help of clerical or nursing staff. In some cases, the PTSD specialist may be able to provide on the spot (or same-day) brief education and counselling for patients who are experiencing acute psychological distress. Pilot clinical studies indicate that healthcare patients find these types of information, screening, and counselling 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 who 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 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 benefit those with PTSD. These therapeutic approaches include 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 the 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 provide the PTSD specialist with a valuable source of feedback and guidance in developing effective PTSD care. In many cases, your patient's participation in healthcare will improve.

This fact sheet was based on:

Ford, J.D., Ruzek, J.I., & Niles, B.L. (1996). Identifying and treating VA medical care patients with undetected sequelae of psychological trauma and post-traumatic stress disorder. NCP Clinical Quarterly, 6(4), 77-82.

Friedman, M.J. (1996). PTSD Diagnosis and Treatment for Mental Health Clinicians. Community Mental Health Journal, 32(2), 173-189.

Friedman, M.J. & Schnurr, P.P. (1995). The relationship between trauma, post-traumatic stress disorder, and physical health. In M.J. Friedman, D.S. Charney, & A.Y. Deutch (Eds.), Neurobiological and clinical consequences of stress: From normal adaptation to post-traumatic stress disorder (pp. 507-524). Philadelphia: Lippincott Raven.

Schnurr, P.P. (1996). Trauma, PTSD, and Physical Health. PTSD Research Quarterly, 7(3), 1-6.