Roberta was a successful healthcare provider working in emergency services at a hospital in Pennsylvania. Eighteen months ago she changed jobs, with a salary increase and greater responsibilities, to run the sexual-assault survivor services at her hospital. The new role entailed daily immersion in the stories and emotional and medical aftermath of sexual assault. Sixteen months later, Roberta filed for extended disability leave due to “burnout.”
She visited her internist and told him she had trouble sleeping, was often ill at ease and exhausted, and was frequently stressed. She suffered from headaches and felt unwell. She had trouble eating and had frequent stomachaches. Roberta also explained that she had no patience for anyone’s “nonsense,” whether it was expressed by her co-workers, hospital administrators, or family members. Her doctor performed a brief diagnostic workup, the results of which were normal. But the physician also agreed that Roberta seemed unwell, and he referred her to a psychiatrist.
It took Roberta several sessions to recognize that her physical and psychological symptoms were connected to her new job. The immersion in sexual-assault cases brought back long-ignored memories of her own rape by a family member when she was 13. Roberta, it turns out, was suffering from post-traumatic stress disorder (PTSD); her recognition of that would aid her path to recovery and healing.
This story illustrates why those caring for patients—in mental-health and non-mental-health settings—need to understand how PTSD can directly influence patient outcomes. Highly traumatic experiences in which death, serious injury, or sexual assault occur (or instances of witnessing someone else experiencing such trauma) are increasingly prevalent. A careful meta-analysis conducted in 2021 found that rates of PTSD vary, with refugees suffering the highest rates (47%).
Overall PTSD prevalence in the U.S. is about 20% of the population. PTSD has the longest delay of any psychiatric disorder between its onset and diagnosis, meaning regular screening for the disease is extremely important.
People with PTSD can suffer from disruptive problems that can damage their emotional and physical health and make life extremely difficult. And trauma survivors reexperience traumatic events in various ways. Psychological symptoms commonly tracked by researchers include reexperiencing such events, either in dreams or flashbacks; avoiding situations that remind people of past traumas; having episodes of dissociation, in which the world feels “unreal”; irritability; difficulties involving anger and emotional arousal; and depression.
Rates of re-traumatization among individuals suffering from PTSD are high; it affects about 20% of patients. Such exposure correlates with increased functional impairment as well as greater exposure to intimate-partner violence. Patients are, for unconscious reasons, drawn to experiences that evoke their previous traumas, including attempts to undo a terrifying experience by transforming it into one in which they achieve a measure of control.
Such unconscious processes can lead patients to place themselves in harm’s way—such as by enlisting in the military. Veterans bear a huge public-health burden from PTSD. While it’s commonly thought that military experience is the cause of trauma leading to PTSD, a 2016 study of those who have served found that more than 85% of Veterans reported having experienced at least one traumatic event prior to joining the military. Only 38% reported combat trauma; the majority of traumatic events occurred before their military service.
PTSD—Trust and Health
A profound problem suffered by trauma survivors is difficulty trusting other people. This can become a serious issue in medical settings, as survivors with PTSD wind up feeling—and being—isolated and alone. These patients often don’t have the social supports (people in their lives who can buffer the effects of stress) needed to allow them to trust doctors, the medications they prescribe, and the treatments they recommend. Furthermore, isolation can make it difficult for patients to find—and act on—rational advice.
As a result, people living with PTSD experience more physical pain and have poorer health outcomes than other people. Studies suggest that PTSD can aggravate the body’s inflammatory responses. More specifically, studies of PTSD show that individuals with the disorder have increased levels of proinflammatory cytokines and chemokines: IL-6, IL-1beta, IFN-gamma, TNF, and C-reactive protein.
We have long known that childhood trauma, chronic adversity, and severe familial stresses increase the risks for developing PTSD. These include surviving child abuse, neglect, and bullying; living in unstable and dangerous surroundings such as war zones; and living with instabilities that come with having parents who suffer from drug addiction or intermittent incarceration. Childhood trauma can lead to insecure attachments in relationships, which is a risk factor for many emotional—and overall health—problems. PTSD can also reveal or lead to insecure attachment relationships in adulthood. That’s another reason why it is critically important for all healthcare professionals to understand the role of PTSD in patient health.
It will benefit everyone with PTSD if all of us in healthcare become more aware of this pervasive problem and intervene rapidly, and as early as possible, to identify risk factors and address them. To do this, we must directly ask patients whether they have experienced trauma and if it continues to affect them. That information can lead to effective treatments.
Medications, such as antidepressant medications for (frequent) comorbid depression, and sometimes mood stabilizers for irritability can be useful largely as adjunctive treatment in dealing with PTSD, although the mainstay of efficacious treatment is psychotherapy. It can offer relief, although not all trauma survivors are comfortable reliving traumatic experiences. It’s been demonstrated, however, that a number of non-exposure psychotherapies such as interpersonal psychotherapy has demonstrated efficacy, and have lower patient dropout rates.
PTSD presents both a risk factor for medical and psychiatric illness, and can be a barrier to the treatment of other medical conditions. This makes it critically important for us to be aware of it and of the need to provide effective relief from its debilitating symptoms.
Dr. Milrod is professor of psychiatry at Einstein and director of psychotherapy research, PRIME (Psychiatric Research Institute of Montefiore Einstein)