Posttraumatic stress disorder (PTSD) has been discussed frequently in the news media in recent years; however, a rather restrictive understanding of the types of patients who may be affected by this disorder still exists. Considerable evidence in the medical literature indicates that many patients who present to their clinician with somatic complaints are experiencing the aftereffects of an emotionally traumatic event from the past.1 These traumas may have been forgotten, repressed, or minimized by the patient, and the clinician often fails to ask about them.
If not recognized and treated, these symptoms can increase the patient's risk for suicide, vehicle collisions, job loss, divorce, social isolation, and illness.2 Recent evidence suggests that trauma causes genuine neurophysiologic changes in the body. The person is physiologically “frozen” in a state of high arousal.3 This aroused state consists of a highly activated, incomplete biological response to threat and is thought to consist of undischarged energy that produces physical symptoms.4
The National Center for PTSD estimates that the lifetime prevalence of PTSD in the general adult population is 6.8%; women are twice as likely as men to have PTSD at some time during their lives. Not everyone exposed to trauma develops PTSD. Persons who have experienced trauma earlier in life are more likely to develop the complex of symptoms characteristic of PTSD when exposed to a later traumatic event.5 Sixty-one percent of men and 51% of women have experienced at least one traumatic event in their lives, and approximately 10% of men and 6% of women reported being exposed to four or more types of significant trauma during their lifetimes.6
KEY DIAGNOSTIC FEATURES
Experiencing or witnessing a severe trauma that provokes fear, horror, and a sense of helplessness are the key diagnostic criteria for acute stress disorder (ASD) and PTSD as described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). ASD symptoms become apparent within the first month after the trauma occurs. PTSD refers to symptoms that continue beyond the first month or begin after the first month.7
The greater the sense of helplessness in the face of a stressor, the more intense the emotional reaction will be. Typical stressors are war experiences; rape; sexual abuse; fire; flood; vehicle collision; or any violent or intense, fear-inducing encounter. Afterwards, the patient re-experiences the event in some way, typically through flashbacks, nightmares, and/or intrusive images or feelings. Physiologic reactions, such as palpitations, sweating, or symptoms and signs of panic, commonly occur. In order to cope with these events, the person attempts to avoid situations that might trigger the memories. In addition, the person may remain in a state of high arousal and become hypervigilant, irritable, and increasingly likely to startle. In some cases, the person may develop a numbing of the senses as a defense against the intolerable reliving of the emotional trauma.7
Unexplained physical symptoms The usual reason for a visit to a clinician is for physical symptoms. Twenty-five percent to 35% of primary care patients are thought to meet criteria for a DSM-IV-TR-based psychiatric diagnosis, usually an anxiety or depressive disorder. Of those patients, 50% to 80% initially present with exclusively physical symptoms.1
A documented history of trauma sometimes makes a diagnosis of PTSD clear; at other times, the diagnosis may be quite elusive. Patients with a history of trauma frequently present with unexplained physical symptoms. Failure to inquire about a history of trauma is not unusual, and patients frequently do not volunteer the information.
THE NEUROBIOLOGY OF TRAUMA
Key researchers in the study of the neurobiological underpinnings of traumatic reactions believe that traumatic memories are locked in the deeper, nonconscious part of the central nervous system—the amygdala, thalamus, hypothalamus, hippocampus, and the brain stem3,8,9—in what has been called a trauma capsule.9 These memories are not accessible to the thinking and reasoning parts of the brain, but they are present and real. A trauma capsule contains the cognitive, emotional, and body memories associated with each traumatic experience. Cognitive material is stored in the cerebral cortex, emotional memory in the limbic system, motor-vestibular memory in the midbrain, and body memories (physical sensations) are thought to be stored in the brainstem (Figure 1).
Emotional and body memories can be triggered or reactivated by present events. For example, a mildly demeaning comment by a coworker can trigger the emotional and bodily reactions of fear, helplessness, palpitations, and nausea originally experienced during an episode of childhood sexual molestation. The intense symptoms may not be connected to the past abuse but may instead be attributed to the negative comment. The intensity of the reaction may also be shocking to the coworker who made the comment. This example illustrates how the contents of the trauma capsule can influence reactions to present stressors.
A sense of helplessness, which is a major part of the original trauma, blocks the normal defensive reactions, and a person remains physiologically frozen in a state of high arousal even after the event has passed. The persistent arousal activates the hypothalamic-pituitary-adrenal axis, which produces increased levels of corticotropin-releasing factor and activates the autonomic nervous system.8,10 These changes may result in physical symptoms that have no identifiable organic pathology. If the clinician concludes that the patient has a purely psychological illness, the patient will feel misunderstood and invalidated. These patients feel real pain and have real physical symptoms; therefore, the clinician should provide meaningful education about the physiology of these complex mind-body processes.
CHILDHOOD TRAUMA
The Adverse Childhood Experience study evaluated the relationship between childhood experiences and medical and public health problems among adults.11 A 68-item questionnaire that asked about experiences in seven categories of childhood trauma was sent to 13,494 adults who had been recently examined at a medical clinic. Seventy percent (9,508) of the patients completed the survey. Of those who completed the survey, 25% had lived with a person who was a problem drinker, an alcoholic, or a street drug user; 22% had experienced overt sexual abuse; 19% had lived with a mentally ill person; 12% had witnessed their mother being treated violently; 11% had been emotionally abused; 11% had been physically abused; and 3.4% had experienced a household member being sent to prison.11
Adults with one to four adverse childhood experiences (ACEs) had a significantly increased incidence of health problems compared with persons who reported no adverse childhood experiences11 (Table 1). Adults with multiple ACEs are more likely to have adopted behaviors that increase their risks for disease, disability, and socialization difficulties that culminate in an earlier death.11
In many cases, a diagnosis of PTSD does not adequately characterize the effects of chronic childhood trauma. Therefore, the clinical presentation of a child may be confusing and a diagnosis of ADHD, anxiety and depressive disorders, or a conduct disorder may be made. The National Child Traumatic Stress Network proposed a new diagnostic entity called developmental trauma disorder.12 This entity takes into account the etiology of the presenting symptoms and recognizes the need for treatment to address a complex trauma history (Table 2). Because the disorder affects children during their critical developmental years, it results in both shortterm and long-term sequelae.