ADULT TRAUMA
Intimate partner violence is just one type of adult trauma, albeit a significant one. According to US Justice Department statistics, 1.3 million women and more than 800,000 men are physically assaulted by an intimate partner every year in this country.13 Intimate partner violence may result in the battering syndrome, an increase in general medical symptoms and emotional problems, including anxiety, depression, and low self-esteem.14,15 Negative health consequences persist long after the abuse ends. Psychological distress is believed to lower the symptom threshold, which increases the number and severity of physical and emotional symptoms. This results in increased seeking of health care, refractoriness to treatment, and increased referral to medical specialists. Although numerous other types of adult trauma could be discussed here, domestic violence is a representative example of repetitive trauma that can have lasting consequences. In addition, domestic violence is often missed by health care providers because patients are ashamed to mention it and clinicians do not ask about it.
MAKING THE CORRECT DIAGNOSIS
According to DSM-IV-TR criteria, a diagnosis of PTSD requires the affected person to have experienced an event that involved a serious threat to self with a sense of intense helplessness. PAs need to realize that our understanding of the DSM-IV-TR criteria may be too restrictive. Ordinary trauma can also produce PTSD-like signs and symptoms.1 The difference between extraordinary trauma and ordinary trauma rests in the eye of the beholder. What may be consid ered by some to be minor, or ordinary, trauma may have felt overwhelming to the patient. Embarrassment; profound disappointment; a shameful event, such as a job loss or marital separation—these can all result in an intense feeling of helplessness and fear.
Although a single severely traumatic event can produce the classic symptoms of PTSD, repetitive trauma can have profound cumulative effects on the CNS. This leads to alteration in regulation of affect and impulses, attention or consciousness, self-perception, and perception of the perpetrator. This repetitive trauma over time results in complex PTSD.16,17 PTSD may be confused with other psychiatric disorders that produce physical symptoms in patients, such as somatization disorder, hypochondriasis, conversion disorder, and pain disorders. Checking for a history of trauma can help the clinician to make the appropriate diagnosis. Trauma can have a profound impact on a person's ability to function in a healthy manner, and PTSD may contribute to other comorbidities, such as depression, anxiety, and personality disorders.
SCREENING FOR TRAUMA
One of the best ways to screen for a history of trauma is to make it a routine part of the history, particularly the social history. A PA can introduce the topic by saying, “We're learning that past trauma can change the way the body functions or reacts to stress. Have you had any serious physical or emotional events that have upset you?” You can then ask more specific questions about childhood events, relationship problems, alcohol or drug-related events, and physical or sexual abuse18 (Table 3). Patients will not share painful memories if they feel rushed or if they do not feel safe with you or trust you. Patients need to believe that you care about them and are trying to help. Sensitive information is commonly revealed slowly over time as trust is established.
TREATMENT FOR TRAUMA-RELATED DISORDERS
PTSD is a complex disorder with deeply embedded neurophysiologic effects; therefore, treatment is also complex. A multidisciplinary team approach is crucial for effective management. The team consists of a physician and mental health professionals experienced in abuse recovery work and may include a physician assistant. Frequently, abused persons resort to using substances to numb their pain. In those cases, substance abuse should also be dealt with.
Medication alone does not address the underlying trauma, and may only partially suppress unpleasant symptoms. In addition, the symptoms are likely to return when the medication is discontinued. However, selective serotonin receptor inhibitors play an important role in stabilizing the patient's mood and reducing anxiety while the patient deals with the past trauma.
Relaxation techniques, addressing negative self-talk and negative self-image, reframing, and various desensitization modalities can all be helpful and may be an integral part of treatment. However, recent research strongly suggests that truly effective therapy also focuses on dealing with the patient's body memo ries and emotional memories. Although some controversy exists about this, increasing evidence suggests that a bodymind approach using somatic and energy therapies to access the contents of the trauma capsule is important. Unless the somatic contents of the trauma capsule can be expunged, symptoms will emerge with every event, contaminate the present moment, and promote further sensitization to trauma.9
Some currently used therapies include somatic experiencing, eye movement desensitization and reprocessing, emotionally focused therapy, and thought field therapy. These therapies attempt to access and deal with some of the deeper contents of the trauma capsule.9
A safe therapeutic environment is crucial to successful treatment. A major goal of treatment is for patients to acknowledge what happened and process the horror of the event, while reconnecting with their emotions and physical sensations in a therapeutic manner. Patients must learn how to control and master the physiologic stress reactions that terrify them in order to deal with triggering events. Treatment needs to prevent the contents of the trauma capsule from spilling over into current experiences.9,19
CONCLUSION
The aftereffects of trauma are a common and underrecognized cause of many of the symptoms that patients manifest to their clinicians. Most PAs see patients on a regular basis who have a history of either childhood or adult trauma. As clinicians, PAs need to be alert to the clues that may help them to make a proper diagnosis, although most will not have the opportunity or training to become involved in the psychotherapeutic aspects of the treatment of PTSD. However, PAs can do their patients a great service by spending time with them, establishing a trusting relationship, listening for signs of emotional reactivity, and checking for evidence of prior trauma. Identifying community resources for effective treatment may be a challenge initially, but the rewards will be worth the effort and patients will benefit greatly. JAAPA
James Meyer is medical director of the PA program at Midwestern University, Glendale, Arizona. He has indicated no relationships to disclose relating to the content of this article.
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