Re: Medical Disorders as a Cause of Psychological Trauma and Posttraumatic Stress Disorder

[Guest guest]

Bernie; Here's that article you requested, Hope your find it helpful.

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Medical Disorders as a Cause of Psychological Trauma and Posttraumatic

Stress Disorder

Mundy; Baum

Curr Opin Psychiatry 17(2):123-128, 2004. © 2004 Lippincott &

Wilkins

Posted 04/01/2004

Introduction

As the study of psychological trauma and posttraumatic stress disorder

(PTSD) has evolved, it has broadened to include non-traditional stressors or

situations that share characteristics of the criteria for psychological

trauma but differ in important ways. For the past 30 years, combat veterans

and disaster victims have been the modal populations for studies of PTSD,

and much of what we know about PTSD and subsyndromal stress conditions is

derived from them.[1,2] More recent studies have investigated more commonly

occurring potential sources of trauma, including motor vehicle accidents,

sexual assault, and terrorism or human caused disasters.[3-7] Because

research on trauma has shown that the types of events that cause or enable

PTSD are more common than uncommon (e.g., rape, assault),[8] the Diagnostic

and Statistical Manual of Mental Disorders (DSM) 4th edition[9] has changed

criterion A of PTSD by omitting the description of the stressor as 'outside

the range of normal human experience'. Instead, criterion A now requires

that the individual's experience in response to the stressor must include

intense fear, helplessness or horror. This definition expands the type of

traumatic events that qualify for PTSD to include violent personal assault,

motor vehicle accidents, natural or manmade disasters, learning about the

sudden, unexpected death of a family member or a close friend, learning that

one's child has a life-threatening disease, or being diagnosed with a

life-threatening disease. Research has increasingly targeted serious or

life-threatening illnesses as traumatic events, and a growing literature on

PTSD among medical patients has developed (e.g. cancer, myocardial infarct,

HIV diagnosis). These developments have helped broaden and enrich the

investigation of psychological trauma, but differences between medical

stressors and more traditionally studied sources of trauma raise questions

about the application of PTSD to this population. This review considers some

of these issues.

Are Medical Events Really Traumatic Stressors?

The defining characteristic of a traumatic stressor or of psychological

trauma is the presence of an implicit or explicit life-threat and reactions

that are extreme and generally negative. The development of PTSD may be only

one of many related consequences of exposure to trauma. There are many other

stressor effects that can be considered, most of which reflect the effects

of life-threat on biological, emotional, or cognitive functioning. Traumatic

stress may thus be associated with unusual or unique endocrine changes,

immune system changes, upset and distress, cognitive distortions, and

existential anxiety.[10-13] These changes may occur as a function of direct

threat, as when one is diagnosed and treated for serious illness, or more

indirectly, as a function of witnessing or caregiving for people with

serious illnesses. For the most part they occur because of the life-threat

involved, and this threat or its direct implications form the nucleus of an

emotional complex that appears to cause the reordering or modification of

one's worldview.[14,15]

Many medical stressors share these characteristics of traumatic stressors.

Cardiovascular events such as myocardial infarct or malignant arrhythmia

convey life-threat, as do the diagnosis and treatment of cancer, HIV disease

and AIDS, and other acute and chronic disease states, and some of the

treatments and remedies for underlying disease. As with more traditionally

studied traumatic stressors, the intensity, immediacy, and certainty of

life-threat will vary with the specific disease, prognosis, side-effects of

treatment, and other exposure and response-modifying variables.

Medical diagnoses and events have been found to result in extreme fear,

helplessness, or horror. For example, myocardial infarction (MI) connotes

danger of disability and death, the event is sudden and usually unexpected,

and the patient experiencing it can feel powerless to avoid it. Ginsburg et

al.[16] found that the degree of life-threat during the MI predicted the

severity of acute stress disorder in a sample of 116 patients who were

assessed an average of 3.5 days post-MI. In a second study,[17] the degree

of life-threat at the time of the MI predicted re-experiencing symptoms, the

severity and frequency of intrusive thoughts and PTSD symptoms of intrusion

and arousal. Anticipation of permanent disability from the MI, which can be

construed as the degree of life-threat, was also significantly related to

the development of PTSD based on DSM-III.[18] The subjective sense of

life-threat is paramount for the development of PTSD, and was reported by MI

patients who were then at heightened risk of PTSD symptoms.

How are Medical Stressors Different?

Despite the outward similarities between medical stressors and well-studied

traumatic stressors, there are also important differences that may modify

PTSD symptoms or otherwise affect the expression of threat, distress, and

disorganization. Perhaps the most important difference is the relative

prevalence of PTSD. In general, the likelihood of PTSD is lower among

medical patients; among cancer patients approximately 0-32% have been found

to exhibit PTSD,[19-24] compared with 35-47% in studies of rape or

battery.[5,25,26] The rate of PTSD after MI has varied from 8 to 16%

depending on the assessment timepoint and sample size. et al.[27]

assessed 75 MI patients on average 3 months post-hospital admission for an

MI, and found that 16% of patients met the criteria for PTSD on the basis of

the PDS questionnaire. In a second study of 100 MI patients, Kutz et al.[18]

also found that 16% of patients met the criteria for PTSD on average 14

months post-MI. Doerfler et al.[28] assessed 50 men who had an MI or

received coronary artery bypass surgery, and found that 8% met the DSM-IIIR

criteria for PTSD 6-12 months post-cardiac incident. Shemesh et al.[29]

followed up 102 MI patients from hospital discharge to 6-12 months

post-discharge, and found that 10% met above-threshold criteria for PTSD

avoidance and intrusion symptoms. Finally, and [30] had

completed data on 44 patients who suffered from an MI 6-12 months

previously, and found that the rate of PTSD was 10%.

PTSD has been examined in medically ill populations, including cancer, HIV

disease, and among patients receiving a heart transplant. Cancer diagnosis

and the severe effects of treatment may also produce trauma and stress, and

although rates of distress in this population are low and patients seem to

cope effectively overall, traumatic stress syndrome has been observed.[31]

Similarly, organ transplant can convey a life or death experience for

patients. At 12 months post-heart transplant 11% out of 158 patients met the

diagnostic interview criteria for PTSD.[32] Being diagnosed with HIV is also

life-threatening, and matches other medical illnesses and conditions because

of its chronic course and other stressful experiences that can occur as part

of the disease, treatment, or context. et al.[33] interviewed 61

HIV-positive homosexual and bisexual men who had been diagnosed with HIV on

average 4 years earlier for the presence of current or past PTSD related to

the HIV diagnosis. They found that 30% of HIV-positive men met the criteria

for current or past HIV-related PTSD. In a second study of HIV, Matinez et

al.[34] assessed 41 women who were HIV positive for the presence of PTSD

from a clinic-based sample, and found that 42% of the women were likely to

meet the criteria for PTSD on the basis of a questionnaire assessment, but

the questionnaire was not tied to specific stressors or PTSD symptoms

occurring in response to the HIV diagnosis. Instead, participants were asked

to rate their distress and extent of bother by PTSD symptoms in reference to

whatever event distressed them the most. If the women were exposed to other

traumatic events in their lives, we do not know if the reported rates of

PTSD referred exclusively or at all to the HIV diagnosis or were in

reference to alternative trauma exposures (e.g. assault, domestic violence).

There are many possible explanations for the lower observed rates relative

to other sources of psychological trauma, including the transformation of

symptoms, method of assessment, limitations in the assessment of distress,

more effective coping, or unexpected benefits of chronic rather than acute

stress. The lower incidence of PTSD in medical situations parallels general

findings that the development of psychopathology in medical populations is

also relatively low. A recent analysis of cancer patients[35] indicated no

more distress among patients than in the general population. This is in

comparison with generally elevated rates of distress in most victim groups

that have more traditionally been linked to PTSD. To some extent this may

reflect methodological issues, including limits on the severity of diseases

and stages of disease that have been considered, and when assessments are

conducted. Frequently, early stage breast cancer samples are studied because

of the relative ease of recruitment. The relatively good prognosis of these

participants may artificially limit the generalizability or likelihood of

experiencing psychological trauma. Heightened symptoms of traumatic stress

might be expected immediately before (if anticipated) and after diagnosis,

after recurrence of disease, and possibly as the end of treatment approaches

as a result of the lack of continuous medical visits for treatment and

longer times between follow-up care appointments.[20,21,36,37] These

patterns of rising and falling symptom experience contrast with studies of

non-medical stressors, in which distress is greatest immediately after the

event and decreases (often rapidly) over time.[5,38]

Perhaps the key difference between many medical stressors and more

conventional traumatic stressors is the focus of threat in time. For the

most part, conventional traumatic stressors are acute events that can give

rise to persistent, chronic stress and adjustment difficulties. They are

past traumatic events and the impact of the ongoing sequelae of these events

(e.g. court proceedings involving a motor vehicle accident, medical pain

from soft tissue damage from such an accident) that continue to affect

response is less than the effects of the psychological 'blow' of the trauma.

Medical stressors share this characteristic if one considers the diagnosis

of life-threatening illness as a traumatic stressor, but they also contain a

future-oriented aspect in contrast to traditional traumas, representing

fears and worries about treatment, survival, recurrence, stigma, and the

persistence of life-threat and new dangers yet to come.[39,40] Also,

knowledge about disease recurrence can produce greater PTSD symptoms

compared to the initial diagnosis, if the degree of life threat is perceived

as more intense. Cancer, HIV disease, and other chronic, life-threatening

diseases are characterized by often drawn-out periods of treatment and

disease-free survival.[31] Life-threat is not an acute stressor, and

difficulty with accommodation to this persistent, ongoing threat may be a

factor in the other differences between medical and non-medical stressors

described above.

If the focus of threat to life is not based on a past event for medical

patients but is based on the future, the intrusions and re-experiencing

symptoms that occur as part of posttraumatic stress syndromes may be of a

different type than those experienced by individuals exposed to traditional

traumas. The re-experiencing symptom cluster of PTSD is based on past trauma

exposure, rather than future-oriented events. For example, the symptoms

constituting this cluster are: Have you had intrusive thoughts about your

trauma that have popped into your mind without there being something to

remind you of them? Have you had flashbacks to the event, felt that it was

happening all over again? Have you had recurrent distressing dreams about

the event? Have you experienced physiological arousal symptoms when you were

reminded of the event by cues in your environment or thoughts? Have you

become very distressed when you were exposed to internal or external cues

that reminded you of the trauma? Cancer and MI patients may not be having

intrusions that consist solely of the past event, but rather the majority of

their intrusions may be future oriented (e.g. Will I live to watch my

grandchild get married? Will the cancer progress to the point that I'm in so

much pain that I would want to die? Will my family be provided for once I am

gone?). Intrusive thoughts could also be associated with past events (e.g.

the physician telling me that I have breast cancer and that it has

metastasized, the oncologist telling me that the cancer has progressed and

the treatment has not been effective, the only treatment now available is

experimental). Cancer and MI patients may experience both types of

intrusions. The only way to examine this empirically is to ask patients not

only 'Have you experienced intrusions?', but to ask them about the content

of their intrusive thoughts (e.g. Have the intrusive thoughts been about the

past diagnosis, MI, or have they been future oriented?).

What Do You Measure as Your Criterion?

Answers to this question require observational research and qualitative

analyses of the types of intrusive thoughts that medical patients

experience, and categorization of these experiences as being future or past

event oriented. Extant research examining PTSD across the diagnosis and

treatment continuum in cancer patients has shown that the diagnosis is the

single most traumatic timepoint for breast cancer patients, but this

research has not evaluated whether some intrusions are future oriented.[22]

In the MI literature, investigators have cued patients to answer questions

about intrusive thoughts and avoidance as 'memories of your heart attack',

'the extent to which you've suffered from each of the acute stress disorder

symptoms in response to the MI', 'the experiences related to the MI or

coronary artery bypass graft', and 'thinking about your heart attack even

when you did not mean to'.[16,17,28-30] In the HIV literature, patients have

been asked about PTSD symptoms in reference to the HIV diagnosis,[33] but

also in reference to how much they had been bothered by their reactions to

whatever event had distressed them the most.[34] These examples underscore

the importance of defining the traumatic event before conducting the study

and using it consistently in measures and interview assessments. Questions

surrounding 'your cancer experience' or 'whatever event caused you the most

distress in the past month' do not provide further knowledge about the

specific event that leads to PTSD, if one decides to use the PTSD model to

measure psychological distress in medically ill patients.

What are the Differences Between Lasting Effects of a Past Event and Ongoing

Effects of a Persistent Stressor?

The lasting effects of a past event such as sexual assault can lead to a

change in the victim's worldview and view of herself and others. She may

fail to accommodate or rather overaccommodate, meaning that she can alter

her beliefs about herself and the world to the extreme in order to feel safe

and in more control. She may believe that all other men might be potential

rapists or the world is not a safe place. She can also fail to assimilate

and alter incoming information to match her previous beliefs. She may come

to believe that because a bad thing happened to her, she must be getting

punished for something terrible that she did, because bad things only happen

to bad people, or she may question as to whether it really was a rape

because she knew this man and thought he was a good person and a good person

would not have done this (e.g. the world is a just and fair place).

For cancer and MI the individual can also overaccommodate, by believing that

life is dangerous and that one should always fear what could potentially

happen. Assimilation could also occur and people could believe that they

must have done something very bad during their life to deserve this.

However, during the normal processing of a past trauma the goal is for the

individual to accommodate the trauma into his/her life, which means altering

one's beliefs to incorporate the new information. For example, the cancer

patient may start to believe that the world is not always a just and fair

place and he is not a bad person for having cancer. Sometimes bad things

happen to good people, and the world is not a dangerous place. However, if

this person has a recurrence or there is a rational fear that the cancer

might return, his fears and intrusions might be justified and therefore the

natural process of accommodation might be more difficult for this patient.

A cancer diagnosis and MI also involve new and persistent stressors that

follow the initial diagnosis and cardiac event. For both cancer and MI the

patient may have subsequent bone pain, chest pain, fatigue, and loss of

appetite that can result from the original disease or treatment-related

side-effects. Shemesh et al.[29] found that MI patients who were symptomatic

(e.g. experience angina) after MI were more likely to have intrusion and

avoidance symptoms of PTSD than MI patients who were asymptomatic. PTSD

symptoms were also strongly associated with poorer medication adherence. The

stage and severity of illness or illness-related impairment should be more

influential in determining the impact of medical stressors than the

conditions themselves. However, cancer may have a different emotional

impact, particularly just after the diagnosis. An important component of

PTSD is the avoidance of reminders of the trauma. Medication use, follow-up

visits and medical screenings could all serve as potential reminders of the

cancer diagnosis or MI. If a patient is seeking to avoid these cues he/she

may not be medically compliant with treatment and follow-up care, because

doing these activities reminds him/her of the cancer or MI.

Can Current Methods of Measuring Posttraumatic Stress Disorder Detect

Medical Illness-Related Psychological Distress?

PTSD may not be the right model to represent the anxiety and distress that

cancer and MI patients feel after the diagnosis or cardiac event, because

distress appears to be experienced differently than when considering more

traditionally studied traumatic stressors. In addition, medical stressors

may be characterized by intrusions centered on future-oriented events. If we

consider that the intrusions are more future oriented, generalized anxiety

disorder (GAD) could offer a better fit for the symptom presentation. The

defining features of GAD are excessive, pervasive, and uncontrollable worry

characterized by anxious apprehension. Anxious apprehension refers to a

future-oriented mood state in which one becomes ready or prepared to attempt

to cope with upcoming negative events. This mood state is associated with a

state of high negative affect and chronic overarousal, a sense of

uncontrollability, and an attentional focus on threat-related stimuli (e.g.,

high self-focused attention, hypervigilance for threat cues).[41]

It may be possible to distinguish whether medical patients presenting with

intrusive thoughts and anxiety have PTSD versus GAD using physiological

assessments. GAD is the one anxiety disorder in which somatic presentation

involves inhibition of the sympathetic nervous system, a restriction in the

range of system variability, and resulting physiological inflexibility at

rest and when challenged.[42] In contrast, trauma survivors with PTSD

exhibit greater sympathetic reactivity than trauma survivors without

PTSD.[43,44] Alternatively, a new diagnosis may need to be formulated

surrounding medical life-threatening illnesses if the intrusive thoughts are

both focused on the discrete past event and future-oriented events.

The advocacy of current conceptual and methodological approaches to PTSD

when considering the impact of stressful medical conditions is good

regardless of these potential problems or key differences among syndromes.

In general, psychopathology is variable in the face of most stressors, and

medical conditions are no exception. The highly variable prevalence

estimates for PTSD in medical populations reflect this variability.[45,46]

Evidence of a relatively low incidence of PTSD among cancer patients derives

primarily from studies of breast cancer patients, mostly early stage

patients with relatively good prognoses. This could have suppressed

estimates of PTSD in cancer populations. With some modification in the

assessment time point (e.g., assessment immediately after the cancer

diagnosis), tools, and conceptionalization of PTSD and psychological trauma

associated with medical illness (e.g., including past and future-oriented

intrusions) it may become evident that the rates and patterns of experience

are not as different across stressors as initially thought. Conceptualizing

post-trauma syndromes that are characteristic of medical patients provides

important and useful information about pre and post-treatment adjustment,

mental health complications, and the management of chronic illness.[46]

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Reprint Address

Correspondence to Baum, PhD, University of Pittsburgh, Department of

Behavioral Medicine and Oncology, University of Pittsburgh, Pittsburgh,

Pennsylvania, USA Tel: +1 ; fax: +1 ; e-mail:

baum@...

Abbreviation Notes

DSM, Diagnostic and Statistical Manual of Mental Disorders; GAD, generalized

anxiety disorder; MI, myocardial infarction; PTSD, posttraumatic stress

disorder

Mundy and Baum, University of Pittsburgh, Pittsburgh,

Pennsylvania, USA

------------------------------------------------------------------------

On 4/8/04 1:28 AM, " ceda " ceda > wrote:

>

> Subject: RE: Medical Disorders as a Cause of Psychological Trauma

> andPosttraumatic Stress Disorder

> I have not been able to access this article and would very much like to

> read it. Would anyone be able to obtain it and send it on to me?

> Thanks for the help.

> Bernie, Toronto

>

> http://www.medscape.com/viewarticle/470032?mpid=26934