Posttraumatic Stress in Medically Ill Patients

A major physical illness or procedure, such as a myocardial infarction (MI), a transplant operation, or a life-threatening attack of asthma, can be emotionally traumatic,^1,2 but the study of posttraumatic reactions in the medically ill is relatively new. Only in the past 2 decades or so it has been recognized that, in fact, medical illness and its treatment can be traumatic, and only since the publication of DSM-IV in 1994 has medical illness been included as a potentially traumatic event that may lead to the development of posttraumatic symptoms. Consequently, many patients and their physicians are not fully aware of the potential of medical illness and procedures to cause symptoms that are similar to those experienced by victims of other traumas, such as combat- related trauma. It is now known that almost all patients who survive an acute medical illness or procedure report some symptoms of posttraumatic stress, and as many as 30% may meet criteria for a psychiatric disorder related to the experience.^1,3

CASE VIGNETTE

Rachel is a 55-year-old married woman with 2 adolescent children. She comes to a consultation 1 year after she has had an MI. Since that time, she has not slept well, her appetite has substantially decreased, she thinks that she will die soon, and she has not been able to return to work.

On further evaluation, it seems that Rachel is not sleeping well because of recurrent nightmares about having a second MI. In fact, she reports no less than 10 visits to the emergency department in the past year because she felt as though she was "having it all over again." She believes that she will not be alive next year, and therefore "what is the purpose of continuing to work or caring for my children, if I am going to die soon anyway?" She finds it hard to keep her appointments with the cardiologist because "it is stressful to see these doctors again and again. . . . I just can't handle it anymore. No one understands me. My family is not aware of the things I have gone through, and the doctors treat me as though I am well. They even joke with me about these horrible chest pains."

Rachel is a fictional character, but when she complains of not being understood, she is echoing the complaints of many real-world patients. It is important that we at least try to understand their plight. In this article, the importance of correct recognition and treatment of posttraumatic stress symptoms along with depression and general anxiety in a subset of medical patients who are emotionally traumatized by their illness is emphasized. The discussion will use Rachel's case as a framework to translate theoretical considerations into clinically useful information.

It has been known for at least a decade that depression is common and debilitating in patients with cardiovascular illness,⁴ and indeed the reader might think that Rachel is experiencing a major depressive disorder. However, while depression is possible, the distress that Rachel feels seems to be more consistent with a stress disorder.

Treatment considerations

The treatment of trauma survivors may be different from the treatment of patients who may have similar symptoms but have not been traumatized in the usual sense of the word. It is important to recognize that medical illness can be traumatic because this understanding could inform specific interventions and the management of symptoms of distress as well as depression in the affected patient. Of note, trauma survivors may suffer from a whole spectrum of symptoms, including depression and anxiety.^1,3 Posttraumatic stress is not the only outcome of traumatization, and it is not even the most common one.

When addressing the traumatic impact of a medical illness or its treatment, the clinician will probably need to manage symptoms that are consistent with depression, anxiety, or even behavioral disturbances (particularly in children). These symptoms are consistent with a diagnosis of major depressive disorder. Indeed, a co-occurrence of symptoms of posttraumatic stress with symptoms of depression is the rule rather than the exception in patients with cardiovascular illness^3,5 and probably other medical illness as well.¹

Whether Rachel has depression, posttraumatic stress, or both may not be easy to discern, but it may not be important to make the distinction. Targeting the impact of the traumatic event could be approached in the same way-whether it has caused depression, distress, or posttraumatic stress.

Trauma-focused treatment directly addresses the cause of the symptoms in addition to the symptoms themselves, with the hope that eliminating the cause would also eliminate the symptoms. In that, it is akin to many medical treatments that strive to correct the root of a problem as opposed to targeting a specific constellation of symptoms. For example, the treatment of hemolytic anemia would strive to identify and correct its cause, whether it manifests with jaundice, fatigue, and so on. Certainly both jaundice and fatigue would be eliminated if the anemia is corrected. Conversely, the treatment of jaundice (a symptom) may be entirely different depending on the cause: if hemolytic, a certain set of possibilities exist, if caused by liver failure, a completely different set of treatments is appropriate. Similarly, the treatment of depression or anxiety in the absence of traumatization may not be the same as the treatment of depression or anxiety in the context of a traumatic experience.⁵

A trauma-focused approach targets the traumatic experience as the reason for the mental health symptoms. This is different from other psychiatric and psychotherapeutic approaches (such as medication treatment), some of which do not focus on the reason for the symptoms but on the alleviation of the symptoms regardless of their origin. A trauma-focused approach is also different from psychoanalytic psychotherapy because it focuses on the traumatic event rather than on experiences from the distant past as a focal point that can explain the development of the mental health symptoms.

During the evaluation, Rachel firmly stated that the start of her symptoms of distress and dysphoric mood was related to the time she had been hospitalized for the MI. She had been treated for a panic disorder when she was a teenager ("talk therapy"), but she is currently not receiving any mental health treatment. She repeatedly says that she is "not crazy" and that she wants a "short treatment" and does not want any prescribed medications because she "had enough of taking drugs for my other problems." A diagnosis is made of depressive disorder not otherwise specified accompanied by posttraumatic stress disorder (PTSD) related to the experience of having had an MI.

Psychopharmacotherapy

At this point, several treatment options are available. Both paroxetine and sertraline are FDA-approved for the treatment of depression and PTSD in adults.^6,7 Sertraline (and quite possibly paroxetine) is safe in patients with cardiovascular illness.⁸ However, these agents have not been specifically evaluated for the treatment of PTSD in adults or children who are medically ill. Therefore, their use in this population, although reasonable, should be accompanied by a discussion of the limitations of current knowledge regarding the pharmacological treatment of PTSD in patients who are medically ill.

The use of pharmacological agents can be complicated by the fact that persons who are medically ill are frequently taking other medications, and the drug interaction profile between SSRIs and those medications may not always be known. Caution is recommended, especially when using other medications that are metabolized by the liver and have a narrow therapeutic window (such as valproic acid).

The blood levels of these medications can be affected by SSRIs. Therefore, if a patient is taking both preparations concomitantly, blood levels should be monitored regularly and frequently while the SSRI is being taken. Furthermore, insomnia or other somatic complaints may develop in patients who have PTSD, and it might be difficult to determine whether these complaints are related to PTSD or to the adverse effects of a medication.

When a somatic symptom develops in temporal relation to starting a pharmacological treatment for PTSD, the symptom should be assessed for severity and trauma-specific content (for example, nightmares about the traumatic event are more likely to be caused by PTSD, whereas insomnia without nightmares is more likely related to a medication side effect). Ultimately, it is up to the clinician and the patient to determine whether it is desirable to stop the medication or wait to see if the symptom subsides.

Trauma-focused psychotherapeutic interventions

Some patients prefer medication treatment, whereas others prefer a nonpharmacological approach. Trauma- focused cognitive-behavioral therapy (CBT) with elements of relaxation and prolonged imaginary exposure is an example of the latter. Rachel was adamant about not using additional medication, but she agreed to participate in a once-a-week, 2-month-long course of trauma-focused CBT.

During this period, she was taught relaxation techniques and was asked to describe her traumatic experience (the first day of hospitalization) in detail, as though it were happening again. At first, she was unable to recall many details, but as she continued to talk about the experience over and over again, details emerged: it seems that she was aggressively treated to preserve the patency of her coronary arteries. During therapy, she was able to acknowledge that this approach led to quick recovery, but it was very confusing when she was in the emergency department and "everything happened at once." Through the act of repeatedly describing the experience, she became more comfortable with it and began speaking about her experiences and feelings to her friends. At the end of therapy, although she still did not like to think about the event, the nightmares had subsided, and her mood had improved.

Trauma-focused CBT that uses imaginary prolonged exposure is a highly effective treatment for PTSD in adults and children.^9,10 A recent randomized controlled trial of 284 female veterans⁹ showed that a protocol consisting of only 10 weekly sessions was effective in reducing PTSD symptoms to nondiagnosable levels in 41% of patients-an improvement that was significantly better than the 27% improvement experienced by the control group. Similarly, a randomized, controlled trial of 229 children who had posttraumatic stress as a consequence of child abuse found that a trauma-focused approach reduced not only symptoms of posttraumatic stress but also depression and behavioral problems.¹⁰ In addition, pilot data indicate that cognitive-behavioral approaches are safe and potentially useful in the specific treatment of PTSD in medically ill adults¹¹ and children.¹² As expected, trauma-focused CBT improves symptoms of depression in trauma survivors in general¹⁰ and in patients who are traumatized by their medical illness in particular.¹¹ Hence, it is appropriate to offer this treatment option to a traumatized patient with both depressive and PTSD symptoms.

Choosing between treatment options

In Rachel's case, this was an easy decision (she specifically requested a nonpharmacological approach). In other cases, when making the decision about which modality is preferable (pharmacotherapy or CBT), the following should be considered:

• Availability of a clinician who is familiar with trauma-focused CBT or with medication treatment for PTSD.
• The patient's motivation and ability to follow a structured CBT regimen (it is much easier to take a pill).
• The patient's age (trauma-focused CBT may not be appropriate for very young children; pharmacotherapy for PTSD is not approved for children of any age).
• Can the traumatic experience be characterized as a discrete event? (It would be hard to apply trauma- focused techniques to life circumstances that are distressing but are not specific events. For example, the experience of being debilitated may be very distressing but may not be associated with a specific traumatic event or occurrence. In such cases, the distress is probably better addressed using more general techniques, or medications.)

Combinations of several modalities of treatment have not been properly investigated. While they may ultimately prove to be the best way to treat PTSD, currently the combination of psychotherapy and psychopharmacotherapy in this setting should be considered experimental.

PREVENTION

Is there anything that can be done to prevent the reemergence of posttraumatic symptoms in patients like Rachel before they actually need to go through another procedure that has previously proved traumatic? Although Rachel currently feels much better, it is possible that she will need recatheterization soon.

Medical illness-related traumas offer an opportunity that is rarely encountered in the general emotional trauma field, ie, the opportunity to engage in secondary and tertiary prevention. While it is not likely that a therapist will know in advance that a person is about to be raped (or injured), procedures such as scheduled cardiac catheterization or a transplant operation may be viewed as "scheduled traumas" that allow the treating physician to prepare the patient and parents or caregivers for the experience. What that preparation should entail is a matter of some debate.

Ongoing research is trying to elucidate what works and what does not seem to work in the medical emotional trauma-prevention model.¹³ There have been reports suggesting that propranolol, a ß-blocker, administered immediately after the trauma, may block the formation of traumatic memories¹⁴; however, it is currently premature to recommend this approach, except in the context of a clinical trial. The general recommendations in the Table might help reduce the traumatic impact of a procedure or a medical event.

With her consent, Rachel's cardiologist was informed about her symptoms and successful treatment. He promised to be aware of the importance of trying to prevent future traumatization by using the general approach delineated above and by being attuned to the importance of letting her play as integral a part as possible in determining the course of action in any further treatment decisions.

References:

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