Post-traumatic stress disorder (PTSD) is on our minds lately, often as it relates to veterans. However, people with medical illnesses develop PTSD too, and this happens more often than you might imagine.
As you may know, the DSM IV-TR (4th ed., American Psychiatric Association, text revision, 2000) requires the following criteria for PTSD: (a) a traumatic event that involves actual or threatened death, or the threat of physical integrity to self or others and the person’s response to that event was intense fear, helplessness, or horror; (b) at least one symptom of re-experiencing of the event, such as intrusive memories, nightmares, a sense of reliving the event, and/or psychological distress when reminded of the event; (c) three or more symptoms of avoidance, such as avoidance of thoughts, feelings, or reminders of the event, inability to recall aspects of the event, withdrawal from others, emotional numbing, sense of a foreshortened future; and (d) two or more symptoms of increased arousal, such as insomnia, irritability, concentration difficulties, hypervigilance, and exaggerated startle response.
Those of you who have been seriously ill or know someone who has may recognize some or all of these symptoms. Roughly one-forth of medical patients with heart disease and cancer meet criteria for PTSD. Some studies suggest that rates of this anxiety disorder are even higher.
As common as PTSD is, it is striking that medical clinicians don’t talk about this more with patients. Then again, maybe it is not so surprising. Talking about trauma requires a great deal of sensitivity, time and vulnerability on the part of physicians. Medical professionals often experience trauma as well, as least the vicarious kind. Having to watch patients suffer over and over again can be overwhelming.
Patient factors likely come into play as well, however. I always suspect I am treating someone with PTSD when they tell me about a frightening hospital experience, without going into detail. Or they may describe some aspects of what they experienced with their illness with the bland detail someone might use to describe a routine trip to the grocery store. In other words, emotion is often absent from discussions of trauma in people who have PTSD—that is until someone becomes flooded by feelings—and then they cannot shut them off.
This is why avoidance is a key symptom of PTSD. Avoiding talking about and thinking about traumatic events helps people function. It keeps them from being overwhelmed. Certainly this fits well with the culture of medicine, as I have described.
Avoidance carries a price. Traumatic events remain cleaved off from identity and people can feel lonely and misunderstood. Additionally, when people with PTSD work hard to stave off thoughts and memories, it takes a lot of energy. Avoidance itself can create unpleasant feelings, which is why some people with PTSD can drink too much and find other ways to self-medicate.
People who have experienced the traumatic impact of illness often long for someone to talk with. Even if they seem like they want to avoid talking about what has happened, it is more likely the case that they simply need to feel in control of interactions in which they talk about illness.
No one wants to talk about trauma. Patients, loved ones, and even doctors can all be tempted to avoid thinking about illness. Illness makes us all feel vulnerable. But avoiding talking about reality only worsens distress, for all involved.