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

Elizabeth Mundy; Andrew Baum


Curr Opin Psychiatry. 2004;17(2) 

In This Article

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]