Post-traumatic Stress Disorder in Primary Care Patients

PGY-2: Ms B is a 43-year-old woman who is new to the area in the past few months. She’s here today for a physical exam. She’s pretty healthy, really. A bit of minor low back strain from time to time. This is not bothering her right now. I want to order a mammogram; its been over 1 year, but her previous mammogram was fine. She’s never had an abnormal pap smear; the last one was less than a year ago. I plan to follow-up with that next time. She’s not on any medications so won’t need refills.

Dr F: Anything else of interest?

PGY-2: I’m not really sure. I was in there for more than 30 minutes. She kept dropping “bombs” about psycho-social issues. I didn’t really know what to do. With everything else we needed to talk about, I didn’t feel there was time to address these bombs.

Dr F: When you say bombs, what do you mean?

PGY-2: Well, about 5 years ago, she left an abusive marriage. She hadn’t seen him in about 2 years, and he lives in a different state. Apparently, last week he just showed up to see their kids.

Dr F: Okay, how did seeing him affect her and their children? Did you ask her if she is safe at present?

PGY-2: Like I said, I had so much to cover, there really wasn’t time to get into details. I’m not sure what I’d be able to do about her psychosocial issues anyway. By the way, she also told me that she was raped at age 25 and that she was sexually abused by her stepfather as a child.

Dr F: Okay, let’s just take a deep breath here. I think you may be feeling that your job is to “fix it” with this patient. Obviously, it’s not possible to fix the impact that each of these traumatic events had upon her sense of self, certainly not in your first meeting! So, we need to start by having you define what your role is with this patient at this time.

PGY-2: What do you mean, my role? I’m just trying to get through a complicated history and physical. All this psychosocial stuff is overwhelming. I just don’t know what to do!

Dr F: Let’s start with the idea that you are feeling what she is feeling—anxious and overwhelmed. This is a key clinical finding; you have recognized what she feels about herself and her life. It is anxiety provoking and overwhelming! Right now, your job is not to fix that for her. Rather, your job is to tolerate these feelings, her feelings, while you do two things. First, you need to take the time to form a relationship with her. Second, you need to gather clinically relevant information that helps you to understand the major factors that may now, or in the future, impact her health.1,2

PGY-2: Well, she already has a psychologist that she has been seeing to talk about these issues. Isn’t knowing that she is going to someone enough?

Dr F: Let’s talk about what this patient needs from you. Like any patient, she needs to know that you understand what is important to her. This is how you go about forming a trusting doctor-patient relationship with her. Communicate to her that you know what is important in her life.1,2 Do you think it is an accident that she told you at least three times that she has been abused repeatedly in her life?

PGY-2: I guess not, but it still seems hard to address psychosocial needs with so little time.

Dr F: It is a challenge but not impossible. For example, I want to tell you about a study that some colleagues and I conducted at this clinic. We interviewed 411 adult patients and asked about traumatic life events, mental health symptoms, and patient attitudes about their doctors. Almost 90% of patients agreed it was appropriate for their family doctor to ask questions about traumatic life events and related mental health issues. But, only 25% of men and 40% of women reported that their family doctor had asked them about such things.

PGY-2: So, you’re telling me that patients don’t mind being asked about sexual abuse, rape, or other traumatic events? That’s pretty amazing!

Dr F: That’s what adult patients tell us. They think it is appropriate for their family physician to ask about traumatic events and about how such events impact their mental health. Think about it—people often come to their doctor to fight a sense of being alone or isolated with regard to some problem.1,2 So, a key task to forming a meaningful doctor-patient relationship, particularly if the patient has experienced a traumatic event, is your being willing to ask some simple questions about such events and how these events affected the patient.

PGY-2: Okay, I see what you are saying, but I still worry that I will get bogged down in too many details. I mean, what do I do if the patient falls apart?

Dr F: Remember, your task here is twofold. First, you are trying to form a trusting doctor-patient relationship. That comes from her experiencing that you understand how her past rape or other traumatic events are an important issue in her life. Second, you are trying to gather clinically relevant information. You don’t have to fix anything today. While you’ve picked up on her underlying anxiety, it is not your task to take that away from her right now.1,2 Her psychologist or other aspects of her support system will help her to cope with her emotions. By not overreacting, you are providing her with a model that there is no need to be frightened by what she is feeling about herself.

PGY-2: I think I see what you are getting at, I should just accept that she may leave here today feeling overwhelmed or anxious. It just doesn’t feel right, but I see what you are saying.

Dr F: Our assessment is that feeling overwhelmed and anxious is a natural state for her given that she has been repeatedly abused throughout her lifetime. I mean, first she is sexually abused as a child by her stepfather, then she is raped at age 25, finally, she is physically abused, and goodness knows what else by her ex-husband. It would be disrespectful of me as her physician to make her pretend that such events in her life have not been terribly painful.4 By offering her a chance to be herself with me, no need to pretend that she feels better than she does, she gains a sense of acceptance from me that may carry over until the next time that I see her.1,2

PGY-2: Now I see what you are getting at. I’m serving as sort of a role model. If I can discuss what is most important to her, even briefly, without becoming overly emotional, I am really conveying a sense of validation and respect toward her.1,2

Dr F: That’s right, and a sense of hope, an expectation really, that she can cope with whatever is going on in her life, well enough until you are able to see her again. Why don’t you go wrap things up with her for today but offer the opportunity to see her back in a few weeks. You might tell her, “I just want to check back in with you to see how you are managing all of this stress in your life.” I think she’d appreciate the offer.

In about 15 minutes, the resident physician returns and the conversation continues.

PGY-2: That went a lot better than I thought it would. She gave me a hug as she left and said she would be back in 3 weeks. I’m a little nervous about where all of this will take us—me and her that is.

Dr F: Well, let’s remember that your anxiety about all of this is a clinical finding. You are picking up on the fact that she is feeling overwhelmed and anxious, remember?

PGY-2: I know you’re right, Dr F, but I still feel like I’m getting in over my head.

Dr F: I’m actually glad to hear you say that you feel over your head. That tells me both that you recognize the importance of this patient’s psychosocial problems and that you recognize that you need more knowledge and skill to properly address her psychosocial problems.

PGY-2: Okay, but where do I get the knowledge and skill to deal with this patient’s problem? I’m not being trained as a psychiatrist in this residency!

Dr F: You’re right, you are not her psychiatrist, but you are her family doctor. Did you know that family doctors and other primary care clinicians provide most of the mental health care delivered in the United States?5

PGY-2: I didn’t know that. Is that really true?

Dr F: It is true and let me tell you why. There are a lot of barriers to seeking mental health care.6 From the patient’s perspective, there are many advantages to seeing a family doctor: accessibility (it is easier to get an appointment with a family doctor), cost (it is cheaper to see a family doctor), insurance issues (most plans limit visits to mental health specialists), trust (patients generally trust their primary care doctor), and privacy (no one but the patient and the doctor need to know why the patient is being seen).

PGY-2: So from my patient’s point of view, it may be a lot easier for her to see me for a mental health problem instead of a psychiatrist or other mental health specialist?

Dr F: That’s right. I’m not saying that you can’t or shouldn’t ever refer to a mental health specialist. But, I am saying that you should listen to your patient’s psychosocial concerns care­fully, be aware that your patient may want and trust your help with such problems, and develop the knowledge and skill base necessary to manage such problems and to recognize when referral is appropriate.

PGY-2: So, I should be willing to talk to my patient more about these psy­chosocial issues and how these impact her mental and physical health. I also need to improve my knowledge and skill base about how traumatic events may affect mental and physical health. Is that right?

Dr F: That is what I’m saying. You should also be willing to provide mental health treatments within your scope of expertise: psychotropic medications, education, basic psychological counseling. You will learn to recognize when referral is appropriate.2,7 At your stage of training, most doctors err on the side of referring too early. Without sufficient trust between you and your patient, they are less likely to accept your referral to speak with a mental health specialist. The patient may even view a premature mental health referral as a rejection by their primary care physician.

PGY-2: I think you’re onto something, Dr F. Less than half of my patients re­ferred for mental health issues actually show up at their scheduled mental health appointment. You’re saying I should “hold onto” those patients longer, talk to them more, and develop my knowledge and skill base further so that I’m more comfortable with at least initially addressing their mental health concerns.

Dr F: That’s exactly right. Let me give you some resources to read over. Once you’ve read over these sources, I want us to talk again so that you will be better prepared to understand and address this patient’s mental health needs when you see her next (see below for list of resources suggested to PGY-2).

PGY-2: Thanks Dr F, I’ll read these things over and then you and I can talk again.

Dr F: I’ll look forward to it!

Suggested Resources for PGY-2:

  • Bisson J. Clinical evidence concise: post-traumatic stress disorder. Am Fam Physician 2006;73:120-4.
  • Freedy JR. Post-traumatic stress disorder. In: Ebell M, ed. Evidence-based medicine. New York: John Wiley and Sons. In press.
  • Stuart MR, Lieberman JA. The fifteen minute hour: applied psychotherapy for the primary care physician, second edition. Westport, Conn: Praeger, 1993.
  • Sudak D, Ambrosini P, Alici-Evcimen Y. Post-traumatic stress disorder: medical topics. First Consult Web site: Evidence-based answers for the point of care. www.firstconsult.com. Topic last updated September 12, 2007. Accessed September 6, 2008.

John R. Freedy, Medical University of South Carolina, Author
Alec Chessman, MD, Medical University of South Carolina, Editor

References

  1. Coulehan JL, Block MR. The medical inter­view: mastering skills for clinical practice. Philadelphia: F.A. Davis and Company, 2001.
  2. Stuart MR, Lieberman JA. The fifteen minute hour: applied psychotherapy for the primary care physician, second edition. Westport, Conn: Praeger, 1993.
  3. Freedy JR, Magruder KM, Zoller JS, Hueston WJ, Carek PJ. Traumatic events and mental health in civilian primary care: implications for training and practice. Unpublished data.
  4. 4. Freedy JR. Post-traumatic stress disorder. In: Ebell M, ed. Evidence-based medicine. New York: John Wiley and Sons. In press.
  5. Coyne JD, Thompson R, Klinkman MS, Nease DE. Emotional disorders in primary care. J Consult Clin Psych 2002;70:798-809.
  6. US Public Health Service Office of the Surgeon General. Mental health: a report of the Surgeon General. Bethesda, Md: National Institute of Mental Health, 1999. www.surgeongeneral.gov/library/mentalhealth/chapter1. Accessed September 6, 2008.
  7. Sudak D, Ambrosini P, Alici-Evcimen Y. Post-traumatic stress disorder: medical topics. First Consult Web site: evidence based answers for the point of care. Topic last updated September 12, 2007. www.firstconsult.comAccessed September 6, 2008.
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