The traumatic side of illness

When I read last week about a new study that found heart attack survivors can be at risk for post-traumatic stress disorder, I confess to a rather cynical reaction: “You mean it took this long to recognize that heart attacks are traumatizing for some people?”

The research, which was published this month in the PLoS One journal, analyzed two dozen smaller-scale studies and concluded that about one in eight survivors of a heart attack develops signs of PTSD – and that these people can be at higher risk of a second heart attack.

We’ve become better at recognizing PTSD among the military, especially combat veterans, although it’s debatable whether we’re any better at providing help to those who need it. We’re also better at recognizing that PTSD can occur among survivors of a natural disaster, a fire, an assault or other immediately life-threatening event.

But it seems we have much farther to go when it comes to recognizing that trauma also can be part of people’s medical experiences.

There’s no denying that patients sometimes struggle with anxiety, intrusive thoughts and panic attacks in the wake of a major illness or a hospitalization. Consider the mom who wrote last year to an online parenting advice column about her toddler, who had recently been hospitalized, catheterized and poked repeatedly with needles and IVs. Two weeks after coming home from the hospital, he was clingy, fearful, frightened of unfamiliar places and people, and having trouble sleeping.

Did he have PTSD? his mother wondered. And what could she do to help him?

Post-traumatic difficulties have been reported among both heart and cancer patients, as well as among people who have been hospitalized in intensive care units. They also can occur among patients who’ve experienced a medical injury.

The medical community has been slow to take this issue seriously, however. In fact, there doesn’t even seem to be a consensus on how prevalent it is or the most reliable way to diagnose PTSD stemming from the medical setting. One recent study put the incidence of PTSD at anywhere from 4.8 percent to 29.2 percent of cardiology and oncology patients and concluded that more study is needed.

The PLoS study in fact appears to be the first time that researchers have systematically attempted to more closely examine PTSD among cardiac survivors. The authors write:

In recent years, cardiologists and the broader medical community have become increasingly aware that psychological disorders, particularly depression, are common in patients with [acute coronary syndromes] and are associated with adverse clinical outcomes. Even so, abundant evidence suggests that psychological disorders are underrecognized and undertreated in cardiac populations. While awareness of depression has increased in cardiology practice, awareness of the possibility of PTSD due to ACS has lagged, possibly because many still see PTSD as primarily a disorder of combat veterans or sexual assault survivors.

A commenter who responded to a New York Times news story about the study described her own experience with severe heart disease and how she’s “never been the same since.”

“I suffer from extreme anxiety, hypervigilance and a host of other psychological symptoms related to my cardiac history,” she wrote. Her attempts to relate this to her doctors have “fallen on deaf ears.”

“Now that I have read this article I am hopeful that maybe I will get the help I so desperately need to rebuild my life and rid myself of this insidious fear and stress,” she concluded.

Why has this area of the patient experience been poorly addressed for so many years? Perhaps the medical community has had trouble coming to grips with the fact that their actions, carried out with every intention of helping the patient, can be experienced as upsetting, frightening and traumatic. Perhaps we just have a hard time thinking of PTSD in any context other than combat or violence – and indeed, there seem to be some differences between the two, not to mention a dearth of research on acute medical trauma. Does it have the same fundamental effect on the brain as combat- or violence-related trauma? Or is medical PTSD a separate entity, with different forms and different causes?

One of the most troubling aspects of medical PTSD is that it can leave people fearful and avoidant of anything to do with the medical setting – or, conversely, hyper-anxious about the need to be tested and reassured. Realistically, the avoidant ones will not be able to get through the rest of their lives without ever setting foot in a hospital or doctor’s office again, and the anxious ones are all too easy for busy clinicians to dismiss as being high-maintenance. Researchers, clinicians and the mental health community owe it to these individuals to understand what may be going on in their heads and to find ways to help reduce their suffering.

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