- Trauma is common, and leads to PTSD in a significant fraction of traumatized people.
- PTSD includes familiar symptoms including intrusions, avoidance, changes in mood and thinking, and hyperactivation, less so body symptoms.
- Research on military personnel with various levels of PTSD finds a strong correlation with specific physical symptoms.
- Trauma, which affects our basic sense of safety in the world, undermines a healthy, integrated relationship with the body.
By Grant Hilary Brenner
Post-traumatic Stress Disorder (PTSD) is a psychiatric disorder diagnosed in patients with multiple symptoms following exposure to trauma. According to the National Center for PTSD, about 50 percent of people experience at least one traumatic event in their lifetime, and about 6 percent of people will experience PTSD, although some other estimates are higher. Women are more likely than men to be diagnosed with PTSD. The National Institute of Mental Health reports that about 3.5 percent of U.S. citizens had PTSD in the past year and that the lifetime prevalence of PTSD was about 7 percent.
Is PTSD a hidden epidemic?
As the stigma surrounding mental illness gradually fades, there is growing recognition of the role of trauma across the lifespan. In spite of advances in research and clinical practice, and public education, a full integration of how trauma impacts individuals and groups has been quite slow, partly because so much of trauma is perpetrated by people against one another, because trauma is often accompanied by shame, avoidance and withdrawal, and because a great deal of trauma is built into social systems.
Trauma remains split off, or dissociated, from the identity and worldview of many, preventing progress. On a deep level, fear of—and inability to deal with—death anxiety interferes not only with individual fulfillment, but also may impede cultural evolution as society grapples with terror.
The symptoms of PTSD are diverse, often appearing to be a collection of different conditions unless the role of trauma is realized. They include intrusive thoughts, memories, and nightmares; avoidance of activities, memories, thoughts, places, and people related to a trauma (this can become generalized, leading to severe isolation); changes in mental clarity (cognition and memory); mood disturbances (which can resemble depression or mania); changes in activation level, including irritability, anger, or rage; and dysregulation of emotions and behavior, including potentially risky behaviors putting oneself and others in harm’s way.
People with PTSD may also experience dissociative symptoms, ranging from out-of-body experiences to the sense that oneself or the world isn’t real (depersonalization and derealization) to profound disturbances in identity and sense of self.
Mood and cognitive symptoms were only recently added to the diagnostic criteria for PTSD, in recognition that depression and thinking difficulties, rather than being separate, may be integral to the disorder. PTSD can be chameleon-like, appearing as attentional problems like ADHD, or with mood instability like Bipolar Disorder. Careful diagnostic evaluation is essential to guide treatment and avoid misdiagnosis.
The body keeps the score
However, while many people recognize that trauma affects our bodies, only a subset of physical symptoms are recognized in the formal diagnostic model. Yet—as was so well articulated by Bessel van der Kolk in his book The Body Keeps the Score—people who live with and treat trauma know that PTSD is associated with a variety of physical complaints affecting all body systems. Very often—especially for those for whom the body was the target of abuse or neglect, or for those who felt betrayed by their bodies in the face of trauma—these physical or “somatic” complaints are of prime importance. More and more, body-centered approaches have become a key component of trauma therapy, and addressing the dissociative fragmentation between mind, spirit, and body is a key part of healing.
In order to gain a clearer formal understanding of the role of somatic symptoms in PTSD, and determine if there is a case to include bodily symptoms in the formal diagnostic framework, McFarlane and Graham (2021) conducted a large study of veterans with PTSD, published in the Journal of Psychiatric Research. They review ample reports that among combat veterans and other survivors of trauma, physical symptoms are significant, even when the remainder of symptoms are not sufficient to meet full diagnostic criteria.
They analyzed data from over 14,000 predominantly male participants from the Mental Health Prevalence and Well-Being Study of active Australian Defence Force troops. They measured PTSD symptoms using the PTSD Checklist (PCL), a range of somatic symptoms with the Personal Health Questionnaire (PHQ-15), and lifetime traumatic experiences including non-interpersonal events like accidents and disasters, intimate relational trauma including rape, domestic violence, sexual and emotional abuse in childhood and adulthood, “non-intimate” trauma including physical abuse and assault, threat, torture, capture, and witnessed violence.
They found that about half of survey respondents had deployed to combat zones, with an average age of about 35 years. Average PCL and PHQ-15 scores were normal across the whole group, and the average number of lifetime traumatic events was 3.5.
Among those with full PTSD, there was nearly a 60 percent rate of “somatoform disorder," twice as high as the 26.5 percent in the partial PTSD group. Less than 3 percent in the non-PTSD group had significant somatic symptoms. Somatoform disorder (now called “Somatic Symptom Disorder” or SSD) is a psychiatric condition which includes at least one, and often several, physical symptoms which may not have a clear medical cause, including pain symptoms, neurological issues, gastrointestinal complaints, and sexual problems.1
Somatic symptoms included: stomach and bowel problems, nausea, back issues, pain in the joints or limbs, headaches, dizziness, feeling faint, heart symptoms like palpitations or racing heartbeat, shortness of breath, tiredness and sleep difficulties.
Integrating mind and body into PTSD evaluation
While follow-up research is needed, this study strongly supports the notion that somatic symptoms are a core part of PTSD for a majority of patients. As has historically been the case, military psychiatric research is at the vanguard of understanding how trauma affects people.
As with cognitive and mood symptoms, which were only in the last several years included in the diagnosis of PTSD and which formerly might have been seen as separate conditions for many patients potentially interfering with comprehensive care, one can make a strong case that somatic symptoms should be included under the umbrella of PTSD for many patients. Future work can look not only at groups other than military members, but also at other at-risk patient populations, and take into consideration the presence of other conditions often co-occurring with trauma, including eating and substance-use disorders.
This is more than an academic distinction, because properly formulating a diagnosis is key for developing effective and personalized treatment plans. Especially given how easy it still is to downplay trauma, not only is it important to consider treating somatic symptoms when PTSD is present, it is also critical to assess for trauma in people with somatic symptoms.
Of crucial importance is the recognition that trauma is a triple-threat to mind, body and community. Going beyond understanding and treating the physiological and neurological consequences of trauma which cause somatic symptoms, recognizing the core role of somatic symptoms in PTSD underlines how important is our relationship with our bodies, and how key to healing is to right that relationship.
1. SSD can only be diagnosed after investigating conventional medical causes, so is a “diagnosis of exclusion”. Somatoform disorders are common, and related to Illness Anxiety Disorder (previously called “Hypochondriasis” and Conversion Disorders (also called Functional conditions), in which people may have sudden unexplained neurological symptoms, including movement abnormalities, numbness, paralysis or weakness, or seizures.
These symptoms often do not have any significant findings on conventional medical testing, but as with pain syndromes like Fibromyalgia, newer imaging studies show a “central” component, meaning that there are abnormalities in how the brain processes information related to the body. Unfortunately, though there is progress, people with unexplained medical symptoms often have negative experiences with healthcare providers who are dismissive, unsympathetic or worse.
McFarlane Ao A, Graham DK, The ambivalence about accepting the
prevalence somatic symptoms in PTSD: Is PTSD a somatic disorder?, Journal of Psychiatric Research
(2021), doi: https://doi.org/10.1016/j.jpsychires.2021.09.030.
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