Exposure to adverse or traumatic events in life is a common experience (van der Kolk & McFarlane, 1996). These events can vary from minor to severe, can affect individuals or communities, and people react to them in different ways. Many people are resilient, but some develop symptoms of posttraumatic stress disorder (PTSD), have lower physical health, higher rates of mental disorders, and lower psychological well-being. Furthermore, these reactions can vary in how they are expressed between cultural contexts, can be vastly different for everyone, and can both improve or worsen over time. PTSD relates to numerous biological processes, including brain chemistry and hormonal changes. McFarlane (2010) writes, “…PTSD is not simply a psychosocial disorder, but one underpinned by a major neurobiological disruption” (p. 8). In assessing the whole-person impact of PTSD, it is important to consider and treat a variety of factors.
Allostatic load refers to the cumulative stress on the hypothalamic pituitary adrenal axis (HPA) as well as the autonomic nervous system (McFarlane, 2010). Exposure to trauma may not elicit symptoms of PTSD, nor acute stress disorder (ASD), for a significant time (more than 6 months) after the event; this is called delayed-onset PTSD. Furthermore, those who have experienced depression or been diagnosed with ASD may be able to initially manage symptoms to the point of remission – only later to have a resurgence of symptoms. In the case of ASD, this would change the diagnosis to PTSD. Research speculates that this is related to another traumatic event, or even the cumulation of smaller stressors, until the system becomes overloaded. This commonly results in somatic manifestations.
Chronic pain without a medical cause has a strong relationship to PTSD (Andreski et al., 1998), largely thought of to be related to the allostatic load (McFarlane, 2010). In those with chronic pain and PTSD, there are also noticeable changes in the hippocampus, cortisol, amygdala, and gene expressions. These biologic reactions also correspond with fibromyalgia, chronic fatigue, and irritable bowel syndrome. Furthermore, individuals with PTSD are at an increased risk for hypertension and cardiovascular disease, connected with repeated traumatic triggering leading to hyperactivity of the sympathetic nervous system. Significantly higher levels of cholesterol and triglycerides have been found in people with PTSD, even when compared to individuals with depression (Karlovic et al., 2004). Individuals with PTSD are also more likely to be overweight or obese or have coronary heart disease (McFarlane, 2010).
In a study of pregnant Peruvian women, there was shown to be a high correlation between those that had both migraines and PTSD (Friedman et al., 2017). Interestingly, the authors explain that there are numerous overlaps in brain chemistry and hormones between both migraines and PTSD, including lower levels of cortisol, plasma, norepinephrine, higher levels of pro-inflammatory cytokines, and reduced or unstable levels of serotonin. A study of Syrian and Iraqi refugees similarly found increased pro-inflammatory cytokines among those who had PTSD, depression, or anxiety (Grasser et al. 2020).
All of these medical issues are frequently comorbid with individuals with PTSD. Interestingly, many of them also correspond with common cultural idioms of distress in collectivistic cultures, such as in Syria, who often describe trauma and mental distress symptoms as having headaches, racing or pressure on the heart, insomnia, unexplained pain, and stomach pain (Hassan et al., 2015). Systemic, social, cultural, and community factors should also be addressed – especially if one is from a collectivistic society, or the traumatic event impacted a group – a family, a community, or a whole culture or country, such as in the case of war and genocide.
Furthermore, general psychological well-being is also often dramatically reduced in conjunction with traumatic stress. Roberts et al. (2020) write that more than “80% of individuals with PTSD will experience at least one additional lifetime mental health disorder, and around 50% will experience three or more comorbidities” (p.417) in the general population. Common psychological comorbidities are depression, anxiety and panic disorder, substance use disorders, severe mental illnesses, and personality disorders, especially borderline personality disorder. ADHD is also a common comorbidity (van der Kolk & McFarlane, 1996). Furthermore, people impacted by PTSD tend to organize their whole lives around the trauma, such as recreating the pattern in their relationships, and avoiding any hint of a traumatic trigger, causing profound changes in their thoughts, feelings, and behaviors (van der Kolk & McFarlane, 1996). Adults with a large number of adverse childhood experiences have significantly increased risk of a poor mental well-being (Hughes et al., 2016). Such individuals also have shown to have significantly lower social well-being (Mosley-Johnson et al., 2019).
Clinical implications are that treatment and assessment needs to expand to consider all of these factors. Traditionally, the use of anti-depressants and cognitive behavioral therapy have been the norm in treating PTSD (McFarlane, 2010), and medical doctors treat physical problems as separate issues. The ideal treatment would occur shortly after the traumatic event, even if an individual has not yet expressed symptoms, to train one’s psychophysiology to regulate itself early on. A study of Tutsi genocide survivors showed high rates of PTSD and CPTSD, and their children also suffered secondary symptoms of trauma (Shrira et al., 2019). Both parents and offspring had lower rates of resilience when parents suffered from CPTSD. Had trauma focused interventions occurred shortly after the genocide, it is possible that intergenerational trauma may have been avoided. Additionally, co-morbid symptoms both psychological and physical should be addressed in holistic approaches. One promising recent therapeutic modality that seeks to do this is Somatic Experiencing, which has been found to reduce symptom severity of PTSD and depression (Brom et al., 2017) and in PTSD-related chronic pain and disability (Andersen et al., 2017).
Clearly, the implications of the havoc of PTSD are severe. “There is the potential for a pervasive disruption of an individual’s neurobiology and psychophysiology following exposure [of traumatic stress], and PTSD is only one end point…exposure to traumatic stress leads to a general disruption of an individual’s underlying homeostasis” (McFarlane, 2010, p.7). Trauma-exposed individuals should be treated immediately even without symptoms and should be educated to self-assess over their lifespan. Holistic models which treat both physical and mental disruptions and comorbidities are paramount. Culture and environmental factors also should be carefully considered in assessment and treatment. Trauma changes us to our very core and in our entire well-being; increasing awareness and treating it as such is critical for both sufferers, and medical and mental health providers.
References
Andersen, T. E., Lahav, Y., Ellegaard, H., & Manniche, C. (2017). A randomized controlled trial of brief Somatic Experiencing for chronic low back pain and comorbid post-traumatic stress disorder symptoms. European Journal of Psychotraumatology, 8(1). https://doi-org.tcsedsystem.idm.oclc.org/10.1080/20008198.2017.1331108
Andreski P, Chilcoat H, & Breslau N. (1998). Post-traumatic stress disorder and somatization symptoms: a prospective study. Psychiatry Res, 79, 131-8.
Brom, D., Stokar, Y., Lawi, C., Nuriel, P. V., Ziv, Y., Lerner, K., Ross, G., & Nuriel-Porat, V. (2017). Somatic Experiencing for Posttraumatic Stress Disorder: A Randomized Controlled Outcome Study. Journal of Traumatic Stress, 30(3), 304–312. https://doi-org.tcsedsystem.idm.oclc.org/10.1002/jts.22189
Friedman, L. E., Aponte, C., Perez Hernandez, R., Velez, J. C., Gelaye, B., Sánchez, S. E., Williams, M. A., & Peterlin, B. L. (2017). Migraine and the risk of post-traumatic stress disorder among a cohort of pregnant women. The journal of headache and pain, 18(1), 67. https://doi.org/10.1186/s10194-017-0775-5
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Karlovic D, Buljan D, Martinac M et al. (2004). Serum lipid concentrations in Croatian veterans with post-traumatic stress disorder, post-traumatic stress disorder comorbid with major depressive disorder, or major depressive disorder. J Korean Med Sci, 19, 431-6.
McFarlane A. C. (2010). The long-term costs of traumatic stress: intertwined physical and psychological consequences. World psychiatry : official journal of the World Psychiatric Association (WPA), 9(1), 3–10. https://doi.org/10.1002/j.2051-5545.2010.tb00254.x
Mosley-Johnson, E., Garacci, E., Wagner, N., Mendez, C., Williams, J. S., & Egede, L. E. (2019). Assessing the relationship between adverse childhood experiences and life satisfaction, psychological well-being, and social well-being: United States Longitudinal Cohort 1995-2014. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation, 28(4), 907–914. https://doi.org/10.1007/s11136-018-2054-6
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