I noticed something on a recent trip to the doctor’s office with my mom. She required an assessment with a cardiologist for a suspected heart problem. The doctor went through his assessment as per usual, starting first with a history.
The components of a full patient medical history include a section entitled History of Presenting Illness or HPI for short. We use the mnemonic OPQRST to remember the important questions to ask. The mnemonic stands for Onset (of symptoms), Palliative/Provoking factors (things that make the symptom worse or better), Quality (for example, of pain, using descriptive terms such as sharp, stabbing or dull), Region and Radiation (Is the pain in one spot? Or does it radiate to other places?), Severity (How severe is the pain, on a scale of 1 to 10?), and last, Timing (When does the pain occur? Does it come and go or is it persistent?)
As you can see, each question requires an intimate knowledge of one’s body and how it feels. As the doctor asked my mom questions, I noted that she seemed unable to answer them in a succinct manner. I realized that my mom, who grew up in a dysfunctional household that exposed her to traumatic situations, seemed disconnected from her body and how it feels to her.
There are various definitions of traumatic disorders, some contained within the Diagnostic Statistical Manual or the DSM for short (used by doctors, psychiatrists and psychologists worldwide), and others in the lexicon of psychological disorders that are not included in the DSM. First, most have heard of Post-Traumatic Stress Disorder or PTSD for short. PTSD is defined by several specific criteria. The first is criterion A, which requires exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. Furthermore, the exposure must occur in one of the following ways:
- Direct exposure
- Witnessing the trauma
- Learning that a relative or close friend was exposed to a trauma
- Indirect exposure to aversive details of the trauma, usually in the course of professional duties (e.g. doctors, nurses, first responders, medics)
Another, less well known, but certainly often experienced traumatic psychological disorder is that of Complex post-traumatic stress disorder. Wikipedia provides the following definition: “Complex post-traumatic stress disorder (C-PTSD; also known as complex trauma disorder) is a psychological disorder thought to occur as a result of repetitive, prolonged trauma involving sustained abuse or abandonment by a caregiver or other interpersonal relationships with an uneven power dynamic. C-PTSD is associated with sexual, emotional or physical abuse or neglect in childhood, intimate partner violence, victims of kidnapping and hostage situations, indentured servants, victims of slavery, sweatshop workers, prisoners of war, victims of bullying, concentration camp survivors, residential school survivors, and defectors of cults or cult-like organizations. Situations involving captivity/entrapment (a situation lacking a viable escape route for the victim or a perception of such) can lead to C-PTSD-like symptoms, which include prolonged feelings of terror, worthlessness, helplessness, and deformation of one’s identity and sense of self.”
After witnessing my mother’s difficulty in answering the doctor’s necessary questions, I ruminated that first, the HPI is an important part of a patient’s history, as it can cue the doctor to follow and investigate a certain diagnosis. Sometimes a diagnosis can be made based on history and physical exam alone, doing away with the need for many expensive laboratory tests. Second, I realized that people with traumatic psychological disorders may be disconnected from their body (due to, for example, suppressing the uncomfortable physical sensations and thus the psyche’s negative response to those sensations). Tying these two thoughts together, I surmised that this potential phenomenon can lead to a decreased quality of care, owing to the decreased ability of the traumatized patient to communicate their medical needs effectively.
So, I decided to do a literature search to confirm my reasoning. I started with a simple Google search trauma and body disconnect where I found a plethora of articles confirming that this is indeed a known phenomenon in traumatized patients.
One article entitled Reconnecting With Your Body After Trauma highlighted two things. First, the term mind-body disconnect in medical terms is known as dissociation and people affected by traumatic psychological disorders often dissociate (or experience a mind-body disconnect) for the reasons mentioned above. Second, I read about an experiment conducted by Dr. Bessel van der Kolk. Dr. van der Kolk is a world-renowned expert on traumatic psychological disorders (in fact, I have been slowly making my way through his book The Body Keeps the Score.) In the experiment, he asked his patients to hold certain objects in their hand (a car key, a coin or a can opener) and found that they were often not able to identify the object without looking.
If patients cannot identify an object by feel alone, then how can they be expected to identify a symptom that makes their body feel a certain way so they can answer the OPQRST questions I wrote about above? This is certainly a more complex task than recognizing a car key by touch.
Next, I used PubMed to search for any literature on the effects of trauma, dissociation, the ability of a patient to provide a succinct medical history and the resultant quality of care.
A quick search provided no results. Although there are a plethora of articles on the neurobiology and the effect dissociation has on specific medical disorders, patient populations and situations (for example, HIV, Borderline Personality Disorder, immigrants and refugees and mother-infant bonding), I could find none that addressed the answers I seek.
Why are the questions I am pondering important at all? In medicine, we are taught two things that can be at odds with one another, and to balance the two. The first is to provide patient-centered care. This means that it is important for the physician to view each patient as an individual and to address their complex biopsychosocial and medical needs to provide the best care possible for that person. As such, I believe identifying and acknowledging the individualized needs of trauma survivors is important. Second, we operate in a limited resource health care system and thus should aim to choose intelligent and prudent health care tests and treatments. No doubt about it, healthcare systems are burgeoning worldwide and as a Canadian medical practitioner, I am even more acutely aware of the effect on patient care. Saving money is always a plus and true, it is a balancing act to provide the best healthcare to each individual patient while mitigating the costs to the system.
As such, I am always interested in discovering new avenues of research if they impact patient care and if they can potentially reduce the costs to the healthcare system. Thus, I believe the effects trauma and dissociation on quality of care and costs is an important avenue of research.
The take-home point for me is to recognize that traumatized patients may not be able to adequately describe their physical symptoms. Therefore, I need to be mindful of that while taking my patient history and come up with novel ways to tease the required information out of my future patients.